00010085 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Awoi Q
CITY OF CUPERTINO BUILDING-ELECTRICAL �PBRMIT-NOe.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINT AUDRP_SS: SANITARY NO. APPLICATION SUBMITTAL DATE
! C) 7 S` FAlL#2 L0 NE- D dL• say�> I e '
OWNERSSIA;r: Q ���_ PHONE:ry CONTRACTOR'S NAME: D��LIC NO
ll.� tt L / � NIC CONTROLp
CHITECTIBDRESS
NGINEER: LIC NO: AD : ` C/ 11' 3�1SPF2 yl-. o.c�
CONTACT: PHONE: // BUILDING PERMrJ INFO
❑ Consultant Fees Paid by Applicant(Initial) B fLECT eLu B M'CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby mErm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OegZ with Section of Division Sof the Business and Professions Code,and my license is
WOO PERMIT ISSUANCE, RESIDENTIAL:
FK ty F m full force unJ eliect - ❑SFDW h ❑KITCHEN REMODEL
a U U Licence Claes — Lie# r
1, W Date Convunir P APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
L,prn ARCHI IECT'S DECIARATION
uQ 1/9
✓� MULTLUNIT ❑STRUCTURAL
ZOr24 I unden an lmy lunvbll heneed mPublicrecoPANELS MODIFICATION N
OZ^0
Oil 200 AMT'S [I INTERIOR ❑CHIMNF,Y REPAIR
rr'.`4.. M Licensed Profir"numl 2111-IINNIAMPS ERIOR ENT
6 F.'.4a OWNER-BUILDER DECLARATION E]SWIMMING POOLS
C�C 6 I herchy tiff....mm 1 um exempt from the Contractor's License Law far the OVER 1000AMPS REMODEUREPAIR ❑DEMOLITION
❑Ix O¢FU- following recon.(Seetcm 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
which requires n permit In construct,filter,improve,demolish,or repair any structure
Prior to issuance.also requires the applicant for such permit to File a signed statement SPECIALCIRCUITIMISC.
C 4� trt
hat he is licensed pursuant in the provisions of the Contractors Licca Law(Chapter 9
acr pO (commencing with Section 701 of Division 3 ofthe Business and Professions Code)or TEMB METER OR POLE INST COMMERCIAL'
a 0.e�[ that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDGIADDITION ❑DEMOLITION
^may Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
TSDnot more than five hundred do][.PS500). 001 IMPROVEMENT
❑Las owner of the progeny.or my employees with wogesaztheirsole compensation, SWIMMING POOL ELECTRIC
WF-m 'it]do the work.and the structure is na
ot intandloroRerea for sale(Se 7044,Business ❑OTHER
W and Prafesdons Cocle:'Me Contrncmr's License taw does not apply it,an owner of OUTLETS-SWITCHES-FIXTURES
proper who builds or improves thereon,end who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET
side.IL however the building or improvement is sold within one year ofeampletiot,the SQ.FT.FLOOR AREA LSQ.FT.
onsaverbudder will have the burden of proving that he did not build or improve for pur-
pose of smeJ.
❑ 1,as owner of the proper,am exclusively contracting with licensed contractors u, TOTAL:
instruct the project(Sec 70,14,Business and Professions Cade:)The Contractor's Lt.
