B 0486 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO
BUILDING DIVISION APPJACATION/PE IT PLUMBING-MECHANICAL 11 /�qqk' Q{/��s
BUILDING PROJECT IDENTIFICATION' SOOOI LL V V
BUH.DINGADDRES.: , SANITARY NO. APPLICATION SUBMITTAL DATE
� fl � 2
OWNER'S NA PHONE: CONTRACTORS NAME LIC NO:
ie U SIC CONTROLp
ARCHITE EER: LIC NO: ADDRESS: ❑ ' �/�
CONTACT: PHONE.
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
0z- -�!T
LICENSED Co RAC'MR:S DECLARATION QTY � ELECTRIC PERMIT, - FEE
1 hereby aRnn that Ina license)under provisiims of Chapter 9(commencing - l JOB DESCRIPTION
with with Secton V(m0).f Dtv ---
'onJaftheBusinesxandPm ssinns RESIDENTIAL,
Wr in fun farce mW effect. PERMIT ISSUANCE IJ_S
a V U License Lica ❑SFOWL ]KITCHEN REMODEL
HVW Date Contmctor APPLIANCES-RESIDENT AL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECIA PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z on G 1 understand my plans.hail be used as public mrords UP TO 200 AMPS
MODIFICATION
E'W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
,14 „p 201-1000AMPS IMPROVEMENT
�..I OWNIiR-BUILDER DECLARATION [I SWIMMING POOLS
IY 6 1 hereby affirm that I um exempt from the Contractor',License Law for the OVER IM)AMPS ❑BATH REMODF.IJREPAIR ❑DEMOLITION
3 a following teas....(Section RI
3L5.Business and Professions Core:Any city or county SIGNS ELECTRICAL ❑OfHER
y C which requires a permit to common,.],a,,improve,demolish,or rapid(any sbuaum
hj. pd.,to its issuance,chatelaine,theopplicint,dr.ach pminam file,ta,mod thatcher, SPECIAL Cl RCUITIMISC/
iM� that be is licensed pursuant to the provisions.(the Contractor's License Law(Chapter9
wp0 (commencing with Section]O(10)o(Diviaian3of]he Business and Pndeksi.nsCode)or TEMP.METER F.INST. COMMERCIAL
Lyme' that he is exempt therefrom and the banal,for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ElD17MOLITION
Scrunn703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of MOWER DUVWES
FZ} act more than Eve hundred dollars($500/. El TENANT E:1 FOOD SERVICE:
SG [ I,as owner of the phwrtg or my employees with wages as their sole compensation, SWIMMI P .ELECTRIC IMPROVEMENT
allF� will do the work,and the swcmre is net intended.rmorcd for she(Sec.]044,Business []OTHER
`m and Professions Code:The Contractors Licertae Law thcs not apply to an owner of OUTLETS-.WI 'XTURC.S
y�' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered far NEW RESIDENTIAL Ill.ED'1 S L
sole.IL however,the building.,improvement is sold withirime yemofcomplead,the SQ.Fp.FLUOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve fon put-
❑I,as owner of the See,Property.ora sines and contracting Cwh licensed contractors m IOTA 2-'0I
construct Ne project(Sea.]M4.Business and Professions Code:)T--11 vector's Li- t -�
ase law does not apply to an owner of property who builds or improves thereon,and QTY: t], PLUMBING PERMIT " l PEE
who contracts for such Projects with a commands)licensed punt an to the Convectors 41 a.,O
License Law. PERMIT ISSUANCE
I]I am exempt under Sec. ,R&P C for this reason (O/'
ALTER-DRAIN&VENT-WATER(EA)
Owner, pure VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROT'EC'T'.DEVICE n Pl
I hereby
ancon under Por of peduryone.f,ha fallowing declarations:
