S 1388 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY " a
CITY OFCUPERTINO BUILDING-ELECI'RICA I. — PE Tf NO, 1388
BUILUINO DI VISION APPLICA'I'ION/PERMIT PLUMBING-MECHANICAL
WILDING PR0jEC'I'IDILNTIFICA'L'ION
BUILIANOADDRESS: SANITARY NO. APPLICATION SUB91TTAL UA FE
OWNIiR'S NAMIi: I'1 B: CD TRACTORS NAME: LIC NO:
SIC CONI Rol,x
191 Q io
ANCIII'IiCT/EN(. E : LICNO: - ADDRESS: ❑
Gt
coN'l'nCT: 1I „ ,,.., m)NIi: , HLIILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(IniliaUB�L-D-rG// ELECT PLUMB MF.CH
C 4� ❑ ❑ ❑
LICENSED CON RAC O . UECLARA'1'EO QTY. ELECTRIC PERMIT FEE
1 hereby dfina that I am noosed ander fraviomas of chapter 9 0,otnmen,Ng JOB
WOO DESCRIPTION
O with Section of Division 3 of PERMIT ISSUANCE Business and Professions Code,and my license is r !�^ RFSIDEN I IAL:
t+lJ V
F-w in full tome and effect. CSFDWL CJ KITCHEN REMODEL.
,1UULicenm Class Lic.p
NAPPLIANCES-RESIDENTIAL CADDITION El PLUMPING RE-PHIE
Ztil Datc Cnnlmcnrt
6¢F
ARCfITPANELS []MULTI-UNITCSTRUCCIRALECPS DHCLARAT
MODIFICATION
ION
Z p m Z 1 understand my plans shall he usea as public reasNs
OZ=`O /0MA.J `41`
UPTO2(0AMPS INTERIOR CSWCHIMNEY
MING PCAIR
fQ-��W LicensN Prolessinnxl 'VV 200-(XXtAMPs IMPROVEMENT SWIMMING POOLS
pG s1 .,] OWNER-BUILDER DI3CLARA'fION OVER 11X10AMPS ❑BATH REMODEUREPAIR [IDEMOLI"P[ON
I hereby afi rrn that I sent escmpt Gnm the Contractor',License Law for the
d O i U following reamn.(Reelimm 7031.5,Business and professions Gde:Any city or county SIGNS ELECTRICAL C OTHER
LLLL y which requires a permit to consw4 Wler,improve,demolish,Or repair any stm ance
tF�- OQ prior to its issuance,also requires thoatpplicvnt fonuch pe.it n file a signedamtement SPECIAL CIRCUITIMISC.
G;!(y'"' dru he iv humieed fusion m the pruvisiomol'the Contmm
er'I license Lnw lChafrer9
04�2 (°omnsncing with sedion](XMgof Diviaiun3nflM1e Business and l'rufessinns Ctde)or TEMPMEI'IiRORM)LMNST. COMMERCIAL:
6 a y Nat he is exempt therefrom and the buil for the alleged exemption.Any violation of - NFRLDG/ADDITION C DEMOLITION
2 Satinn703L5 byanyapplicantheap,rin,objeemarn.,licant m aeisil penaltyof POWER DEVICES NANT El FWD SERVICE
ammorethan Eve hundred Jollas($5fp). IMPROVEMENT
� ❑ Idly owner of Nefmperty,nr my empinyenv with wages sex their axle comfenmtlon, SWIMMING POOL HI.LICTRIG
ei the wod,vnd lhCalNflOre isnot intendedoroftered forsule sat.7044,Basin
ess HD [D OTHER
LL1 m and Profusions Cede:The Contractor's ctor's License Law does napply to an owner of OU'I'LIYS-SWITCIICS-PI%TUN13
property who builds or improves thereon,and who does such work hlmmlf or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.IL however.the huilAing nrimfrovemem issaldwlthimormyetr ofeanmlmion,the SQ.PT.FLOOR AREA WSQ.FT.
owner-builder will have the hang of proving faults,did not build or improve for par
prom,of sale.).
