S 0526 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
sU11,DING UIVINIDN API'I,ICAT'ION/I'F.RM17• TING PR PROJECT
IDUNnFIC $ 0526
I3UI1.1)LU BIN -M IDEN'1'IP'ICATIUN'
;SANITARYNO. APPLICAHONSUBMIITALDAI
U INC,ADDRIiSg,Soo P.iDG 7) yja couK=T i3uil.Di► 1G 17 cu rJ0 O EN 5 tt � PHON C�M'RDAOORSHMV- S1� CONIHOI.p
06
ACHrri-C/ENGINEIiR: L1CND: ADD "'S
sTINNe'TT C--IG N e 1
CONTACT: PHONE: BUILDING PERMITINFO
IMiN _ w.1 Mhc11I _.qIg3Qd6 � t
LICENSED CON'TRACTOR'S DECI ARA'DON Q'TY. ELECTRIC PERMIT FEE JOH}If I�j)'ESCRIP'PION XYZ'
1 hereby affirn that I ten licensed under Provisions of Chapter 9(commencing
Z wiO Scninn 7(XIB)mf Division Tdthe Businessand Professions Gde,waraylustaxis RESIDENTIAL
PERMIT ISSUANCE.
N1—O tcR hu,,,and eReal. ❑SFDWI, ❑KITCHI?N REMODEL.
QULimn,Class LIGN APPLIANCE-9-RESIDENTIAL ❑ADDITION E]PLUMBING RE-1'11'1:
ZZ a Date Contr¢mr
ARCHITECTS DECLARATION PANELS ❑MULI'1-UNIT ❑STRUCTURAL
F y Z 1 wWcrsmnJ my plans shall he meJ as public records MODIFICATION
Z Om„ UPT020OAMPS ❑INTERIOR ❑CHIMNEY REPAIR
OZ—�
F4~Y1 Licensed PmlGszinwl 201-I0X1UAM1•S IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER BROAMPS ❑PATH REM1IODEI/REPAIR ❑DEMOLITION
Y G'< 1 herehy,vflina that I um exempt Irnm rhe Contractor's License Law for one [:1(Y LER
X 3 d U following reason.(Section]811.5.Business and Pmfcssions Gyle:Any city or county SIGNS ELECTRICAL.
W a y which requites.permit to construct.alter.improve,demolish,or repair any sanctum
prior to its issuance,also requires the applumn forsnch .it file a signed smmmem SPECIAL.CIRCUII/MISC.
ythat he is licensed pursuant m the proviximnxnithe Conto.'al I Llan,Law(Chapmr9
a' af (armmenoingwith Seep...70(Xpnl'Dlvlslan 3ofma Business and 11 f..ans Gde)or 11;A1 P. iH ORPIILEINS'T COMMERCIAL:
16 Oo C that he in exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^h Section 7031.5 by any upplicnnt for a permit,subjects the applicant m u civil penalty of POWE CES ❑TENANT FOOD SERVICE
a more than Five hundred dollar,(85(X1).TSG IMPROVEMFNI'(]L as owner ofthe proerty.
pam mn
rmy employees with wages their sole cspensation, SWIMMING .13.EC'RIC
will do the work.and the smscame is not imenJed or offered for,xic(See 7(W.Bmmv, ❑OTHIiH
C f-o )UTLEIs-S - 1X'1 FS
and erom.dans sale:The canlrarmrn L1nenXe haw dews not apNy to an owner ar
pmpcny who builAs or improv,,IM1ercnn,and woo A ss such work himsdl'or Ihrnlgh NI7.W BESIDE 1. .:C SQ F'F.
his own employees,provided that such improv ancras are not intended or offered for SQ.IT.FL00 _1 SISQ.FF
sale.IL however,the building or improvement is sold within one year of completion the
rr-huilder will have the harden of proving tont horrid not build or improve for pur ��
q, f:Ie.).
