B 0282 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 PERMIT NOy{��O ^ �x
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOO1 J,rj• L l?J( L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: `" SANITARY NO. APPLICATION SUBMITTAL DATE
qso
OW ER'S NA`G (HC NE:aS7-$7,7' CONTRACTOR'S NAM is LIC NO: " NIC CONTROL#
ARCHITECT/ENGINEIBIC LIC NO: ADDRESS: L ❑
00 4n,4209 SA
CONTACT: i lk�Onry� PHONE:q&7 BUILDING PERMIT INFO
�oo �" Nrj 1 oIf ❑ Consultant Fecs Paid by Applicant(Initial) BI ELECT PLUMB MECH
O tAIjeSIr
El El El
LICENSED CONTRACTOR'S DECI.ARA ON QTy ELECTRIC PERMIT FE
I hereby affirm that l am licensed under provolons of Chapter 9(commencing JOB DESCRIPTION
O ,with Section 700 )of Division 3ofthe Business and Professions Code,and my license is RESIDENTIAL:
a Ey_ n full force and eRc PERMIT ISSUANCE
aU�'j License Clms (. 'f� Lic.# ❑SFDWI. ❑KITCHEN REMODF.I.
�
G6 Date Conroe APPLIANCES-RRSIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ppNEIS
Fly ❑AtULT1UNIT ❑STRUCTURAL
Z O!�K lundersmnd my plans shall be used as public records MODIFICATION
OZ::11 UP T0200 AMPS
FWN Lmensed 14nfeemmal ❑INTERIOR OVE CHIMNEYRPOOL
,� 201-Iq0 AMPS IMPROVEMENT SWIMMING POOLS
Y M, OWNER I ma BUILDER m the Car ION
yxIY�Q I hereby affirm that 1 am exempt from the Cnnmcmrs License Low for the OVER I(0(IAMPS ❑BATH REMOD�I/REPAIR D DEMOLITION
W O y U following reason.(Section 71131.5,Business and professions Code:Any city or county ❑OTHERwe.Ik.
3 LLr SIGNS HLECTRICAL
W ca wren requires a perms n eamatmeL rotes,improve.aemahan,at repair any amewre C eegi t r �f—�11 ff 0
vsm.] prior to its issuance,also requires The applicant for such permit to file o signed statement SPECIAL CIRCUIT/MISC.
yWWy thatbaislicensedp...can to the provisions of the Contractor's License Law(Chapter 9
CLQ (commencing with Section 7")of Division 3e fine Business and Professions Care)in 'TEMP.METER OR HINST. COMMERCIAL:
6 6 m q that he is exempt therefrom end tM1e heels for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by anyepplicam for a permit.mhjectsme applicant to u cieil,mcli,of POWER DEVIC
Z y not more Nan five hundred dod.($500). - ❑TENANT 11 FOOD SERVICE
�'-Q ❑I,as owner ofthe property,or my employ as win wages as their sole campensmion. SWIMMIN )L ELECTRIC IMPROVEMENT
will do Nc work,and the nrvcture is not intended oro0ered for sale Nec.7044,Business ❑OTHER
and Professions Cgle:The Cutars,Ks License Law does not apply a an owner of OUTLF' '-SW1TCHpS-PIXTUItIi
�' .. property who build or improves Neremm,and who does such work himself or through
his own employee.,provided that such improvements art but intended or offered for NE RESIDENTIAL ELECTR SQ FT.
