00010027 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 10 0 o '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDupNICA1, SOM
BUILDING I•ROdECT IDI:NI'IFICATION 7�
BUILUINGADDRESS: // /� SANI'MRY NO. AI'I'I,ICAI'ION SUHMI'I'IAI.DA'1'f
7575' rt.LGtk /7/csscrr. a. �� D 0
TOWN' "NAME: PHONE: CONTRACTOR'S NA E: ,r LIC NO:
J If �� NIC ONTROLp
ON Hti
ARCHIT[LT/b GINIiIiR: LIC NO: /FYY? /C�`r�"/ /�/ ❑
G
CONTACT: PHONE: BUILDING FERMI'IINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EPLUMB MECH
7 Z/ oo 2--- LECT' ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing
OaZ with Section 7(XM])nfDlvision3ofthe❑usincxs and Pnd'casioas Coda and it,,license is RESIDENTIAL
WOO PERMIT ISSUANCIi
QUV intelfimc and effect --') f3y3 i APPLIANCES-RESIDENTIAL ❑AD TION ❑KHCHE,\'RERH•IEL
II'E
U Ltrense I4s3 hie,p /ter/-
FZ61 Date //O�Cnmrxmr tPGS
m66 ARCHITECTS DECLARAT[ON ❑h1ULThUNIT ❑STRUCTURAL.
z ota)z I understand my plans shall be used as public records UP 1t)201AMPS MODIFICATION
❑INTERIOR ❑CIIIMNF.Y RIiI4CIR
O
ul Licensed Professional 201d0CX)AMpS IMPROVEMENT' SWIMMING FOULS
�•d � OWNER-BUILDER DECLARATION OVER 100 AMPS ATH REMODEUREPAIR ❑DEMOLITION
YC.
Q I hcmby affirm that 1 am exempt Gum the Cnm,mmr's License Law for me OTHER
X O y U following reason.(Section 7031.5.Business and Professions Cafe:Any city or county SIGNS ELECTRICAL 110,S)
Ia1'31LI- which requircx o permit ur....drect.al v,improve,demolish,tit repair any swcode
artOQ priu t t cls q ' tl ppli if hp is II :6 J tutamen, 3 SPECIAL CIRCIII'TIMISC. - /y /q
that at is licensed pmeu (lo thporskionsordic C t or's Lioem,I (Chapmrl COMMERCIAL:
6100 (comm c g ith Secl 7") fDivisionJ fthH . es audP (.. .Code)nr TIiMI'.METER OR TOLE INSI'.
a 6 eC that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^N
Section 7031 S by any applicant for a permit subjects theappheam to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m more than five Imnmcd dollars($500) IMPROVEMENT
=Q C] I,as owner of the property,or my employees with wages as their vole cnmpnsation. SWIMMING POOL ELECTRIC
F. will dolhework.andlhe.stmcmre;stanl inandederollandforeale(See 7014,Business El OTHER
W.
an and Pmfe,,ions Code:*Me Contractors Licenu law docs not apply to an owner of OU-STETS—SWITCHES—FIXTURES
praWay who builds or improves theme n,and who docs such work himself or through
his own employees,provided that such improvements are not Intended ur offered lot R U I
late.111 hnwevee the building or imprevcmcnl is sold witmeo.e year of completion,far SQ.IT.FLOOR ANCA $ISOFI'.
.
nerhuilder will have the burden of proving that he did not build or improve for pur-
pose of tale.).
1,as owner of me property,am exclusively contracting with Ecensed mnuacmrs to
unslm0 he project(See.7014.Business and Professions Code)The Contract's Li-
se Law does not apply to an owner of property who builds or improves thcram,and QTY. B I
GW contacts for such projects with a contractor(s)licensed pursuant h,the Contractor's
cense law. PERWIMAW
O 1 am exempt under Seo. .B&P C for this mama
1 CTI ( ^ VALUATION
Owner Date S f�
WORK ER S
under
COMI'IfNSATION DfthefRATION .O P "I' ICI' / (`� (7 (/
I hereby affirm under penolty of perjury one of the following Worker ions
❑Ihavc and will I by eCeAOcae of the LAW,
sum for Workers Compere DRAINS-FLOOR.ROOEARPA,COND. STORIES TVI'Ii CONSI'R11C1"IOD
scion, r provides fpr to Ss issued,
d, of the Luba Csdc,for the perfn,munce of the
work lirt which this permit is ixwcJ. FIXTURES-PER TRAP
I have and will malmain Worker's Cpmpen,satlon Insurance,as tnlmed by Section
3700,411he i,facGde,fenthe plafenmreofthc work for L which his ppermit lsisaued. GAS-EA.SYSTEM-1 INC.4 OUI'l.E'IS ICC.GROUT' �y
My Cmcrr r.Co Miy,unn umnccc Policy Noam Y/r/7/U 6oi GAS-EA.SYSTFM-OVER4BiA) 39
.J �O
CGSITII PfION FROM WORKERS GRIiASiIINDUSTRh WASTE INTIikCEPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
fThisseclianneed mol lcmnmplcmd iflhepcnmhl,I'oronchundmddollatx($ID) GREASE14AP
PLANCI{LCK hili
or less.)
