B 0206 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING.ELECTRICAL FERMI NO.
BUILDING DIVISION APPLICATION/PF.RMIT rLunmwc MECHANICAL 1 .0020- 6-
BUILDING PROJECT IDENTIFICATION V..J
BUILDING DRHSS: , SANITARY NO. APPLICATION SUI3MIPIA
L])Art
L VO c .Qin 0 4— D ZO
ONffIR S NAME: 1 PHONE: CO C O 'S N LIC NO:
W �1/ �� NIC CO. ROLtt
ARCHITECT/ENGINF,ER: LIC NO: A UItF55:2 a�O P� p�s��hl�� F ❑ /
CONTACT: BONE: C BUILDING PERMIT INFO
H4S �� �� fid' v Z b� ❑ Consultant Fces Pail by Applicant(Iniliap nhnG ELECT PhuM�H MP�CH
( JM
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT I$E
1 hereby afro that I mm licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
WOO with Section 7000)ef Division 3 ofthe Businessand Professinns Code.and my license is RESIDENTIAL:
FW- in full in.and effect. PERMIT ISSUANCE
UPIPE
kFk� se Class L la p ❑SFDWL KITCHEN REMODELF.ZLicenAPPLIANC13S-RESIDE
u) Date Connector-
ARCHITECTS
nntr cur NTIAL N❑ADDITIOEl PLUMBING RI's
fah ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑ST'RUCTURAI,
Z O�j I undersand my plans shall he used as public records MODIFICATION
OZ—Q UP T0201AMPS El INTERIOR ❑CHIMNEY RF.FAIA
F� Licensed Professional 201-10(X)AMPS IMPROVEM17NT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IWOAMPS ED BATH RHMODEIJREPAIR ❑DEMOLITION
Q 1 hereby affirm that I lift exempt from the Contract..'.License].me for the
�4�( 6 U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
YI 3 4 N which requires a Permit n)consumct,alter.improve,demolish.or repair any structure
F OQ prior to its issuance,also requires the applicant far such parrot to file a signed spoliator SPECIAL CIRCUIT/MISC.
C 2 that he is licensed paramount(be provisiwn of the Gommann',License Law(Chapter 9
W CO (comnamdng with Section 7000)of Division 3 ofthe planar,and Prafeadons CWe)o 'TEMP.MIT I ER OR POLE I his I'. COMMERCIAL;
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Senion903 IS byany applicant fora pernit subjects the applicantma ciENANT El 1700D SERVICE
not
pmed,of POWER DFVICFS
not more than five hundred dollars(S500). fyq-/�'F
C�Q ❑ Lusnwnerof the prrpcng or my employees with wages as their sole compensation, SWIMMING POOL LLECI'RIC / IMPROVEMENT
will do da work,and the Xlrmcture is cont lmemdel orniTcred t'orsale(Sec.7(94.Business [101 HER
L m and Parelveions Code:The Comoreaus License Law does nor apply m an owner of OUTLL'1'S-SW ITCBES-FIXT'URF_S O
property Jr.wbuilds or improves thereon,and who docs such wart himself or through
his own employees,provided than such improvementsarc not intended or offered for NEW IMSHA NTIAL.ELIiCfR SQ FT
sale.It,bnwevice the building reimpravmcem is sold within nneyearafmmplerion,the SQ.FT.FLOOR AREA $/SQ.Pn
wneohullder will have the hurden of proving that he did not hmild cr improve formal.
