S 0053 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL p�y.�g,^7
BUILDING PROJECT IDENTIFICATION
BUILDINOG7DRESS:7 %1''!/ / C /� SANITARY NO. APPLICATION
SCENE
rrAIL DATE
OW NAME: /� ) PHO CO ACTO �INAMM1 LIC NO.
1 � L l N/C CONTROLp
ARCHITECT/ENGINEER: l' L O: ADDRESS: ' ❑
5 0.JIco A —5. ► 9/
CONTACT: PHONE: BUILllING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE FLU MECH
LICENSED CONTRACTOR'S DECLARA'f10N QTY. ELECTRIC PERMiT FEE
I hereby.frm.at I am licensed under previsions of chapter 9(commencing JO DESCRIPTION
aQ00c4z with Section]0W)ofDivision 3.1 the Business and Professions Code,mdmy license is -- RESIDENTIAL:
Op in full f doff PERMIT ISSUANCE
W F �'3-0 t — ❑SCOWL ❑KITCHEN REMODEL
Q U U License as./' Lt..N
F+�WUatc i_/ Contracmr APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION LJ MULTI-UNIT [I STRUCTURAL
PANELS
4
Z FO m 7a. I understood my Plans shall be used m records cords MODIFICATION
OZ-Q UP102WAMPS L1 INTERIOR EI CHIMNEY REPAIR
[-r,�Ey"LL1 Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER itIamexempt
Ex DECLARATION ❑SWIMMDEMOLITION POOLS
1 hereby affirm Ihm 1 am exempt from the Contruaor's License Lew Por the OVER IfNIO AMPS [_1 BATH REMODEL/REPAIR �DEMOLITION
4 U following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
CF which rcgoires a permit m empower,alter,improve,damaksh,or report any awclure Nfiii
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant tote praskimnsof the Contractors License Low(Chapter 9
qq0 (commencing wiN--he.]WO)af Division Sof the Business and Professions Code)., TEMP.METER OR POLE INST. COMMERCIAL,
Il p�m y
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ' ❑NEW BLDG/ADDITION ❑DEMOLITION
W..m Section]03 L5 by any.,hear t far a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
11.... netome than five hundred dolista($5W).CZIMPROVEMENT O ❑1,as owner of the pmpenY,or my employees with wages as Ncirsole compensation, SWIMMING POOL ELECFRIC`
AA will do the work,and the sweture is not intended or offered Eased,(Sec.]044,Business OTHER
Wand Professions Cade:The Conmumn's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
., propcny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ ET.
sale.If.however,the building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
[]1,assowne TOTAL. w
I,as owner of the property,,I exclusively ad Poorest...with:)Ths C mammos i- tl
cmmrue the project(Sec.9046,Business end Professions Code)The Cmntrectors Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cmntmemgs)licensed pursuant to the Committees �$
Elapse I. PERMIT ISSUANCE. Ig/
❑I am exempt under Sec ,B&P C for this paten L
Owner Date ALTER-DRAIN&VENT-WATER(CA) / VALUATION
c'urEkrllyp
WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
41' 1 hereby elf rat under penalty to perjury one of.e following declarations:eCa
❑ Ihavc andwill for
ntn..37W of the Labosent inr
Codesalf-fortfor Worker's Captain-me DRAINS-FLOOR,ROOF AREA,CONK STORIES TYPE CONSTRUCTION
crimp,as provided for mi Section 3]00 of the Labor Crile,for the performance of the
w farwhichthis maintain
is issued. FIXTURES-PER TRAP
1 have and will mai.Win Workers ante ofine and,for which
h required by Section
i ]W of the Labor Code,for the performance of the work for which this permit Is issued. GAS-EA.SYSTEM-I INC.60UTLETS OCC GROUP APN
My Work Insurance cartierand y No:
Cartier: CC.�4�--YY Policy No.: ILF-J OAS-EA SYSTEM OVER 4(EA)
CERTIFICAT FEXEMPf10NFROMWO KERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE JIM ERCEPI'OR
(This section need not be completedif the permit is for one hundred dollars($100) BUILDING DIVISION FEES
or less.) _ GkEASE TRAP - PLANCHECK FEE
I oenify Nat mine parfmmancaofthe work for which this pcmhit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so re to become subject m the Workers'Compen- - ENERGY FEC
,Z scion Laws of California.Data O ) WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
h NOTICETOAPPLICANT:If,alle,n,Aing.is Cenifcateof Exemption,youshoulit WATER SYS'1'EMfpftLATIN
G
F become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEL
{a forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGCNCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
Ihereby whichalarm that there i ipaed(Seeti3097,Co,agency for the performance of Dute, cciptp
.wP the work fur which thispermit is issued(Seo.309],Civ-CJ
O U Lenders Name - I TOTAL,
W Lenders Address - TOTAL:
0. 1 certify that I have most this application and state that. nv
e ube information is BUILD&GFENJ
F-t h onimedl agree to comply with all dry and county ordinances and store laws relating to QTY. MECHANICALPERMIT -FEE m
C„) ,� building conswctian.and hereby autherixe represemutives of Nis cirymenmr upon the SEIS
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wml
e)agree to save,indemnify and keep haress the City of Cupertino against ELECTRIC FEE
habilides,judgments,costs and expenses which may in any way retain against said City ALT ER OR ADD'TO MECH. PLUMBING
in consequence of the granting of this permit.
If
APPLICANT������%%%%%%D NDS AQP WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
SOURC 10 S.NDS
/ / MECIIANIC FEE
/,1 ft—`c / -1 AIRHANDLINGl1N1'r(OVER PLBWCIM)
n� �CWp L-P ?Q�.�Y Jrr •• CI / CONSTRUC ION TAX
Signarureof Ap sanUContmctor Dam EXHAUST HOOD(W/DUCT) HOUSING 1'fIGAT10N PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle baardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)] HEATING UNIT(OVER 100,000 BTU)
❑Yes El PAID
VENTILATION FAN(SINGLE RESID) Date iplM
Will be applicant or future building occupant use equipment so devices which
emit haurdous air amWmarants as defined by the Bay Ares Air Quality Management BOILER-COMP p1iP OR IIXI,IMNI BTU) -
t DDistrict? Tct^ -
L3 Yes No
BOILER-COME(OVER 100,D)0 BTU)
❑
I have read the hasNeuv materials re inximalx under Chapter 6.95 of the Cali- AIR CONDITIONER
q ISSUANCE DATE
forma Heath&Safety Code,Sections 25505,25533 and 25534.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.EL
building dues nor wrremly have a mount.mar it is my responsibility m notify the oacepatn
of Me ep,no mems which must be met prior to isemee of n CenlfeaW ar Occupant,
Owner or authorized agent Data TOTAL: 'ISSUED BY:
OFFICE