00010010 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _(Y)(7 U
CITY OF CUPERTINO BUILDING.ELECTRICAL. PI:ftMIT NO.
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISIONRIBLDING PROJF,CTIDENTIFIc ETON 50001
BUILDINGADDRISS' SANITARY Nf 1. N'1'IACATIONSUBMItlTAI.DATE
O :R' NAME 1 ONE:: INTRACIOR'S NAMie 1.1'No
CONTROL Jr
C I rem t _ I / N/C
Y ')W n 'G t' C�W IL N Sri -S ❑
ARCHITECT'/ENGINEER: TIC NO: ADDRESS:
12323 \1"q u • IP4
CONTACT. � PHONE: BUILDING PERMIT INFO
/n^J I'�tAVe/kq l �S 3-oy1- ❑ Consultant Fees Paid by Applicant(initial) In DO ELECT/ PW^btlt/J MEECC,H
/'x'11+ Lr / B Lam' L7
LICENSED CUNTRACI,IRIS DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby union that I am licensed under provisions of Chapter 9(commencing
JOB DESCRIPTION
W d'Z with Section Dskinn 3oflMBusinceornd Professions Cod,andmylicenseis RESIDENTIAL'
WOO re. I PERMIT ISSUANCE
dad= full Inerrant]enact. DSFDWI. ICHEN REMODEL
QUU License Clans I ILie
-
4 APPLIANCES-RESIDENTIAL DADDITION ElPLUh1BING Rii-PIPE
FZW Doc—� Commcmr
rn6Q' ARCHITI?CPSUIT LARATION ❑MULTI-UNIT ❑STRUCfUkAL
F.z I torkrnind my placental he used as public records PANELS MODIFICATION
OZ= Oil PO 200 AMPS 0INTIiRIOR 0CHIMNEY REPAIR
III Licensed Professional 201-I0H)OAMPS IMPROVEMENT DSWIMMING POOLS
OWNER-BUILDER DECLARATIONOVIiB 1IXX)AMI'S D BATA REMODEUREPAIR DDEMOLITION
C Q (hereby union that I am exempt from the Contractor's License Law for the
Oke yU following reason,(Section 7031.5,Business and Processions Castle Anycilyo,eemELECTRICAL
SIGNS ELECTRICA ❑OI HEk
LL O Ian which requires a permit as consumer.alar,improve.demolish,or repair any structure
ai 5 prior to its issmncc,also rVuiw,I1wafpl'ieanl ba,uch penia.filcasignedmnerwal SPECIAL CIRCUI"UMISC.
fly
but lie is olased pmsaam In the Provilimnol'the Commaors Latae Law(Chapter 9 COMMERCIAL
� (commencing with Senion7000)of Division 3 of the Business and Professions Code)or TEh1P.MEIER OR POLE(NST.
61 e C find he is cncmpl mercfrnm and the basis fur the alleged exemption.Any violation of D NEW BLDG/ADDITION [IDEMOLIT10N
W 1e.4. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 1'( UItVIC1iS ❑TF:NAN'I' ❑FUOII SIiRVICIi
W y of more than rive hundred Aolla,s($SW). IMPROVEMENTfC
F-1
p,as owner afnc�property,nr my employees wish wages its,heir ante annpcnaminq SWIMMING POoI.ELECTRIC
F will dothe work col lhesmrmare isnm intended.,offered for mle(Sce 7(W,Business ❑O'1'llliR
63m and Professions Coda The Contra tor'.s License Law does net apply to an owns,of OUTLETS-SWITCHES-FIXTURES
property who hard,or anionic,ihareon,and who does ouch work himscll',,thouh
rg
_R
his own employees,provided mm such improvements are nut intended or offered lar NEW RES WENT IAL ELEcrR SQ FI'.
sale.If,howevee4 the building or improvement is sold within one Yearufcompletion,the SQ. . .t Os)R AREA LSQ.IT.
owmar-builder will have the burden of posing that he did nm bmto or Improve lotion-
Rose
s,ion- .Y
Roseof sale.). TOTAL.