n1 of the poniverry.am exclusivelye m ei 6air'licensed emartactirs,to
couranno he p j m(Sec 700 H d Prodfiession,Cal )The Contractor,Li
-
cenoc Law does nor applyt d property who builds our i uproves I horrom.unit QTY. PI, I 1 FEE �p
who t Is fc in,pojmu with a comm t..(s)I crowd pursuumm ButC tot s A p.g
License La PI!RMIT V SUANC. l/
❑lam exempt ander year. .13&PC forthi+mexnn
ALTER-❑RNN&VIiNT- V "ION
Owner Dateos
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.Dl CE
I herchy affirm under penalty of perjury one of the fml4ming declarations:
'I huve:md will inuinmin uCenilicu(c of Gmsan to sdf-in<ure lin Wu.kass Compon- DRAINS-FLOOR.ROOEAREAC U. ��eS'Im{Ifi. �' PE CONSTRUCI'It
cation.as provided far by Section 3700 of robe Lahr Code.for the perfomwnce of the �' _
work Por which this permit is issaed. FIXTURES-PER TRAP
❑ 1 have and will mnirta n Workers Compensation Insurance,as required by Section
3700afthe Lubes Code.native
pahmnoncrof,he work for which lave tit nlllers' GAS-PA.S YS'117M-I INC.J OIITLE'IS 01 UP ANN
/ My War 'e C,dry• Lira c -e Iy oficNr'y�wnlA'ur0/') � GAS-EA.SYSTEM-OVER i(LA)
CE I'IFICAIP'E60F EXIiMITION I'RO(M-WORRKF.RRY( GREASEANDUSI RL WAS'll:1MfERClyn-R
COMI'IiNS61'ION INSURANCI? t .UI G DIVISION PEES
DTis,clton need not bccomplmal ifthe permit isforunchundtnl JollampH00) GREASE'fRAP 1•IA C CK IT
or less.)
Loy that in pedmnnunccal the wmklinwhich Nis themhisix,'Cc,ahull SIiWIiR-SANITARY-STORM EA.21X)1T.
bol employ any prnnn in any mmuner sn no to Recon¢suhjen mthe Wnd.cri Cmnpem N GY I�Ii:
Z ,tion Laws of Culifnmia Dam WATER HEATER W/VENT?:I.IiCfR G Di.GFEE
z Applicant
NOIICI?'e.0 API-UCAN'I's If,afar,making this Certificate of Hxempdod,Ydu should WAT13R SYSTEM/TREATING SOILS hili
a ; Masme suhjmm to the Workers Comprnnvtinn pnwisinnxnf the Lahr Gde.You must
n„ fonhwith comply with such provisions inhis permit shall be deemed revoked. WATERSERVICE
(�
CONS'T'RUCTION LENDING AGENCY NHW RI?SIIIENTIAh YLMI1. SQ.FT. PAID Date Racipap
V thereby affirm that here is a comlmaion lending agency for the performance of
the work for which this permit is issued(Sec.3097.Cie C) TOTAL:
0 F lender's Name q1;
ULenders Address BUILDING FE11
C1 cenny aha 1 base read This upplienion and same Nm the above information is
F (Al coned.l agree loasmply with all city and county oNlnances and.state laws relating to QTY. MECHANICAL PERMIT
rFEE SEISMIC[;];.I.Z building consm¢Ilon,nnd hereby aahorisc representatives of this city m cmerupon the
abo,darnamad prnpenY lin impeco as purpos. PERMIT'ISSUANCE ELHCfIIIC FEE
(Wd agree to save.indemnify and keep handless the Gry of Cupertino organism
hahilitics.judgmcm,costs and expenses which may in anywvyvecrue against.said Clly ALTER OR ADDTO MECIL PLUMBING IEE
to nwquencc 0 the granting cloth Ic'r do.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALY NONI OINT AIR HANDLING UN if(TO 10,000CIM) MECHANICAL FHL?
SUURCIri/qEGULAIJpNi' VIZP—
.a
(7/// AIR HANDLING UNIT(OVER ELB00 CFM) [UNSTRUCI'IONTAX
Silnmumnf APP cmbCo ctor Dae EXHAUST IIOOD(WIDUCl) I OUSINGMITIGA'IIONFEE
HAZARDOUS MATFRIAI S DISCLOSURE
Will the applicant or future Indtingu"Ponm store orhandlehasmJous material HEAT'INC,UNIT(TO Inal)(XI BTU)
as defined by he Cupanina Municipal Code.Chuplur 9.12,and roc Hcohh and Svl'cly BEATING UNIT(OVER BX)000 BTU)
Code,Section 25532(x)^
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Duna Receipt N
Will the applicant or future building occupant use rgnlpdaou ar duvims which BOILER-COMP(JHP()R I ailing)If'1'U)
1. a wrardo s air contaminants as delfnM by the Hay Area Air Quality Management 'UGI'AI.:
UrsvinP BUFFER-COMP(OVER 100.000BTU)
.son ❑Yes 0N
\ AIR CONDITIONER ISSUANCE DATE
I time mad the hvaNtws man%255 5. i 533ad under Chaplcr understand
of taut Cali-
oro
ia Health&t,a Safety e Gde,Sections 25505.2s toy and 255?J.1 to acidly
moat if the NEW HLSIDENTIAL MI:CII. SQ.f4.'lailCA
"h o uir nal nrtrech have uammo,that's ismyce al xCeri usnmil ytheacraload ione,
I 'rhe trquirememe which must he me prior¢ri++uance nlnCenilicae nl<kcupmv:y.
\ umomimJ.,cut Dart, TOTAL: ISSUED BY:
OFFICE