S 1165 (2) APPL16ANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUAERTINO' - BUILDING-ELECTRICALL. $`�PF$MIT N°.,11.6 5
BUILDING DIVISION -APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
BUILDING ADDS D',' SANITARY NO. 'APPLICATION SUBMITTAL DATE
Al- c'�T tZG�M LGV
OWNS ME: ON ��/_ O ACfOR'S NAME: ICNO:-F{
�J�{J WIiS {YiLG G Tr NlC CONTR/OLN
ARC ITE ' GINEE LI N 'ADDRESS: Go/� /r 6D ���+
corvTA E: - < BUILDING PERMIT INFO '
bElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
fm
LICEN.'D CONTRACTOR'S DECL RATION QTY - ELECTRIC PERMIT FEE
I bunchy affirm that I.m licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
Daz with Section 7000) Maisano 3 of the Busl.essand Professions Cale,and my license is U
F. in I PERMIT ISSUANCE F. in
full a ClassdeRec[. "DWI, El KITCHEN REMOUEI.
�UU License Class Contract.,
- APPLIANCES,-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
H z W Uate Contractor
> lunderswod my plans shall be used es public recnNa
ARCHITECTS DECLARATION - t ❑MULTI-UNIT El STRUCTURAL
z O D p m PANELS MODIFICATION
v�
Oz:JO UPT02W AMPS ❑INTERIOR.A • ❑CHIMNEYREPOL
I Licensed professional 201-1000AMPS IMPROVEME ❑SWIMMING POOLS
ey' OWNER-BUILDER DECLARATION OVER 1000 AMPS 2EMODELTEPAIR ODEMOLITION
"o w 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the - ((�
aO0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
which requires a permit m cmnatrucr alter,improve,demolish,mf repair any structure
p^(:O prior to its issuance,also requiresthe applicant fnr such permit to file esigned statement SPECIAL CIRCUIOXE C. z+�• V�•
pppp 9y. that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
CO (commencing with Section]000)Of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. - COMME l�(Iyr�)
dy o that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITPON ❑DEMOLITION
iCm
Section 7031.5 by any applicant for aponnit'adject,the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
I,as owner of the rt,orm employees with woes as theirsole compensation, SWIMMING POOL ELECTRIC
wil_❑ ❑ these y Y P Y 6 tensa
.F. and dothe won,ands: he Coreractur License
Law neoffemdws
for of apply .an Rosiness THER
a and Professions Code:The Conatser'.,License Law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES
pfopeny who builds or improves thereon,and who does such work himself of through
his own employees,provided that such imp rovemenu ere not intended or offereddfor for NEW RESIDENTIAL ELECTS SQ FT.
V L
sale.If,however.the building or improvement is sold within one year ofconpletion.the ^ SQ.FT.FLOOR AREA $/SQ.FT
f owner-builder will hnve the burden of pmving that he did not Iwild or improve fnr par- .L
Fuse of sale.). 2
❑has owner of the property,am exclusively commuting with licensed contractors to /
ccri the Project(Sec.1044,Business and Professions Code:)The Contractors Li: -
iae Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
. who contracts for such projects withaconvacmr(s)licensed puommut.the Cmarecmr's
License Law. - PERMITISSUANCE
❑lam exempt under Sec. ,B&PCforthisreason
ALTER-DRAIN&VENT-WATER(EA) %UATION�
Owner ^ Data O
V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /UATI
'
I hereby aff rat under penalty of perjury one of Ne following declarations.
• -
IhaveandwillmaintainaCeniticateofConsenuoself-insum for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
.,alio.,as provided for by Section 37M of the Labor Code,home perfm im.of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as requited by Section
37M of the Labor Cade,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC-GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: -
Carrier: - Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPTOR BUIlwVIVISIONVESS, _
(This section need not be completed ifthe permit is for one hundred dollars(SURE GREASETRAP
PLANCHECK FEEorless.)
I certify that inthe performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT
not employ any Person In any manner so as s b me the Workers'Compen- ENERGY PEE �y
cation Law.,of Calif ate WATER HEATER WNENTMLECR
O Appl' GRADING FF;F,
Vj NOTI L NT:1 after eking thl Cerificam of Ece ion,you should WATER SYSTENUTREATING SOILS FEE
aheroine,object to the is Co provisions of the Lahnr Cade,you all
LiI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY '" NEW RESIDENTIAL PCMB. SQ.FT. PAID
'Z I hereby affirm that there is a comsuuction lending agency for the performance of Data ReceiptN
U'� the work for which this permit is issued(Sec.3097,Civ.C.) AL:
C) •, Leaders Name
lWl Le ce BUILDING FEE Address
y eft fy that I h d th:appl tartisan.famine base inferandom is
IUL
rA correct 1 agreeto comply with ail city and county eminences and state to Q'E
laws Misting MECHANICAL PERMIT FEE -
I - U Z building ciandinection,and hereby authorize representatives offlins cityt nter upon the 0= SEISMIC FEEQ
almn-nnatimed property for inspeion purposes. PERMIT ISSUANCE O
(We)agree to ave,indemnify and keep hufmles,the City of Cupertino against
IMITIG
liabilities,judgmen",costs and expenses which may in any way accrue against said City' ALTER OR ADD TO MUCH, Is
O 1...
in consmuence of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) .
SOURCE REGULATIONS.
9� AIR HANDLING UNIT(OVER 10,010CFM) AX ,
IgnalmeofA icant/Co etor Date EXHAUST HOOD(W/DUC19 TION FEE'AR ATERIAL DISCLOSURE ,Willtheappliconto t ure budingOo t store or handle hazdNons material HEATING UNIT(TO 100,0011 BTU)
as defined by the CuFenin0 hapter 9.12,end the Health-and Safety
Code,Section 25532(e)p HEATING UNIT(OVER 100,00 BTU)
❑Yee ❑No VENTILATION FAN(SINGLE REBID) Dore Be, ptk
- Will the applicant or future building occupant use equipment or devices which BOILER-COMP CHP OR 100.(100 BTU) -
emii hazardous air cois nmmi... as defined by the Bay Area Air Quality Management TOTAL:
District^ BOILER-COME(OVER 1110,000 BTU)
El Yet, ONO
IhavereaddeebarmhousmatedalsfequirmmouImar Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
burns Health&Safety Cede,Sections 25505,25533 end 25534.1 malersmnd that if the NEW RESIDENTIAL MECH. SQ.Fn
building does not currently have a tenant,that it is my responsibility to notify me occupant
of the requirements which must be at Fn.,to issuance of a Certificate of Occupancy.
Owner or authonzed agent- - Data I I$$DEU BY.
OFFICE