B 0485 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIO ERMIT1949 d PLUMBING-MECHANICAL SOOO10485
BUILDING PROJECT IDFNI'IF'ICATI
BUILDINGADDREl$:� O Iff) 1 6^' a_: y� Lr / SANI'IARV NO. APPLICATION SUNMI'I'IAL DAT!
OWNER'S N PH E CONTRACTORSNAME: U LIC NO.
N/C CONIRO p
ARCHITE /P R: I LIU NO: ADDRESS: - �J
CONTACT. PHONE: • 6UILDING P81tMIL/T INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELL'E�CT�'PLUMB MECH
1 Ll— 2--
1 SED COWTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereh R,m that I in.licensed under provisions of Charter 9(commencio
JOB DESCRIPTION
��Z with Scriort 71XXHnf Di 3ofthc ilmomosa and P isk t pe dmylicenneg
F ;.i"
fullfomee Ren 1'ERMI'1'ISSUANCE RES] ENTIAL;'
Ru
LnseC s n Lia# Wh ❑KII'CfIEN RChiOUIiL
tF�a Date Cnntruclnr APPLIANCES-RESIDI?N'IAI. ADDITION ❑PLUMBINGRE-PIPIT
[[--Do - RCIIITECI'S D[CIA PANELS ❑MULTI-UNIT []STRUCTURALZp nz tun cmtand ty plans shall be useJ us public records
MODIFICATION
ONFp UP TO 200 AMPS El INTERIOR ❑CHIMNEYREPAIR
f<�...W Lcensed Pmfessonal 201-10X0AMPS IMPROVEMIisi 0SWIMMING POOLS
MOWU OWNER-BUILDER DECLARATION pVL•R IIIIX)AMI'S O BATA REMODEUREPAIR ❑DEMOLITION
y gyp)6 1 hereby affirm that I am exempt from the Contractor's License Law for the
x3aF following mason.(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
F^ which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such pemm to file a signed statement
w SI'[CIAI.CIRCUIT/MISC.
'hat he
y❑Oinlicensed nptovlsf Contractors Licenxhw(Chapter 9
Ilummenoin6 war,Simn700Uof Diviamn3oheBui0...and PrmlaainsCncmr
'I'I?MP.METER OR I'01.1?INST, '
a qce
C mat he is exempt thercfmm and the basis for the alleged exemption.Any violation of NEW SLADDITION ❑DEMOLITION
i4t1' 4y
Section 7031.5 by any applicant for a forms subjects the applicant to a civil penalty of POWER DEVICCS
.N. y not more than live hundred dollars($5W), TEN NT ❑FOOD SERVICE
�=G [1I.as owner of me property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 1 OVEMIiNT
F will do the work,and thenunmun is not intended or offenal for sale(See 7044,Business 1712HER
and Prnfesnimts Codo:'T'he Contractors License Lew mrcs not apply m an owner of OUTLET$-SWU CHES-FIXTURES
0. property who builds or improves Hereon,and who does such work himself nr IhrougM1
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the but ldingnr improvement Ls sold within ono year of,I ituctlon.the SQ.FT.FLOOR AREA $/SQ.FT.
