S 0652 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAS. I'1'�`k4ll'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL CJ 0652
BUILDING PROJECT IDENTIFICATION❑UILDING ADDRESS: SANITARY NO. JAPPLICATIONSUBMITTALDATI
te , � 2Z
O N•R'S N B: THONG: C '1' R'S NAM S LIC NO,
.f�yx�C1 -Lkov N/C CONTNOI.a
�AECHITECT/P.NGINERR: LIC NO: �1 W AD RESS: L ❑
CONTACT. �(��1/� ��( PPHOON1E_: �p R BUILDING PERMIT INFO
NN l ' "'w' lvV4-4010 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT0 ED
PLUMP M[eH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby affirm that I am licensed finer provisbm of chapter 9(commencing JOB DESCRIPTION
QaZ with Scene.7000)of Division 30fthe Businessand Pndessinm Code,undmy licensees - •
+I 1 O O PERMIT ISSUANCE
WF in full force and eRgt. � ��p� � SFDWL LJ KITCHEN RT:MODF.I.
JWP:
Lmensc Cl se ,�•'j Oso _ Lia« -__--_-( V
U �Y"T� A1'I'LIANCES-NESIDGNTIAL ADURION ❑PLUMB ING RG-PIPE?
HGdDate 7o Cnnmsinr t
Z:)on ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z O ❑ 1 understand my plans shall be used us public rerords MODIFICATION
OX UlIT02MAMPS El INTERIOR EI CHIMNEY REPAIR
[:•� Licensed Professional 201.1010AMPS IMPROVEMENT SWIMMING POOLS
...]]] min I at escri from
DECLARATION OVER Bad AMPS ❑BATH RCM 's R 101.1T�
Rg U I hereby offe n that 1 1. exempt from the Contractor's 1.icenx city
o for the
OyUF which iec'masost"mil1.ra 7031.5.Business Itesx and et,.deiorts Code:Any city orcounty SIGNS ELECTRICAL 11 OTHER
u�3 LL N which its iss x a permit re conmme6 applicant
improves demolish,or repair ed swcturt
that hor nsliesedPrmreto requires Nenppoeamfse Contractsuch ors
icesrite a)Law
SPECIAL CIRCUIT/MISC.
!!f}•.1 icor be islicensedWiit pSectiot 70th)of Divisionf she cBusinss and
Prxelsio lChapmrY
W..CSO
(commencing with Section 700d)of Oivision7of she Business anti ProfessionsCade)atimi or TEMP.MFI'f:R OR POLE(NST COMMERCIAL:
ayx e m that he is exempt therefrom tad the basis for the alleged nemption Any violation of C)NEW BLDG/ADDITION ❑DEMOLITION (
W� Section 7011.5 byany apblood far. endit subjects thenpplicant toes civil pe unity of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m 001 marc Nun fee hundred dollars($500).
IMPROVEMENT
�Q ❑1,of
work.the propeuct or myempinyres with wagesas rN(See.csnnpcusinen, SWIMMING 11001.ELECT RIC
WHO will do she work,and the he Cont is tot intended License
Law
doesed
sale apply o an ownc,of OTHER
W � and Prolbssions Cole:The Commnor's License law Joes not apply m nn owner of OUTh61'S-SWITCHES-FIKTURES
s
hio ny who build.or improves thereon,end who docs mch wnrk himself or thmngh
his own however,
th provided that such intpmvemenw fire not intended m pleered foe NEW RESIDENTIAL ELfCEN
sale.if,huwercgthe building orimpmvcmcm is sold within one year of completion,the 'SQ.FT.1l(XIR ARCA S/SQ.II'.
owner-builder will have the burden of proving that he did not build or improve for par-
""iffsaleJ. TOTALA D
B
❑I,as owner of the property,am exclusively couraming with licensed contructerx In : 6'/
consumer the project(Sec.7044,Business and Professions Codep rbc Contractor's Li-
retail Law doa not npplymnaiwserofpmryenywho Imildsornuisances lhereun.and QTY. PLUMBING PERMIT FEE APR 27
who contracts for such projec s with a e0mnmm
mrbo licensed pursuant the Contractor's Q�Ij4g�.
