S 0475 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA], PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL, n O
IIUILDINC PROJECI'IDEMJ
'IFlcxr[ON
475
BUILIIINGADDRESS: /1 SANITARY NO. AI'PLICA'I'IION1SUBMII"PgL LOAD
OWNERS PHONE: CO Al/CI/J�:S AME: ' LIC NO ` r
N/C CONTROL#
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v.�ARCHITECI'/F.NGINEER: LIC NO, AI M$: ❑
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CONTACE PHONI?: BUILDING PERMIT INFO
�— ❑ Consultant Fees Paid h A limnot Initial
Y PP ) III DO IiLF.CT PLUMB MI?CII
Ur (I�_I(� ❑ ❑ ❑
LICENSED CONTRACTOR, )ECLARATION QTY. ELECTRIC PERMIT ' PPI'
I hereby of irm 0.11 am licensed aad.T pnwkimm of chapter 9 tkommemdag JOB DESCRIPTION
CX00 with Section](N10)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
U.. in full Tora and cITcct. PERMIT ISSUANCE
Fa.UZ�j
Lice
nu Class Lica ❑SFDWL ❑KII CHEN RI;MODEI.
NEL Date — — Commcmr APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE:
ZOO
ARCHITECTS DECLARATION PANELg ❑MULThUNIT ❑STRIIC'TU RAL'
OZ I mak rshand my pl...hall that uswl as public records
:JUPTO200AMPS MODIFICATION
1-4�m Licenced Pndeseinsul El INTERIOR ❑CHIMNEY REPAIR
�Yf[4j OWNER-BUILDER DECLARATION gal-IUIN)AMPS IMPROVEMENT []SWIMMING POOLS
WQ 1 hereby affirm that 1 am exempt from the Conarium',License law for the OVER 1000AMPS ❑BATH RI'
a� 6 U following reason.(Section]OJT S,Business and PndexIms,Code:Any city or county ❑OTHER
j 3 H SIGNS ELECTRICAL , A
Which requires a permit u)construct,aper,improve,demolish,or repair any structure
pdheislinsmneensiorsrptires do.moioofne Conanpermit ice aeignulsmtcs'cm SPECIAL CIRCUIT/MISC.
CWQf Ihm bels licensed pulxuanuo tuc pnrvisinns of the Cnmmnnls License Law lChaprer9 1
aI�GO (cnmmencingwitu Section]OfXBnTUivisinnlof the Business and l4ofensinn Cale).. TEMP.METER OR POLE INST COMMERCIAL
LM o C thin he Is exempt therd'mm and the basis fm the alleged exemption.Any violodnn of - ❑NI?W BLDG/AUDITION ❑DEMOLITION
i,CMI)N. Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICIS
E.
} not come than five hundreddnllam($5W). ❑TENANT ❑FOODSERVICE
�,=Q ❑ I,as owner of the pmpeny,car my employees with wages ns their sole cotnpensminn. SWIMMING POOL ELECHIIC IMPROVEMENT
'
will do the work,and the swctue,is no,inabdisim ulfered liar sale(Sec.](H4,Business ❑O'T'HER
W a and Pmfesaion Cole:The Curer 'e hlccnse Law down not apply o un owner n[ OUTLETS—SWI'I'CHFS—FI X'TIIRES
G
property whit builds m improves thereon,and Who Joss.such Work himself or through
his own employees.provided that.such improvements arc not intended or offered for REST ENTIAL FLEC1R SQ h
sale.If,however,the building or improvement is cold within tine yearufcona Immo the SQ.FI'.FIIIORAREA $/SQ.FT.
ancerec Wilde,will have'he buNen of proving thin he did not build ur improve far pur-
pa a of sine).
❑1,as owner of the pmperty,am exclusively contracting with licensed asntmsrom to TOTAL: PAID
antrum the Novel(See.71141,1.Business and Professions Cade:)The Cmdru,..9 Li-
cense Law does not apply,an owner of property who builds or improves thereon cal QTY, PLL ING PERMIT FEC C��
who contracts for such projects with a commaor(n)licensed Part m oro Counci s S y�
License Law, 1117RMIT ISSUA B s( ^�
❑ lam exclnputndar see ,If&P C coli Itis n7aan {!