Ie,any mainds,in anymannrofaw otoork for becomewh;chmis flit WosLmCampehall. SOWER-SANITARY-STORM E\.2lq FT.
not mnploy any person in any manner n,as to become subject to me Worker'Compere ENERGY FEL
,Z ,ai„n laws of C11finnia.Dae WATER HEATER WNEM1TIELECTR GRADING FEE
Z O Appliam
NOTICE TO APPLICANT:If,after making this Cenifiane of Exemption,you should WATER SYSTEMaREATING SOILS FEE
> hcmrnc subject to the Workers Compensation previsions of die I.atur Code.you must
forthwith comply with such provisions or this permit shall be deemed mvuked. WATER SERVICE �\ ±-1
6"
0. Ca r,,
CONSTRUC PION LENDING AGENCY NEW RESIDENT[AL PLMB. SQ.IT. r?AID r/Wtc C kdc "p
i heretic affirm ihauhere is ucnnnmction lending agency for the performance of II {�
Fthe work far which this pe.,if is issuef(Sec.3197,Civ.C.) 0
t<alce,Name j I '
U 0<ndds Address T(yl'AL: t
GI certify that I have read this application and sam,hat me atone information is BUILDING FEE
rel correct.1 ugree in amply with all city it county ordinances and sate law,relining m QTY. MECHANICAL PERMIT FESEISMIC FE L
U building amametion.and hereby authpn,ercpresenlulives of this oily manlernpon nae
atone-melnioned pmpeny fur inspection p.p.x. PERMIT ISSUANCES ELLCI'kIGFEE-
(We)agree m save,indemnify and keep h ess me City of Cupertino against
liabilities,judgments,ensu and expenses which ay any way eceme against said City pla'ER OR AUD TO MECN. PLUMBING FEE
,txcgnencepfl antlmgaf 's pcnnn.
A I'PLICARED Hi :'1'AND I I C , PLY WITH ALL NON-1'OIN'I' AIR HANDLING UNIT(TO III,INNI CPM) MECO IANICAL FEE
SOURCIi REG LAT )NS
AIR HANDLING UNIT(OVER IOIXp CFM) CONSTRUCTION"I'A%
SignmurcofApplmn t�-'Imactol Date EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEF.
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huildingoccnpanm Npmor handle M1umNous mallial HE
UNI"T('I'IIIW,(HIO HI'll)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heallh and Safety HEATING UNIT(OVER IW.Up HTO)
Calc Sectism 25532a)?
❑Yes ❑No VENTILATION FAN(SINGLE HESID) PAID
Date Rccelpm p
Will mcsi,,omaricre,future a Midlined pccupuBy Are. pnmualitynt Management
BOILER-CO�I'(3HPOR 100.01013HU)
emir haeaMouz air annaninanu as JcGncJ by the Hay Area Air Quality Management Tlll
Dinri"I BOILER-COMP(OVER 000.00)BTU)
EJ Yet Fl No
I have rend the hamolons materials tequitcrcnt,under Chapter 6.95of the Cali- At It CONDI'1'IONER ISSUANCE DATE
fomiu Health&Safely Code.Sections 25505,8533 and 25534.1 understand that if the NEW RESIDENT SAL MECIL SQ.IT.
building does not currently have a meant,ma it is on,re vareib;liry h,utility the oeapant
of the"mad eau which run be met He,to smance of a Cedificam of Occupancy. T
0.ratio,num ild agent Dam T(TI'AhI ISSUED 11Y: `
OFFICE