S 0501 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - - -
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0501
4
BUILDING PROJECT IDEN9'IF'IL'ATION 1
BUILDING ADDRESS: SANITARY NO, AI'Pj(CATION SUBMITTAL DATE
r1Gµ�/ /2,4 tn► 3o kN f�D f PtD '?S-& /Sl ��f'C •�
OWNER'S NAME: r_x111IONE: CONTTRACfOR'S NAME: L LIC NO:
N IVIIC 44-7173- 11217 Iia$ R LC-& N/C CON'fROI.p
ARCHITECJILNGINEER: LIC NO: IADDRESS ID
- CONTACT': N H PHONE: BUILDING PHRMI'E INFO -
❑'Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSIiDCONn'RTOR under
SOisions ATION
fChap QTY ELECTRIC PERMIT FEh
1hereby 0)of matIam licensed ines provisions of Chapter9(my(commencing JOB ESCRIPTION
MDQ Ivbh Section 70c1pa..iviaioa3onnc Business and rrares.nm.coda and my uerns`i. RESIDENTIAL
I.lull force and elTeet. PIiRMIT ISSUANCIi
❑SFDWI, El KITCHEN REMODEL.
<F.UU License Cines Lic.#
NQy Date Cdrunim APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPH
ARCHITECTS DECLARATION
ZFOyZ luoulandand my plaesshill be used republic rePANELSScords ❑MUFTI-UNI"r ❑STRUCTURAL
MOD((CATION
O Z UI'T0 2W ANIPS
(•,yy
101 Licensed['ratessiaaol ❑INTER[OR ❑CHIMNEY REPAIR
.•.J1 OWNFR-BUILDHR DECLARATION 201-IIXXIAMPS IMI'NOVIiMIiNT E]SWIMMING POOLS
C W 6 1 hereby Af ion that l um exempt foam the Comruanrs License Law for the OVER IB(XIAMPS ❑BATH REMO 'PAIREMOLi'I'ION
?65,06 U fallowing reason,(Section 70)15 " CT
.Basinand Profession,Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
a which reyulres a permit re ennswn,nlme improve,demolish nr repair any sm re
o n
rn���777 prion .isnuance.uisoreyuirca Ne applicant for such pennitmfleasigned.uatemamem SPECIAL CIRCUIT/MISC.
K Qf that he is licencen
d pursuant the provisions ofthe Contractor's License Law(Chapter 9
W CO (cammenciagwith Section 7000)afDivivon3 ofthe Business and Prnfe,ions Cars), TEMP.ME I Hk OR POLL INS'I'. COMMERCIAL
0.d cy that he in exempt therefrom and the basis for the alleged exemption.Any violation nl'
X oe l+. Section TO 1,1 by any applicant for a permit sub' t thea cant u civil ❑NNW BLDGIAIIUITION ❑DEMOLI'T'ION
IY�m tax's PP!can penally of POWER DEVICES
I.yy, t morethan five hundred dollars(S500d. ❑TCNANT ❑FOOD SERVICE
C G ❑I,alowne,oftbm propeny.army enspinymswithwugnv ue Pheirsnlcmmpcnxwion. SWIMMING POOLIELECTRIC IMPROVEMI?N'I'
412 p. will do the work,and the structure air.,intendedor offered ha sale(See.7044,Business ❑OTT{LER
L3 eo and Professions Code:The Contractors License law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
prolixity who builds or improves thereon,and who does such work himself or through
his own employees,provided!that such improvente is are not intended or offered far NEW RESIDENTIAL.ILECTR SQ FI'.
sale.If.however,the building or impmventeat is sold within oneyemnfcompletian,the SQfRI'.lilk(X1 DVA ASQ.FI'.