License Law. PERMIT ISSUANCE ^/` R!'lV�(
❑ I am exempt under Sec. ,B&P C for reason CITY
Owner Date ALTF.N-DRAIN&VIiNT-WAT ER(RAI ATlpry
WORKER'S COMPENSATION DECLARATION BACK FLOW PROIECT.DEVICE VV
I hereby affirm under penalty of perjury one of the follow ing declamdons:
El I have anti will maintain a Certificate efComanto self-insure for Werkees Coni DRAINS-FLOOR,ROOF.ARIA.GOND. STORIES 'TYPE CONS'T'RUCTION
salon,as provided for by Section 9700 of the Latif Code,for she performance of the
1.fyyyyyyrrrttr which This pennil is issue). FIKI'URES-PER TRAP
e and will maintain Worker's Compensation Insurance,as requited by Section
,7110 oflhe Labor Cole,for the performance of the work for which this pennil is issued. GAS-EA.SYSTHM-I INCA OUTLETS OCC.GROUP APN
M,Wia sC n envtio ovum 'e camc� d PuNfy
u1m qty
`iT3�SLIO� GAS-EA.SYSTEM-OVER 4(EA)
CfRTIIICATF.( EXEMPTION PROM WONKF.RS'
COMPENSATION INSURANCE GREASDINDUSTRL WASTES INTERCHVMR
BUILDING DIVISION FE1S
(This sec tion need.hecompletcd the pemtit is hoore hundred dollars($100) GREASETRAP
or less.) I'LANCHECK 14iG
I certify that in the performance oftho work forwhich this pcmtil is issued,l shall SEWER-SANITARY-STORM ISA.20017..
not employ any person in any manner nu as to become subject m the Workers Coati ENERGY FEES
Z ,Z nation Laws of Culifnmia.lime WATER HEATER W/VENDELIiC'I'R
Q Applicant • GRADING FEE.
rt wN-t NOTICES TO APPLICANT:IL after making this Cerifeme of Exemption.you should WATER SYSTEM?REATING
a ' become subject in the Workers Compensation provisions of the Labor Code,you muss SOILS FEE
BJ fnnhwith comply with xreh pmvisium fir this permit slwll bedeemedrevaked. WATER SERVICE
O Q
UZ CONTIONLGNDING AGENCY i
NPW RISIDENTIALPLMB. SQ. LAID
V rrte that isoconstruction lendiagency for the performance of [late Receipt
the work for which this permit is issue)(See.)197,Cis.C.)r «
U Lendcr' Name
TOI'A1.:
O W LenJer' x TO MI.
I c renify :
G certify Ihnt 1 M1nve reed this application and xmm ohm rhe above information is BUILDING FFSF.
h cnrrea.l agree to comply wird all city and coumy ordinances and mntc laws minringm QTY, MECHANICAL PERMIT FEF.
V Z building conswf Nix ction.and hereby euthoriw reprewriatives ocity to enter upon the SEISMIC FEE
above-mentiened property for inspection purposes. 11I:RMHISSUANCIi
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECI'N1C IZIi
had lines,judgment,costs and expenses which may in any way aceto)agninsr said City ACIERORADDTOMF.CH.
in consequence of the granting of this permit. PLUMBING FTSE
APPLICANT UNDERST NDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNITCIO 10.000 C1'M)
MECHANICAL.PIiE
SOURC REG It ON .
AIR HANDLING UNIT()VER 10,000CFM) CONSTRUCTION TAX
Sign a Appli actor / Dmc EXHAUST HOOD Will HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE:
if the applicant or future building occupant.vore or handle bfummusmaed.[ HEATING ON]r(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Calc,Section 25532AP HEATING UNIT(OVER 100,000 BTU)
F1 Yes E3 No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt«
Will Ne appliram er future building occupant use equipment or devices which
I
M1vzrdous air canlaminanl as defined by the Bay Amu Air Quality Management BOILER-COMP(JHP OR IOq(MNI BTII)
TOI'AI.:
"District'! BOILER-COMP(OVER Iflo,"BTIH
❑Yes No
I have read the hmardous materials requirements under Chapter 695 of the Cali AIR CONDIT TONER ISSUANCE DATE
burns Health&Safety Code,Sections 25505,25533 and 25534.1 ttndentwd that it the N17W RESIDENTIAL MECH. SQ.IT.
building does not cultural have a)nam,ohm it is my respnnsihil Ity m notify the nccupem
of the
n fits riorcminsn:mce of Cn lf�yS(lc
Owner rn c agem • Dm) TOTAL: ISSUED BY:
OFFICE