pose cf,aa.)' 'I'OI'
1,as owner of the pmpeny,am exclusively contracting with licensed em
nmciors ill1 ) t-�!�
construct the project(Sec.]044.Bovines.and Professions CWe:)The Ca no tar's Li- - - t (�J V
ceirs,Law does no apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT I7EE
who contracts for such projects with a connaeor(s)licensed pursuant to the Caron 'a �J
License law. PFRMITI.SUANCL
I am exempt under Soo. ,B&P C fer this reason f
Owner Dam ALTER-RRA7&VENT-WATER(RA) VALUNI ION
WORKER'S COMPENSATION DECLARATION BACK 1 A ROTECI'.DEVICE
l hereby affirm under Penalty of perjury one of the following della.-.!ons: ` V
E] Ihave and will maintain.Certificate of Comerm n.wif.,m e,for Worker's Care DRAINS-FIE ,RO pAREA,COND. S'I'O I!5 'TYPE CONST RUCTION
sman,as prnvidcd for by Section 3]1X1 of the Labor Code,for the perfonamma of the _
work for which dd,permit is issued. FIXTURES-PER
❑1 have and will maintain Wader's Compensation Insurance,as required by Section
39M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEMdI OUTLETS OCC.vill APN
My Worker's Compensation Insurance carrier and Policy number are:
Cmricr. Poll,No.: GAS-EA.SYSTEM-OVI!R4( ) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
10/
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE IN mr &A
BUILDING DIVISION lFF_S _
('1lisxection neeJ nor becompletW ifthe pemmi.nature handled Jnllam($IW) GREASE.TRAP /1
or less.) I11. KPlili L10
I certify that in the performance ofrhe work for which this permit is issued,l shall SEWER-SANITARY-S'T'ORM EA.
oat employ any prisma in Only manner nn as m lwcome sadolct to the Waders'Compen- ENCR PBB 7 O
ZZ satinn Laws of C.1ifnmirt.Dare WATER BEATER WNENT/ELELTR
2 Applicant k GR )INIFIh
(-' ^ NMICI'.TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTGMPTRFATING
become subject to the Workers Compensation provisions of the labor CWe,you must E
Wti fnnhw hit comply with such provisions or arrant shall he deemed revoked WATER S17RVICE sD
F A
U O CONSTAUCI'ION LENDING AGENCY NEW Rf S11lF.NTh\L PLMii. Dape Receipt 9
1 hereby aBimuhe, here isa commettion lending agency for the performance of
the work for which this permit is issued ISm.3097,Civ.C.) r
Lender's Name Ur wCI-i�SV '1'
V Lender's AJdren )'fA
W I ernify that 1 have read Ods application and spate that the above information is - BUILDING FEC 2
f0./] correct.I agree to comply with all city and county ordinances and state laws minting nr QTY. MECHANICAL.PERMIT FEE
V Z buildingcanswetion,and hereby mahndre representatives of this citym enter upon the Sl!I$MIG FEL
alcove-mentioned pmpeny for inspection purpmes. PERMH'ISSUANCE O
(We)agree to Tuve,indemnify and keep hamdess the City of Crapenion against ELECTRIC FEE 1
IiaM1ilitica,judgmena,cont,.tmJ expenses which may in any wry seethe against said City AITERORADDTOMFCIL
in ucyuence nfine griming of this permit. PLUMBING FLT.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ig000 CFM)
it
SOURCE REGULATIONS, MECHANICAL hili
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION'I'AX
Signature of ApplicamVCantriemr Date EXHAUSTIIOOD(W/DUCT) I IOUSINGMITIGA'I'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicnm nr future building oec.pardmareor handle bcOmduus material HEATING UNIT(TO 101,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(m? HEATING UNIT(OVER 100.000 BTU)
❑Yes El NO, VENT]LA] ON PANTS ING 1.17 RESID) PAID
Date Receipt p
Will the opp]icam or furore building oxcupant use egnipmem or devices which
emit hanmir rom
laus an as defined by the Bay Area Air Quality Management BOILEk-COMP IMP OR i W,000 BTU) 1 f
Dapncr7
E]Vcs Fl No BOILER-COMP(OVER IW."BTU)
I have read the huiallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety CWe.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT.
building does act currently have a tenant,that it is my res,amemility to notify the occupant
of be nyuiremena wh!ch mast be met prior m issuance of a Cenificute of Occupancy.
TOwner nr uulhnriutl a6tnl Date TOTAL ISSUED BY:
OFFICE