Owner Dec N:IER—DRAIN&VIiNT—WA9ER IEA7 (JL.�yq�ynTl(IN
t1. WORKER'S COMPENSATION IIECLA RATION BACK[TOW PIIOTF,C'P.DEVICE ff7l 1'1IVVU
I hereby affirm under penalty of perjury one of the following dcelarations:
❑I have and will nmintain a Certificate of Consennoself-in.sure(m Worker's Compen- DRAINS—FlAOR,ROOF,ARBA,COND. S'I'ORIliS 'fYPIiCONS'I'RIIC'1'ION
satins,as provide)I'or by Section 7]1X1 oI'the L.Na Coforde, the pmfomwnce of the
Work for which this permit is issued. FIXTURES—PER TRAP
❑ I have trod will maintain Worker's Compcns,iol in...mees as requital by Section
3)0)ofthe Labor Code.for tl,perfomance ofthe work forwhich thicpemtit is issued. GAS—EA.SYSTEM-1 nce INC.4 OUTLET'S OCC D
My Worker's Compensation Insuracarrier and Policy number art: AI'N
Carrier: Policy No.: GAS—EA.SYS'I'IiM-OV 17R 4(IIA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASITNDUSTRL WASTE INTERCEPTOR
ffla,wcsiannerA not hecum IelrAifthe Lisliaone hundred Jnlluml$IIXp < BI DING DIVISION F'N
p pent; GREASHTRAP
or less.) PLAN' FF.
Loy an,o,-at to perfom.acc.us to , at
this the on WisissoCcmIpn- SEWER—SANU'ARY—S'r ORM EA.200 IT
out employ any pcnnn in any manner so as car bxnn,subject m the Warkeri Compen- F,NT iii
0Z .,full Lawsof Califania.Dam WATER HEATER WNEM/ELECTR
Applicant C !li
rNi NM ICF TO APPLICANT:If,after necking Ihis Cenidcam of Exemption,you.haul) WA'1'Ek SYSTEM?kEAI'ING
f'a > become subject to the Workers Compensation provisions of the labor Code,you must SO S
LaTIQ fonhwitheontply with such provisinosorlhispennit shall Wdecnted revoked. WATER SERVICE
4
Uz CONSTRUCT[ON LENDING
a,flurAGENCY NEW RIiSIUENTIAL.1'hMR. SQ.FT. PAID
Up I here by affnmthe,
Krafts inncamswn 3097,Cu,agency(nnhc perinrmance of Uum Rctniptp
Fthe dark for Which Itis pemsit is issue)(Sec.J09],Civ.C.)
Under,Nstnc
0V Leadm's Address TOTAL:
I certify that 1 have mad this application and stunt that the shave inrorm,ion is B LUING IEE �a
14 correct.I ague to comply with all city and county mdinxncm and num lawsmismtgtu Q-Ty MECHANICALPERMIT FEli
U Z building emoccorm.,and hereby amhorire represemmilelafthiscity to enter upon the S Is IC PER
above-mentioned property,for inspection purposes.
(We)agree lost indemnify and off, farm City at Cupertino egainsl PERMIT ISSUANCE .ECI'RIC FI?E
liabilities,judgmems.costs an nsesw ' nervy way accrue against said City ALTER OR ADD TO MECH.
imine fmcgr ago a. P UMBINGFCE
APPI ANTU IlE S N WILI OMPLY IT ALL NON-POINT AIR HANDLING UNIT IO,g10 CFM)
SO ERG TIONS. _ �� ME ANICALFEE
AIIt HANDLINGUNI"I'(OVF,lt IO,WOCFM) CONST CION TAX
Applica. Contractor Date EXHAUST HOOD(W/DUCf)
HAZARDOUS MATERIALS DISCLOSURE HOUSING IGATION FEE
Will the applicant or future building occupant store orhandle haurJom material HEATING UNIT(TO 110,000 H'1'U)
as defined by the Cupenino Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 25532(1 HEATING UNIT OWER IINk0(o BIG)
❑Yen
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt A
emit hazardous mrconmminems as defined by the fifty Arca Air Quality Management BOILER—CGMPQHPOR IBO,(NN)BTU)
-Dlslrid9 'IOTAL:
E-1 Y,., t—aRt,. 1301LEk—COMI'(OVL'It IIX1.INX)BTU)
I have mad life Imperial,mumind,oquircoenls under Chapter 695o the Cull- AIR CONDITIONER ISSUANCE DATE
(cola Health&Safety Cale,mations 25505,25533 end 25534.I oalemaad Wal tithe NEW RF.SIOENTIAI.MIiCH. SQ.Irl'.
building Joos not cunenlly huvcaonant,ohm it is my rcs 'bility m antify tie oxcurymt
of the requiomeos which mus ,Ip' Cenifie eaf Cqc. ancy.
Owner or amhnrizml age Dam TOTAL:
ISSUED BY.
OFFICE
I