S 0866 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY�FCUPERTIN0 BUILDING.-ELECTRICAL PE ITNo
BUILDING DIVISION e - - APPLICATIONIPERMIT DING BINGPROD -MECHANICAL
0866
BUILDING PROJECI'IDF.NTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBh1IPIAT.DATE
/also SAn17A LUC414- ,W PiLI�ERTinlo Q� �� f l - -a
: PHpNI CON'IRAC'I OIt'S NAME: LIC NO:
( nlC /tom /),//,_ .I pll�f N/C CONTRDI.#
HTECT/ENGINEER:
IAC NO: Y-G`V A)DRI?,M153: 7 !1'T ❑
*NEWFIC
HCS M-442
CONTACT, PHONE: BUILDING PERMIT INFO
PAT
1� A O ❑ Consultant Fees Paid by Applicant(Initial) PIA'MB Iirjl
LICENSED CONTRACTORS DECLARATION TY. ELECTRIC PERMIT FEL?
I hereby affirm that lam licensed under provisions of Chapter 9(commcming Q JOB DESCRIPTION
CCy wiSction 900E ofLdiesion 3ofthe Business and Professions Cade.spot my license is RESIDENTIAL:
pPERMIT ISSUANCE
F+�.. "211"force and effect. ❑$FOWL ❑KITCHI?N liIiMODIiI.
�UU License Class Lie.# APPLIANCES-RES]DIiN'GAL ❑ADDITION ❑PLUMBING III:PIPE
r-714 Dmc Conform,
m6y ❑MULH-UNIT' ❑STRUCTURAL
ANCHI'TF,Cr'S DECLARATION
FHZ l understand my pEr,,ImII lx used us public records PANI?IS MODIFICATION
OOZ4EO I1PT02tNIAMPS RIOR ❑SWCHIMNEY
MINGREPAIR
POOLS
a4�l li Licensed Professional 201-1000AMP$ I PROVIiMENT �SW'IMM1fING('0015
y' JJ OWNER-UUILDER DECLARATION
Iy Oc J OVER]Bud AMPS BATH REMODI?11REPAIR El DEMOLITION
U heresy anion that 1 1. exempt from the Co,drn,Co License Law fur he iq5 6 U adiowing reason(Section]1131.5.It,fuer,and improve,
de in demolish,
Code:Any tory m ooamY SIGNS ELECTRICAL [_1 OTHER
tq O I" which requires u permit re construct,allnr,improve,h Imf ill t oreminatoryastmdurc
Prior be
Im Forequireethrvisiocoo for enchrancia mfilcu Law(ad mhapterl SPECIAL CBCUIT/MISC.
thoporde licensed of Id lionao P
pursuam mor, fore Comrmm�r'xl icenne Law(chv(Chapter COMMERCIAL
RI0z (car he is ingwith arefro oil
Dlvision3 ofthe
c,Odexe and on�f.,visCMe)nf 'TP.MP.METER OR FILE INST.
dy ey� mat he is exempt therefrom and the k fie for the alleged exemption,Any violation of ❑NEW NLDG/ADDITION ❑DEMOLITION
WMtor Section 7031.5 by any applicant for o permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ez,} nm mote than Eve hundred dollars($5(pk IMPROVEMENT
�Q ❑I.as owner ofthe property,or my cmpdoyces with wages as,heirsole compensation, SWIMMING POOL ELECTRIC
Sat will do the work,and,hemrucmre is not intended oroUered for sale(Sec.70)49.Business El OTHER
W 3 and Professions CMtr
e:The Contractor's License Law due,,not apply to an owner of UTI.FI'S—SWITCHES—FIXTURES
property who builds or improves tnerton.and who does such work himself ter through
his own employees,provided that.such improvements amelre m,imcndc l or offered for NEW RESIDENTIAL IiLECIR S
sale.If,however,the building or improvenissold within one yuuofcomplaion,the OO
SQ.IN.P.. R A@GA F/SQ.Pf.
ptxcer-hadder will have tile burden of proving that by did not build or improve for par- (J�jlIT71\
oor, mla.).