C 1,u owner of the property,v exclusively contracting with licensnl mntmemrs to Al
' i
the project(Sec.7(1 ,Business and professions Cede:)The Cantmcmrs Li-
uc l.uw does nut apply to sea owncrol'properry who buildv ter improsevnmreon.and QTY PLUMBING PERMIT FEE
who contract for such projects with a commnaons)licensed pmsuam to the Contmetors
License Low. PERMIT ISSUANCE
1 am exempt order Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLAW PROPEL'.DEVICE? T 0 t� r\
1 hereby affirm under parehy of perjury oma of the following decluddinns: V V V
❑ I have and will maintain a Certificate ofConmat to elf-insure for Workers Coope.- DRAINS-FLOOR,ROOP,AREiA.COND. STORIES TYPE CONSTRUCTION
cation,us provided for by Section 3740 of the LaMn Code,fnr the pedmormacc of the
wutk I'ot which this perrnit ix i.sacd, FIXTURES-PERI RAP
C 1 have and will maintain Worker's Compensation Insurance,us required by Section
3700 afire LaborGde,far the perGmnence.f the walk for which this permit is foam. GAS-P.A.SYSTEM-I INC.i OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy nuVr
Cmricr:lU`P01 2l4 '"Lli Policy N.,:r" GAS-FIA.SYSTEMOVERY(F:A)
CHRI'IPICATE OVVXEMVI'ION FROM WORKERS' GREASIYINDUS'I'RL.WASTE IN'I'IiRCFPTOR
COMPENSATION INSURANCE BUILDING DIV[ PE16
(This sectionnced not hecampletW flow permit is harem,hundrd dollen.($1000 GREASHTRAP
or Ins.) I'LANCHECK PIAT O
I certify that in the perforntunce ofthe work for which this permit is issued l shall SEWLiR-SANITARY-S'fORMIiA.2WFT.
not urnpluy any person in any numncr so ism hanmc suhjecnnlhc Workers Cnntpen. ENERGY FEE 20
OZ moan Laws of Cali birds.Date WATER 1117ATER W/VENDELECI'R GRADING HE
Z Q Applicant
try NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/1'REATING
h" brown®cuhject m he Worker's Compe...than pmvixiou Of the Lulcor Coda,you must SOILS FEE
Wforthwith comply with such provision,or This pemril shall be deemed revoked. WA'I'EIt S17RVIC17
aQ
CONSTRUCTION const LENDINGngAGENCYagency
NEW RI?SIDENTIAI.1'LMB, SQ.I'll PAID
v7 z Thereby aftinn that there ixuconnroction lending ag<ncy for the perfnrntantt of Date acciplN
U the work for which thio Permit is Nuel(Seo.3097,Civ.C.)
Lender's Nerve 'TOTAL:
{U Lender's Addres. TOTAL:
I certify that I have read this apithemit n and state that the above information i. BUILDING FEE
rF. L40 Correct.E agree to comply with all city and county ordinances and state laws relating to QTY. ME.CHANICALPERMIT FHE
UZ building consimalcir and hereby authorize mpmsemativec of his city tocaler upon the SEISMIC FEE
above-amotioned prapery for inspection purpuvec. PERMITISSUANCE.
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FF.F� O
liabilities,judgments.costs and expenses which may in any way accrue agmml.said City ALTERORADUTOMECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS ANI WII OMPLY WI I ALL NON-POINT AIR HANDLING UNI1'('1010JXX)CFM)
EDE11 EGULA'I'Ir 5. MEiCIEANI AI �
AER HANDLING UNIT(OVER I0.000CFM) Qs
i CONSTRUCTION TA s�
Si um.fA,,liamVCmd.%r Dae EXHAUST HOOD(W/DUCO HOUSING I FEII
HAZARDOUS MXTERIAI S DISCLOSURE
Will the applicant or future building occttpant store mlmndlchavardous material HEM ING UNIT(9'0 (oO,WO BTU) vvN
e.definal by the Cupertino Municiip Cede,Chapter 9.12,rmJ Ne Health and Safety
Cede,Section 25532(x)? HRAI'INC.UNIT(OVER 110,001)11 Do .\� Qs
❑Yes VEN'I'I LATION PAN(SINGLE RUSLD) PAID G
Will the applicant or future heading
eadm =-opal use equlpagmt of dCVIWh which nota Rcucipt x
emit himucal alr-conmminants a;J by the Bay Area Air Quality Management R011.RR-COMP(311P OR 101000 RTIi) TOTAL.
UisWmP
Yea IV6BOILER-COMP(OVER 100,000 IffOf
❑
AIR CONDITIONER
I have read the haeardouv nmterml,requirements under Chapter 6.95 of the Celt. ISSUANCI3 DATE
Runs Health&Safely Cade.Suctions 25505,25533 and 8531.I undemand thin if Ne NEW RESIDENTIAL MECH. SQ.ET. � '
building does not court have a meant,that it is my respersihil' oe
ay to notify the eracia
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Ovencro,mahmizeJagent Dam TOTAL D ISSUEDBY: 0
OFFICE