,ale,If,luom ce The buildingor improvement ie soldwilluroin,cm.fcompictitim the SQ.FT.FLOOR AREA $/SQ.FT.
casner-builder will have the burden of proving that he did not build or improve for pur-
poseofsle.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7144,Business and Professions Code:)The Convector's Li-
marm Law does not apply to an owner of property who builds or improves thereon.and QTY. PI.UMBING PERMIT FEE
who contracts for such projects with a commands)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
❑I um exempt under Sec. ,D&P C for this reason
ALTER-DRAIN&VENT-WATER IEA)
Owner pate VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PPo)TECT.DEVICE t� 535. as
I hereby of inn under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Content toself-insure for Worker's Compete DRAINS-FLOOR,ROOF",AREA,GOND. STORIES 'TYPE CONSTRUCTION
sitio.,a,provided for by Section 3710 of the Labor Cade,for the performance of the .
work(or which this permit is issued. FIXTURES-PER TRAP
10 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the perlormance of the work lin which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUT LET OCCGROUP MEN
My Work
e o pensatioJ1,Insum�ma^g�e carie and Policy pp rc:
Cartier. • 'IY��Policy No.: GAS HA.SYSTEM-OVER4(EA)
CF.RTIFICA'rEOF EXEMPTION FROM WORKERS'? qp'
COMPENSATION INSURANCE GREASFYINDUS'TRL WASTE 'I?RCEPTOR
i
(This section need not hecompined Base penrdt is for one hundrMdollars(slap BU1 ING DIVISION FEES
in lens) GREASETRAP
PLANCI K
Loy any
rutin The permymaance rs.Nethecoofor wlyc this permit icirs'CNripen-I shall SEWER-SANITARY STORM HA.200 m'.
not employ any person in any manner so as to hecome subjcn m the WorEen%ComKn- 1ER FEE x�J
smion laws of California.Date
O Applicant t WATER HEATER /VENT/ELELTR ADING jFs v
y NMICI7 TO APPLICANT:If.after making this Cenifeme of Exemption,you should WATER SYS ?REATING
abecome subject m the Warkces Compensation provisions of the labor Cade,you nun SOILS .E
lTa forthwith comply with such provisions or this permit shall he deemed revoked. WATER RVICE l
0. Q
CONSTRUCTIONisacraLENDINGAGENCY N RP.SIDENTIAL PCMB. SQ.FT. PAID s
V l for
reby which thi that issued(Sec,i3097,Cm agency for the pednnnance of Uma Receipt#
V. F the work(or which this permit is issued(Sec.P097,Civ.CJ
O V Lenders Name TOTAL:
Lkl Lemberg Address - TOTAL:
Cls I certify that I have read this application and state that the noose information is BUILDING FEE7 7-
N cmrect.l agree to comply with all city and county ordinances and slide law.relactiga QTY. MECHANICAL PERMIT FEE
U z building convection,and hereby authodm representatives of this city to enter upon the SEISMIC EEE
shave-mentioned property for inspection purposes.
(We)agree to sam.indemnify and keep harmless the Cater Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilitin.judgmenms,cons and expenses which may in any way aceme against said City
in consequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS ANI)WILL COMPLY WIT 11 ALL NON-POIN'1" AIR HANDLING UNIT(TO IB,M)CFM) MECHANICAL FEL'
SOURCE REGUTATIONS.
AIR HANDLING UNIT(OVER 10,000 C 1 CONSTRUCTION TAX
Signature of ApplicentlCommcar Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE:
Will rheapplirmtnrfar..building occap.same nr handle M1azardnus material HEATING UNIT ITO 100,0KU)
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Heahh and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 1,(0OBTU)
❑Yes rNo PAID
VENTILATION FA SINGLE RESID) Doc Receipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous it contaminations as defined by the Bay Area Air Quality Management BOILER-CO (3HP OR 100,000 BTU)
District? TOTAL:
❑Yes J09 No BOILGI2- M P(OVER 100,000 IS OUT
I have read the nmardous mmnials requirements under Chapter 6.95 of the Cali- AIR 50ADMONER ISSUANCE DATE
Emma a Health&Safety Credo,Sections 25505,25533 and 25534.1 undersand that it the RESIDENTIAL MECH. SQ.FT. (7
building does no,currently hevitmnam,that it is my responsibility mngtHime occupant
of the tequjE las which must be act prior us issuance of a Certificattee IOccupa��
�/�Qlll;� t/ gory// ?? n^
Ownermauthorud t Date TOTAL: ISSUED BY: M1 L•
OFFICE