❑ Ih:rve and will mainminn Ceninaam.l Consemmself-in,mre far Workers Compen- pkAINS-pLOOROSYSTEMORPATINO
ROOF AREA,COND. SI'(ORIE5 TYI'Ii CONti TROCI'IDN
cation,as provided for by Section 3](MI of the Labor Cade,for the performance cf the
work fur which this permit is issued. -PER TRAP
I] 1 have and will maintain Worker's Courtrai Insurance,a required by Section
3700 the Lu ,Code,for the fon9Uace nfthc work fur whit pecan isismod, SYSTEM-I INC.40UTLEI'S OCC.CROUP qi'N
My Worker's^ (�Cgsa' nhas �[r�me ap Jlphp m -s
Carrier: / IX $•(JIBR111FfM1� SYSTEM-OVER4(EA) '
CERI'1FICATL OP EXUMPI'IOLFROM WORKERS' '
COMPENSATION INSURANCE NDUSTitL WASTE INTIiRCGPTOR BUILDING DIVISION I'Uf5
(This •c t e' I• f�ttgB: 1 ddI I
orlesaJ `tI✓"(j/rwW 7 ) RAP PL .CK-�EE2�/t /
leartifytha]inthe pedorm..a', the walk
forwhich IN massae .Ia al ,
not ennploy any person in any manner so oxmbecnme xuhjccno the Wnrkers'Compen- ANITARY-STORM EA.2001T. Y -72
O Z each Laws o1 Califomia.Data BEATER W/VENT/1?LECTR '
O Applicant I
2,0
Z . G MING LLE
NOTICE TO APPLICANT:If,otter making this Certificate of Exemption,you should S'TEM/fRPATINO
a ' hennnc subject In the Worker's Compensation Previsions of the Lubar Code,you must SLS ELE
Lkl forthwith comply with such provisions or this pcnnit shall he dttmed rev.ked. WATER SERVICE
P Q -
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.1.7. PAID
U O Thereby aRi,m thauhere is acomwdiun lending agency funhe performance of Date Receipts
GL g the work for which this permit is issued(See,3097,Civ.C)
O
U Lender's Name NOTAL:
Lender's Address - T(UA f
1 certify,]but I have rood th'o application and stem that the above infornetion is BUILDING PEIi a
corer.l agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FE,U� builJing construction.and hereby auNodze represematives of Nis ciryto steer upon the SEISMIC PE
17
mdwe-mentioned Empathy for inspection purposes. es PERMIT ISSUANCE
(We)ug.m sive,indemnify and keep h uncle.]he City of Cupertino against ' ECT
Iiabilities,judgmems,costs and expenses which may in any way acerve against said City gLTHR OR ADD TO MEC
in nxoluence of the granting of this permit. MHI z
APPLICAM UNDERSTANDS AND .1.COMPLY WITH AL NO -POINT AIR HANDLING UNIT(T( CF
SOU IDEATIONS. ` ryCII CAI.FEE
/�/"J') AIR HANDLING UNIT(O H,I.. P ) S'I'R CT'ION TAX
(�
Sngwwm of AppBcanUConveco _r tea¢ EXHAUST HOOD(W/DU IN ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building°ceupantsma orhandle hazardous material HEATINGUNIT(T0100,IXTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)? HEATING 11NIT(OVP,R I[M Ting Lp
❑Yes VNu
VENTILATION FAN(SINGLE RESID) PAID
AW Will then licca or future buildin Date Recci d N
pp gby(beBuse c.Air Quality
BOILER-COME OR 100,000 BTU
qwl emit hazardous air cnnteminants as defined by the Bay Arca Air Quality Managemem )
District? �Q(^� TOl'A
g ✓�yps \o BOILER-COME(OVER I(MI,fXMl I3TU)
to 7C
/ AIR CONDI HONER
Ihave Safieh Node,Se materials,equirementa under Chipmr 695 of]he Cali- ISSUANCE DATE
fu,11 nth&tm7 Code,Section 255U5,355)3 and 255)41 understand thot II'the NEW RP,SIGUNTIAI.MECII. SQ.IT. / 4
build' d snot currtntly haute rot,tductris aina,a onnibility°tau the arupom (/
of a �rc wh' t pdar to ixs an a of u
v e am n TOTAL' �®
ISSUED BY:
OFFICE