S 0094 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ,� n
BUILDING DIVISION APPLICATION/PERMI•P PI,UMBING-MECHANICAI.
BUILDING PROJF.C'FIDENT'IF'ICA TION
BUILDING ADDRESS: - SANITARY O, PPLICA1 ION S UBMI'II'A.DAR.
. FK'. N MP. IPHONIt ON'I' "
D NAME: LIC No. , c
_ NIC CON'IRO[ a
4.0 I'IECT/L INEF.R: /V LIC NO: ADDRI?SS: ❑
1
CONTACT. PHONE:
HUILIJING PERMIT INFO
❑ Canadian[Fecs Paid by APFlicunl(Initial) BDG ELECTPLUM MECII
❑ ❑ ❑
LICENSE])CONTRACTOR'S DECLARATION Q'rY. ELECTRIC PERMIT FEE
I hereby affirm Thal I am licensed under provisions of chapter v(eammencmg JOR DESCRIPTION
,a0 z0 wiTM1 Sccaitn]0Xi)ofDivision3ofThe Business and Pmlwtainnn Crile,nnJ myliccnseir PERM]FISSUANCE RESIDENTIAL
a]F n full force and effect. ❑SFDWL O KITCHEN REMODEL
wu( License Class Lic.# AI•PL[ANCI?S-RIiSIDIiN'1'IAI, ❑ADDITION F1 PLUMBING RH PIPE
h Q L Dme Contractor
ARCHITECTS DECLARATION ❑MUI.T[.UNIT ❑S"IRUCIURAI.
F ti Z 1 mmmoi n l my plans shall he used as public records PANT.IS MODIFICATION
Up 1)2X0 AMPS 0INTERIOR [I CHIMNEY REPAIR
{�.hFW Licensed Professional 201d000AMPS IAf1'HOVEMENT E]SWIMMING POOLS
OWNER-RUILDER DECLARATION - OVER I(XXIANIPS ❑BATH REMODELIRITAIR El DEMOLITION
C C 6 I hereby affirm that 1 am exempt from the Conlmchi License Law for the
X 3 a U following rcomn.(Section 7031.5.Rosiness and professions CoJc Any oily or mmntY SIGNS 131.ECTRICA. DTI{I?R
W LL in which requires a permit to nmstruct.alter,improve,demolish.er tapir any structure
prior o itsissuance.also requires the applicant for such fiction to tilt a signed statement SPECIAL CIRCUI FMISC.
y Ihm he is licensed pursuant In he provisions of the Contmemel License Law(Chirac,9 /
�y—'p0
(commencing with Section 7000)of Division J of the Business and Professions Code)or TEMP METER OR POLE INST. •R I I
W a c C that he is exempt therefrom and the basis for the alleged exempann.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
>�mLL Section 7031.5 by any applicant for a pecoul subjects the applicant to a civil Penalty of POWER DEVICLS I'IiNAM' ❑FOOD 51?RVICh:
�..y not more than five hundred dollars($50E.
F-=QLas owner ofthc rt,orm employees with woes as their sole compensation, SWIMMINGPOOLELECTRIC Thi PNOVIiMENT
EFO ❑ prose y Yemp Y 6 .ansa 01-HER
will Jn the work.and the stmtture n not intended or offered for sale(Sec.](I1J,Bucinecs
eu—so and Num,,na,Code:The Cenosemex License Law does urn apply or an owner of OUTLET S-SWITCHES-FIYI URF- T
a 3- property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements ore not intended ar oWrrod for NEW RESIDENTIAL ELECTR• SQ I.-L
sale.If,however.the building or impmvemem is sold within one year ofcmnplction.am SQ.FT.FLOOR AREA $/SQ.IT.