D 1.as owner of the property,am exclusively contracting who licensed convacmrs m / j
consider the project(Sec.71144.Business and Pro1"ession,s Core.) ase Conor—re's I.I-
e Law does not apply m an owner of property who builds or or improves thereon.and QTY. PLUMBING PERMIT FEE
who
o commas lot tm
such projects with a coater(I)licensoamo
ed parant o Conbnctm's OO S�
License Law. PERMIT ISSUANCE
D I ren exempt under Sec. .R&P C fur this reason
ALI ER-DRAIN&VENT-WATER(HA) VALUATION
Owner Date
W'ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE U 0 p O
I hereby ur'ISran under Iranulty of Perjury one of the following Jcelannions
E)loose and will mainain aCenifcam ofConunt mulGinsure for Wader's Compcn- DRAINS-FLOOR,BLUE AREA.COND. $'IOHIES '1'VPIi CONS I'ROC('ION
lion as provided for by Section 37W of the"No Ccda,fur the peffotance orf the
for whkb This pemnr I,issued. FIXTURES-PER I RAP
have and will maintain Workers Compensation Insurance.as required by Section s OUTLETS] lof the LaWr Code.lot the Performance of the work for which this permit is issued. GAS-FA.SYSTEM-I INC OCC.GROUT' q.2IsN
My Worke's Loanpvnsation Insurance carrier and Policy a tt m�nr arc GGr�
Carrier: )TM('iFV(a��r_Policy N., a- k GAS-EA.SYS]IiM-OVER 4I?A) ODp
CERTIFICATE,OF EXHMPTION FROM WORKERS' GREASFJINDUSTRI.WASTE ETERCEPfOH
COMPUNSAI ION INSURANCE? —BUILDING DIVISION 1:1717S
(thissection need not hearcideal iRhe parrot,is farm,Warned!dollars(SIM) GREASBTRAP
PLANCHECK PER
as.)
Lemony ther chin pby I....ra n a'In
which this'he airWi ke".issued. SI'.WER-SANITARY-STORM EA.XX)FT.
not employ any petmn in any manner so as la became subjcm m the Wnrken'Compan- IiNGBGY Itili
Z dion i,a"'ACuldimtiu.Uom WATER HpiATER WNIiNT/ELIiLTR GRADING Fpip!
z Applicant t
NOTCE'I0 APPLICANT:If,did,making this Ccnificme of Excmllim.you should WATER SYSTEM/IREATING SOILS IEE
tacame subject to the Worker's Cnmpcnation pmvisionn of the Labor Cade, .it nnasl
forthwith romply with such provisionsorthis permE shags deemal revoked. WATER SERVICE
PAID
ZD
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH, SQ.I°. pant Beeeipla
V 0 l hembyollirm neither,is.construction lindingagency for me performance of
U. ;: the work Toe which this factor is issued(Sec.3097.Ci,C.) TOTAL:
Lenders Name
L) Lender's Address TI -
I canny than I have read this application and start that the above information is 'flUrt:DING FEE``\ 1 1 n�s
F" pa arrrcet.l ugrtemmmply suint epi city and county lmmances and slate paws relating m QTY. MECHANICAL PERM I'T FEE VI 1.SfISkuG.fEC--U
V Z building construction.and hereby aaborize representatives elan,city to enter upon the '�
above-mentioned pmryrly for invpectinnpmpaecs. PERMI'pISSUANCE Vii CI'RICI'E13
(We)agmen save.indemnify and keep harmless the City of Copararm a '
habildies,judgmennenses.costs and expwhich may in anyway moerue against migainst
d City ALTERORADDTOMF.CH. PE.U,
in mscgrant.of the granting atlhis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO L0.000CFM) ECHANICA1,FEE
SOURCE REGULATIONS.
AIR HANDLING IJNI'1'(OVER IQfXX)CFM) � CONSTRDCHON TAX��--�
Date EXHAUST HOOD(W/DUCT) I HO
Signannrc of AppllcaH IOlARDO HOUSING MITIGATION FF:F.
HAZARDOUS Ming ca AIS DISCLOSURE
Will the am m pflicafuture building occupant store or handle haavdnm malarial HEATING UNIT(TO 100,000 BTU)
as'coned by the Cupertino Municipal Code,Chuple,9,11,and the Health and Safety EBATING UNIT'(OVER HX),lNX1 ETU)
Gale.Section 25332(a)
❑Yes VENTILATION FAN(SINGLE RESIDE PAID
o Uma Resxipt X
Will the applicant or umre Wilding occupant use equipment or devices which BOILER-COMP(3HP OR lotiolit BTU)
mit tvvardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
Dimriepf BOILI:R-COMP(OVER IWIXIOE'IVI
❑Yes o
I have mealthehvaodous materials rcquimnrents under Clrup¢rl95 of rhe Call- AIR CONDITIONER ANCF,DATE
fnmia Iteala&Safety Code.Sections ZSOY 25533 and 25531.1 undmtotal oat if the NEW RESIDENT LAL MECH. SQ.I.T.
buildingdoesnm currently haven tenant,that it is my renparch aym notify theoccupant l/
nflh wmrement ani rest be mat loin narraaaf a Ciabdcamol'acupane'.
Owner ur nmhuri/J agua "are TOTAL: ISSUED BY: IC�
OFFICE