c se taw does not apply st an owner of Ptolemy who builds it improves thereon,nut QTY. PLUMBING PERMIT FEE
who cc otraas for such projects with a commctor(s)licensed mosuanuo thinContractors
License Law. PERMIT ISSUANCE,
❑ Itiat exlntpl under Sec. ,B&P C for chi,mu,cnn
AIXER-BRAIN&VENT-WATER(EA)
Owner Date El s 0 VALUATION
WORWORKder p COM of Farb I on DECLARATION PACK FLOW PROTECT.DEVICE °'`^
1hereby
andwnll ai Iain a pen:dly n,perjuryaneofthe following Workers
Ia. ,and for toyinenior 37me of ConsenttoCode,
for Worker'sce.1 h- DRAINS-I1,00N,ROOFARLA,COND. STORES TYPE CONSTRUCTION
sntion,as prnvitled far toy Section 3]011 of the Labor Codc,for the performance of me
r which this lemur is i.csoad. FIXTURES-PER TRAP
or have and will maintain Worker's Compensation Insurance,az required by Section
3708 of the Labor Code.for the Performance of me work for which this pemdt is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
MY Worklr;5�syn on lnsf f anner and P Icy NtimbeJ.arg; t, 0/y GAS-EA.SYSTEM OVER 4 MA)
Cartier:S/�1� WORKERS'R 7 !> I 11:1
CERTIFICATE OF I3%EMF'N INN FROM WORKERS' GREASMNDUSTRL WASTE]NTERCE
COMPENSATION INSURANCE - B ILDING DIVISION FEES
(Thi,wenwn..renon In rampdeted if permit i,(mane hundreadouan(slBw )
or lees) GRFASE TRAP
PLANCHECK
Icenify that inthe perfomuneeof the...work fne,ifththis Permit cissued,IshnR SEWER-SANITARY-STORM FA.200Eric —
not employ any person in tiny manner so as m become wbjecuo the Workers'Compcm Y E
O z station laws of California,Dam WATER HEATER WNENDE-LECTR
z O Applicant V GRADIN
y NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTEMTTREATING J
F ; become subject to the Worker's Compemation provisions of the Labor Code,you must SOILS FEE
Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RI3SIDENTIAL PLMB. SQ.Ff. PAID
(� 0Iherchy of llmslhm there isucnnstmmion lending agency fonhe Performance of Date Receipt#
the work for which this Pcrtnh is issued(Sec.909],Civ.C.) 1 ^
O F'' lender's Name /2 1\ TOTAL:
Lmdad,Ad1m,, TOTAL: / / s
04 1 rectify that I hove food thio.,is colon mrd stat that mo..hove informaion is BUILDING PBR
p2 correct I agree in comply with all city and county ordinances and state laws reciting In QTY. MECHANICAL PERMIT FE�4
V Z bulldingcnnetructlan,and hefohyumborire representmivesofthis city bindrulam the •, S 5
abovo-memlomed pmpecty for inspection pmrpo,c,
(Wit agree to save,indemnify and keep hmmless Its,City of Cupertino against PHRMIT ISSUANCE ELECTRI
Iiahilities,juJgmems,costs and expenses which may many way accrveaguinst-sir City MITER OR ADD TO MECH. Y PLUMBING PEE
in consequence of the granting of this permit.
APPh . NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITTO 10,00CFM)SOUR E EGULAHONS.
MECHANICAL FEE
,(h J Q-/��� AIR HANDLING UNIT(OVER 10,000 CFcvH
I /�IB-OU CONSTRULTIO �
/Sign of ApPlicaUte EXHAUST HOOD(W/DUCT)
HAZARDOUS
)US MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or fwure building acupam store or handle hazardous material HEATING UNI'T(TO If ."HO-D)
as defined by the Cupertino Municipal Codc,Chnper 9.12,and the Health and Safety
Cade.Section 2553200? HEATING UNIT(OVER IM."BTU)
❑Yrs ED No VENTILATION FAN(SINGLE RESIDE PAID --
Will the all icam or future building occupant use equipment or devices which Date Receipt#
Tit haeardou.s air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP DHP OR 1(0,1100 BTU)
nnc l TOTAL
❑Yue ❑No BOILER-COMP(OVER 100,000BTU)
1 have read the bumnam,materials requirements under Chapter 6.95 of its,Cab AIR CONDITIONER ISSUANCE DATE
food a Ileah&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. 5 .FT.
buicding do Icno, (Iy haven mown,thus It is my aspomsibicitym notify the occuPunt Q
coommyuit n ..n wrla9sno � priarto issuance of a Ceni0com.10ce�upancy
Owner or a incl agent Date TOTAL: ISSUED BY:
OFFICE