cramer-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). TOTAI.:
p 1,as owner of the property,am exclusively contracting with licensed contractors to
omuuct Ne Fri]Sec.70,14,Business and Professions Cadc:)Ihe Contractors Li- D
se Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY PI.UMHING PERMIT FEE p p 1
whocomrxts foraucb pmjacts with acharectot(.d liamr hiparsuanttothe Committers
License Law. PERMIT ISSUANCE s JUNa
❑Inherent er Sec. .H&PCfor is reason -
---'. Own,-" --- �� D A ALTER-DRAIN&VENT'-WATER(EA) VALUATION
O
RKER:S COAL ATION DECLARATION BACK PLOW PROTECT.DEVICE JlY Ur uurcH I INO
t have
mal tiro under penah f pepury one of the follitheinsure for�dlvice,o ha
6 have mldwill maby,Srmor3MofCeLabor self-insure for Workers Changed- DRAIN$-PLOON.ROOP.AREA.COND. Sppgpg "TYPIi CONSTRUCTION
soden,as pmvidhi for mi Scction 1]W of the Mbar Cale.for the pedummnce of the
work for which this permit is issued. FlXTUHF'_ti-PER TRAP
0.1 have and will maintain Workers Came of the
nrk for which his
Section GAS-EA.SYSTEM.I INC.J OUT.1700 of INC Liber Code.for performance of the work for which this permit is intoe), 0 OCC.GROUI' AI'N
My Worker s Compenmtion Insumnce currier and Policy number ore:
Cartier: Policy No.: GAS-HA.SYSTEM-OVER J IIs)
CERTIFlCATE OF E- EMPCION FROM WORKERS' GREASIYINDUSTRLW'ASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING])]VISION FREES
(Thissectian nCode,.be completW if the pcmdt is fares,hundmddollars 1$100) GREASETRAI'
or lead I'IANCIIIiCK FEE
Irenifylhatin the peHartnuncmfthe work for whicM1 this pnrtniT is issued,[shall SEWER-SANITARY-STORM EA.210 IT.
sol employ any person in any manner so as to become subject o the Workers Campen- ENERGY ME
O ,'Z cation Law. C •Ii V e WATER HEATER WrvIiNT/HLECTR GRADING PIiIS
z Arplmcen .
(� NOTICE T APE VT:H,af. eking T provisions
fof ExemalCod you should WATER SYSTIiM/fRIiATING SOILS PF.L
P
? become subject to it ,kers Cnn s or this arra tient of the Lahr evoke,you mull
TomThwithcomply wishwchpmvinonsorthispermilshallbedeemed revnkeJ. WATER SERVICE
0AID
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Cr.PDate Receipt a
V C) Ihereby affirm that is a constmctian Lending agency far the performance of
the work for which this r,man is issued(Sce.31191,Co.C.) 'TOTAL:
Q Leader'<Name (TDM
r Lender's Address BUILDING FIT
F y I certify that I have read this application and slam that the above Information is
In correct.l agree locomply with all city and county ordinances and state lawvclating m QTY. MECHANICAL PERMIT PEG IT
J buildingCultivation,and hereby thofivere ntravex of this city m enter upmthe SEISMICFIiIi
pews,
abovementionedto shot forinspectionkeep thationcis
PERM TC ISSUANCE ELECTRIC FEE
(W,)agree m save,indemnify and keep harmless the City of Cupertino against
I ishilitics.judgments,costs and expenses which may in any way accrue against said City NET ADD TO M ECTL PLUMBING FEF.
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POI N AIR HANDLING UNIT LTO 10.00ICFM) MECHANICAL FILE
SO' *. P�-T
ONS,
� AIN HANDLING IINI"f(OVIiH IILIXNI CPM) CONS"I RUCTION'TAX
UConwmrLl, m EXHAUST DOUG(W/DUCT) HOUSING MI'DOATION FEE
AZARD(G�IiiS MA'T'ERIALS DISCI.OSUN
Will the applicant or future building occupant store(it handle h'vitdnut oncrial HEATING UNIT CTU 11X1.000131 U)
as JeOneJ by the Cupertino M do,Chapter 9.12,and Ili,Health and Snl"tty [ICA]INC.L1N["C(OVER IOF000[I I Or
Code.Scttian 255"(a)7
�Yos VENTILATION BAN(SINGLE RHSID) PAID D., RIM"#
Wilt The applicant or future building occupant use equipnmm or devices which BOILER-COMP(31111 OR 100,000 ETU)
•":1(a,IN 'is air contaminants as it a ed by the Buy Area Air Quality Manage Cut 'IOTA
[Yin eta BOILER-COMPIOVER IS),00IBTU) i
❑yes 161,11
- Ihava rclW The humrJuns m:neriaB mgnirementt under Chnpwr 0.95 of the Culi- AIR CONDI'1'lONiili ISSUANCE IJA'CL'
fomin Ilcallh&$ei'tty CNe,Sermons 2550.5,25539 unJ 25514.I undcrsamW Ihm If the NEW RESIDEN'T'IAL MECII. SQ.Fir
to mdaemon cahm,lyho,eamam,than it kcal mtpuosilahlylonotifylh,tuanpmn _
11 rryunc h I chair faecal prion re ofu Cmmtll ro t Oela vl
aul t'md agenT we 7 IOTA].: ISStartarLED BY: 4' - •" / "'
OFFICE