F7VVVI,as ownmer of the I actm,am exclusively comrauing wn.
im lneeed commiton n: TOTAL:
tramu e,the project(SCC.7014.Business and Professions CMe:)'Me Caplo Ls Li-
of
comm law does not apply to an owner of property who builds mf improves thereon,and QTY. PLUMBING PE
who contracts for such projects within commends)licensed pursumm to the Commands
License taw. PERMIT ISSUANCE
1 am exam der ec. .B&1'C forthi.rea.on (j
ALTER-DRAIN&VENT-WA'IIiN I' L �.. VALUATION
❑ Ihav hereby affirm tinder$COMPENSATION
on UH Ce following
HACK FLOW PROTI?C'I'.DI?VICE C� u�0/6z
WORKER
penalty of perjury,one of the following Jedurntions:
Cvrtili7M of the Labor
sdGinfurther WorkersCompere- DRAINS-FLOOR,ROOI'.ANIiA.CORD.
S'fOltlliS TYPE CONS'IAl1C'I'ION
work f os provided for period
Scissure 3](X1 of the Labor Codc,for the performance of the
work for which ill pernitis orke, PI%TUBI?$-PP.R TRAP
1 have and will maintain Workers Compensation rkforn h h requiredn i Section
3]n0of@e Labor Cade,for the performance of the wed for which this permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC GROUT' APN
My Worker's Cnmpensatbn Insurance immersed Policy handle,ales:
Carrier: Policy No.: GAS-EA.SYSTEM-OVFR J niA)
CERAHFICA'I E OF EXEMPTION FROM WORKERS' GNIiASE/INDUSTRI.WAS TE INTERCEPTOR COMPENSATION INSURANCEBUILDING DIVISION FEES
(This section need not becompWed irruption lx6mnchundreddallars($10n) GREASE TRAP or
le"'.)(This
Ilii?
Icenilylica lithe perliamunceoflhe wnrklnrwhich Ibis permit osteal IshallSEWER-SANITARY-S'IORM EA.200)FT.
not employ any person in any marmer so as m become subject m The Workers'Camper. ENERGY FEE
Ozration Laws of Califnmia.Dale WATER HEATER WNEN'1'IIeLECIX GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:If,after making orm
is Cen]fice of tuoundion,you should WATER SYSTEM ILS/TREATING SOFEL?
a ; became subject o the Workers Compensation provisions of the LAw r CMe.you must
Lkl fnnhwilh comply with such pmvisions.,,his pumit shall he devoted revoked. WATER SERVICE
y.A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Un Thereby affirm thunherc lsaennstmetion lending agency for the pufonnanca of Dllte c l#
Ip-yl Tho work for which thlx lwrmil Ix isfueA($ac.3119],Civ.Cd
W Lender'a Name of X OTAh:
L) I<ndtrs Address TUI'AU
GI comfy that 1 have read this ap,hom ion and state fiddle aMsve information is BUILDING FEL
h contact l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PI?RMIT FEE
L) z building construction,and hereby amhnrue representatives mf this city a:enter upon the SEISMIC FF.E
` ihnve-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FC:I!
liabilitica,fudgmems,ensu and expenses which may in any way name against said City ATTER OR ADD TO M ECB.
in consequence of the granting of this permit. PLUMBI1 IL
NG PIiE
APPLICANT END RS'I'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'('1010,000CPM)
SOURCf(JtEj1 L 1�:��� 't MECHANICAL Pb?
AIN HANDLING UNI'I'H)VI?k 101X111 CPM) CONSTRUCTION AS
Signal sof APplican Contractor Date EXHAUST HOOD IW/DUCT) HOUSING MIT'IG PION FEF.
HAZARDOUS MATERIALS DISCLOSURE
WilDe.,dicavt mf future building occupant social handle hammers,mmerim HEATING UNIT CIO InLas)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)^ HEATING UNIT(OVER 101,000 BTU)
❑Ye, 0N VENTILATION FAN(SI NG 1,17 RES ID) PAID
Dore Receipt#
WIII the at,comartl or lurare cefirrog occupant use ea Air Gaudily
it devices which
mil humrdous air conlnminnntx rex def nus by the Bay Area Air Q,mllly Managemmn BOILER—COMP(7HP OR IIXI,IXXI RTU) TOTAL:
District?❑Yes ❑Nn BOILER—COMP(OVER 110,000 131 GO
-
I have read the meafdoei materials requimmelua under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 35505,8533 and 25534.1 maderstand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have aTenant.der,it is or,rexrymsibility to„ratify the a mums
of the n,i props which max be me,prior m issuance of a Certifirme of Occupancy. \��
Owner or au,horiacd agent Dale TUfAI.: ISSUED BY: V a"� ✓•��
OFFICE