owner builder will have the burden of proving that he did not build or improve for for,
Pon e of sowne act
��
❑I,as owner of the Sec.70Property.,B exclusively contracting with licensed contractors i- 'TOTAL%
onnmd the projul(Sec.]OW,Business anJ Nafessions Gsdc:)The Contractors Li-
to
c ,s law does not apply to on owner ofpmpeny who builds nr improves thereon,and QTY, pLU BING PERMIT FEE
who contracts for such Pmjcets withe amtraemgs)licensed pursuant to me Conoucmrs • -
LicenseLuw. PERMIT ISSUA C
3 41
C 1 um exempt under Sec. ,B&P C for this reason
ALTER-DRA -WAFER(EA)
Owner Doe VALUATION
WORKER'S COMP17NSATION DECLARATION RACK PLOW PRGTEC.-Ili 3 02-1 52 r1
1 hereby affirm under penalty orati
f perjury one of the following declaons: v a`J
b I have and will maintain a Certificate of Consent to self-insure for Workers Counties- DRAINS-FLOOR,ROUP.AREA"NU' =IECONSIRUCTION
cation,as pmvided for by Section 370X1 of Ne Labor Crain,for the performoncc of the Tom,
work for which this Permit is issued, FIXTURES-PER TRAP �-
El 1 have and will maintain Workers Compensation Insurance,is required by Section (,
J7W of the Labor Code,far Chop luminance of the work for whichthi psoitis issued. GAS-RA.SYS'CF.M-I INC.40UTL. �— ) GIA)UP APN
My Work 'mpcinempinsa nae a brand I' umb n _
Carticc GAS-SA.SYSTEM-OVER4(LA) a�/�
'RTIFI TE OP EXE PTIO Of RKHRS' yy
C STI AN OREASI%INDUSI'RL WASTE IN'1'ERC i"' RN
(This, is n do s medif epetmilis ,onehundmddoi . 100) L-/I BUILDING DIVISION FEES
nr lees.) CREASE'fRAPlu PLANCIII?CK till 3 Q
I certify that in the performance of the work for which this pemdt is issued,l shall
not employ any person in any manner no as to become subject to the Warkers'Compen- SEWER-SANITARY-S'IITRM I:A.21 N- _
O ,Z' sauna Laws of Calif ria.Date -- - '•'�
z Applicant I WATER HPATEI2 WIVEN /ELECI'R GRADING FEE
N NOTICE TO APPLTCANU,If,aper making Thin Cenificme of Exemption,you should WATER SYSTEMITREmING
a becoma subject to the Workers Gsmprowhon pmvisinne of the Labor Cala you Took] SOILS FRH
fLl Q fonhwith comply with such previous,or this .it shut]be deed moored. WATER SERVICE
� z CONST RUCTION LENDING AGENCY NEW RESIDEN'IIALPLMH. SQ.Fit PAID
L)2 Therebyoff nn that Non iso romwetinn lending agency for the performance ofDale Receipt#
dfs Hthe work for which this permit is issued(Sec.3197,Civ.C.)
Lender's None
[U Lenders Address TOTAL: 'TOTAL:
I� fy c 1 certify that 1 have read this application ad state that the above information is �.. BUILDING FEf, O
y omeL I agree to comply with all city and county ordinances and,rote haws relating to QTY MECHANICAL PERMIT FEE
V z
building communion,and hereby aohnriae represeatmivesof his city to enter upon the SEISMIC 70
ti above-mentioned property for inspection purpose,. '
PIiRMI'1'ISSUANCE
(We)agree In save,indemnify and keep harmless the City of Calcimine against 1?Lf:C' 'P• s�
liabilities,judgments,costs and expenses which mayin any wayaccmeri'mmtsoid City ALTER OR ADD TO MECH.
194
in nsetimuceo c gramingof this permit. PL IN FEE
APPLICAN RSTANDS AND WILL MPLY WI'1'11 ALL ON-1' NT AIR HANDLING UNITFFD 10,000CFM)
SOURCE fG . TIONS. I BMIiCH ]CAL ITE
AIR HANDLING UNIT(OVER 14W0CFM) CO 'TItI1CT10N'TAX
Signature fAp tracm, m EXHAUST'IIOOD(W/DUCT) H SING MITIGATION R?E
ARDO ALS DISCLOSURE
Will the applicant or fmurc building occupant entre or handle hammlous material I WATING UNIT(TO 100,050 BTU) /
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc.Section 25512(a)7 [II7ATING UNIT(OVER 100,000 RTU)
E3 yes PAID
VENTILATION PAN(SINGLE RISID) Date Receipt#
Will the uit On o or ens abuilding y the Bt use e.Air Qm o devices which
mit haasrdeus air cnntmrdnants es Defined by the Hay Area Air Quality Management BOILER-COMP(3HP OR 110,gX1 BTU)
Aft, Will
✓ ❑Yes BOILER-COMP(OVER I00.000 BTU)
1 e read the Nazar o!I us materials requirements tinder Chapter 6.95 of me Cali- AIR CONDITIONER ISSU CE ATE
mull.flea &Safely Cnda,gonia $,505,25599 and 25534.I un rsmnd m Iftns NEW RESIDENTIAL MECH. SQ.Pf.
builJin nm currentlyhaveat an that it is my responsibility to rinyth ceup I SIA.
m the qu ems which n dor to issue ceofaCeni-
Own am ate TOTAL: ISSUED BY:
OFFICE