posneehuilder will have the harden of proving that be did net build or improve for put- rr PP11 11 YY
e of sale).-
❑h anowner of the propeny,am exclusively cammcting with licenxd comrannrs c TOTAL: AUG
construct ec
the project(S .70411.Business and Professions Code:)The Contractors Li. - OC(1t�
Ise Law does not apply to an awnerof propeny who holds or improves thereon,and QTY PLUMBING PERMIT FEE CITY
who mntraets forsuch projects with a mmaractor(s)licar smi pursuant to the Conmstors C1T
Licence Law. PERMIT ISSUANCE: Ur CUPEHI INU
O I nm exempt under Sec. ,It&I'C for this mason
O ALI HR—DRAIN&VENT—WAI'HR(HA)
1 VALIDATION
WORKER'S COMIE146ATiO LARATION HACK FLOW PROTIiCf.DEVICE
I hereby affirm under pmaity of perjury one of the following Aeelamtions:
❑Iheve and will maintain aCenificme of Consent to selGinsurefar Worker's Compete- DRAWS—FLOOR.ROOF,AREA,COND'
scion,as provided for by Section 37M of the Labor Cale,far the pentane ace of the S'rORIILS TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES—PER TRAP '
❑I have and will maintain Worker'a Compensation Insurance,as reuded by Section
37(M ofthe Labor Code,for performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC CROUP MIN
Worker's Compensation Insurance carrier and Policy number are:
Carrier Policy N., GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE! GREASE/INDUS TRL WASTE INTERCEPTOR
(Thik.0ion need not lmemalleted Has,permit is bn nne hundred dollars(SIM) BUILDING DIVISION FEES
or cas.) GREASE TRAP NLANCI BECK PEI!
I certify that in the perfnrmenttofthe work for which this permit is issued.Ishan SEWER—SANITARY—STORM EA.200 17.
not employ any person in any manner so i s to become simeat In the Workers'Cnmpen-
ENERGY FEE
moan Laws of Culilitmia.Dam
OO Applicant ' WA'I ER HHAL'I!R W/VIiNTIHLIiCTR
OTICZ t, GRADING PEI!
.�. Ncome sbj APP LICANT,TL Compensation
thisvisio cam of Exemption,youshould WATER Sys'TGM?RHATING
a
become subject y the Workers Coons or
is xama but of the Labor Code,you must SOILS MEL
� limhwith comply with such provisions or CM1Is permit shell he Deemed revoked WATER SL'NVICP.
4
CONSTRUCTION LENDING AG17NCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
U O I brevity anirm that hem is a construction lending agency for the performance of Dane Receipt#
LL E-t the work lin which this permit is issued(Sec.30rD.Civ.C.)
lenders Name
O U Lender's Address ,TOTAL: TOTAL:
y1 Omily Phut I have rend till application and state thin the above inhmnmium is BUILDING FEE
IA correct.l agree to comply with all city and county ordinances and state laws relining to QTYMECHANICAL PERMIT FEE Z building construction,and hereby Authorize reprcsenmtives of Phis city center upon the . SEISMIC FEE
above-meedondl property for impectio i,amlmos,
(Wr)agree to save,indemnify and keep harmless the City.1 Cupenim against PHItMIT ISSUANCE ELECTRIC FEE
liabilities,judgment.cosismnd expenses which may in any way acerae against said City ACIEB OR ADD TO MECH.
in coneeyuence of the granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PUINT AIR HANDLING UNI'T(T,III,IXXI CPM(
SOURCE REGULATIONS, MECHANICAL.FEE
�/q L w"y AIR HANDLING ON]'I'(OVER lo."CPM)
f ( CONSTRUCf10NTAX
Signature of ApplicanVConaunor JE Dam EXHAUST HOOD(W/DUC'q HOUSING MITIGATION FEE
HAZ RDOUS MATERIALS DISCLOSURE
Will theapplicanhandle t or future building occu{amtmore or acrallousnouriml HEATING UNIT(TO 100,0)11(ITU)
nv defined by the Cupenivo Municipal Cuda,Chapter 9.12,Bad Che Ilealth and Safety
Ctdc,Section 25532(u)P HEATING UNIT(OVER]BLAME BTU)
[I yes No
VENTILATION FAN(SINGLE BESIDE PAID
Will the applicant or fmurcbuilding occupant use equipment or devices which Data Receipt#
emit lemurdaus air contaminants as defindl by the Bay Area Air Quality Management BOILER—COMP(CHI'OR 100,00d BTU)
District? TOTAL:
E]Yes [DNo BOILER—COMP(OVHR 100,000 BTU)
I have read the bmmMus mncon,ropircment under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fhmia Health&Safety Code,Sections 255(1.5,25533 and 25m
5)4.1 undemnd that if the NEW RESIDENTIAL.MECH. SQ.FI'.
building docs not currently have a tenant.that it is my responsibility to notify the occupant
mf doe mildraments which must be met priors isms nee of a Certificate of Occupancy.
Owner nr umh hived agent Data TOTAL: ISSUED BY:
OFFICE