S 1506 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUYERTINO BUILDING-ELECTRICAL PE Ir NO, 1506 BUILDING DIVISION APPLICATION/PERMIT TING R PROJECT
TIDENTMECIIANIFIC 1 5 0 6
BUILDING Y.ROJEC'T'IDENTI'ICATWN '
BUILDING ADDRESS: -SANITARY NO. APPLICAION SUBMITTAL DATE
104740 SANTA T6fMsA DR.
OWNER'S NAME: a� PHONE: CON TRACTOR'S NAME: LIC NO'.
MR, t.MRT� 11-14 . 2S 7- '1TL SEC CONTROL#
�ARCHITEC"I'/F.NGINEER: LIC NO. ADDRESS: ❑ Caw
oAv1a Y CT-I V1 440
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) SLUG ELECT PLUMB MHCH
Dew�cl - rw 996--3846 �J � ® �S
LICENSED CONT ACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am Iice:xcd under provisions of chapter 9(wmmnencing JOE DESCRIPTION
Qwz with Scetlon](NNmpmfDivieianJ oflhe Ba.me„and Profeseinnx Code,and nay E,enseiN RESIDENTIAL:
wcp �} p-�-4
�} PHRMI'PISSUANCE ❑SFIIWL ❑KITCHEN REMODEL
1UUFly in full foraeaad effwl, S Lic.#?Y 4'
License Gass APPLIANCES-RESIDENTIAL ADDITION [I PLUMPING RE-PIPE
F1
Q 1 Date ('o DELL ❑MUI TI-UNIT ❑STRUCTURAL
ARCIII I'ECf:S DECLARATION
X)aaI z 1 understand my plans small be used us public records PANELS MODIFICATION
O O y.-, Oil 10 200 AMPS
O Z'-�0 ❑INTERIOR ❑CHIMNEY REPAIR
,;i Lie au1 Pm[cssinnal - 201-I W(IAMPS IMPRBATH R EMENTMODE ❑DEMOLITION P001.5
Oat I am BUILDexempt
DECe RATContractor's
OVER 1000 AMPS El BATH RF.MODEUREI'AIR ❑DEMOLITION
1 hereby alWn that 1 am exempt from Om Commaetor's iiwnsa Law for the
O a.U following reason.(Section 70315,Rosiness and Profession,Cnde:Any city orcpumy SIGNS ELRCI'RICAL ❑OTHER
a y whicb rogtciLc u permit re Gumalter,improve,demolish,or repair ony Nmemm
aaJ pri rl Itce,al4 ;s the
ppl' tf hp nu fl 8 Lrmm,n SPECIAL CIRCUIT/MISC. ,
y ,
hat he is license(]punv the p iso. l trip Coal Tor Lonnie L (Gapte,9
Q� (eonnnenaingwithSeat en]OA)ofIn,an.3oflhe BUNncN,and PmFestiva,Code)or TEM P.METER OR POLE INS'I COMMERCIAL'
d y o a Thar he i,exempt Ihemfmm and for basis for the alleged exemption.Any violation of of ❑NEW BLDG/ADDITION [:1 DEMOLITION
W"m 9euinn']031.5 by any nppllenm[ornpemmit subjen,the applicam ma rnii penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
nor mora than flue hundred dollen($500). IMPROVEMENT
^�< Las owner mfthe et,om loess with woes as their sole comensator, SWIMMING POOL ELFCTRIC
❑ pawrt,, YenmP Y 6 p
�h� will dothe....is ame;The Croeisnot,Liccod or diactapply Oran Bn,inens OT
d 3 m and Professions Cnde:The me,fl..... Lind w Law soca not apply s if owner of OUTLETS-SWITCHES-FIXTURES
haswhy who build,or impmvea therum,and wilt does such work himself, through
his own employees,provided that such Impavanrents am not Intended or Offered for NEW RESIIIHN'flAl.ELECTR SQ F-I'.
sale If,...wever,the baildingorlmpmvement is,old within one year ofmmplarma,rhe O w. SQ.PI'.PhOOR AREA $/SQ.FT.
Owte o
owner-hudder will have the burden of paving that lm did not build nr improve fur na-
f sale.) commit
^
❑1,as owner of me Property,oro exclusively contracting with licensed contractors to 1
mnsWtt tb,project(Sec]044,Business and Professions C aka The Contrmtod N Li- -
cause Law does not apply m at owner of pmosmy who hudds or Inpmves thereon,and QTY. .PLUMBING PERMIT FEE
who contacts for such projects wfrh a eomrnetmfs)licensed pursuant to the Contracmds '
Lhwnsc Law PERMIT ISSUANCE -
❑ I am except toter Sec. ,B&P C let his reason
ALTER-DRAIN&VENT-WAI HIR(EA) VALUATION
Data , 1�
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby at Firm under prmnity of parjury One of the following declarations: viFF��►►►���
L Ite0,and will maintain a Cedihcam Of Consent to self-insum for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE.CONSTRUCTION
salon,as provided for by Section 3700 of the LaborCod,,1'or filo performance of the
kf human,Pe t '''.el FIXTURES-PER IRAP
"h J will t Worker's C p :al' Insurance, byScl'm
)of the Labor Code,[Or the performance of the work for whcludix perm isiomed, CAS F.A.SYSTEM-IINC.4OLU "I:S OCC.GROUP APN
MyWoE S'qU4sNsu �/ Pand Policy number ore:
Crlicy �.
SO,: GAS-EA.SYSTEM-OVER 4EA) L, m
\ CF,RTIFICA'1'E Op EXEMPTION FROM WORKERS' OREASEAN UUS'I'RL WASTEINTF,RCEP'fOR 4ffl�
COMPENSATION INSURANCE. ,1 ,DING DIVISION FENS, e
(Thfssemlon nocdnot be complelcd i f the permit is far one hnndreddNmnd5100) ORRASE'TRAP -
orlesaJ PLAN 'H P ..►.
lecridythut In the performance of the work hawing this permit is is.wed,I shelf SEWER-SANITARY-S'fORM EA.200Fr.
not employ any person in any manner so asubject s to beamme subjeco the Workers'Compen- ENE Qu tn
Z. xann.Imo,of Calif tri n.Date WATER HEATER W/VENT'/ELECTR
Z Q Applicant t GRADING tE
IZI NOTICE'TO APPLICANT.If,aficionados this Cenddeam Of Exemption,you should WATER SYSi'NM/TRF,ATING
(~ become subject ro the Worked,Gnnpensatdon provisions of dm Labor Code,you most
SOILS PGE
Wfnnhwith comply with such povi,imat or this permashill be deemed revoked. WATER SERVICE
Q
ZOO)O CONSTRUCTION LENDING AOENCV NEW RESIDENTIAL PLMB. $Q.FT. LAID Date Rcecipt\
I Immhy video
to mnuhere is n..d(Sce,30 lending agency forme paformvnce of
the work for whicb lM1is permit i,i„unl(Sac.Jl19],Civ,CJ
QU Leadeca sante I
LkJ Lender's Address
�.ta I nn,thatih' llti. application I,t'tethat d h 'fun ",1 11 BUILDING FISHh m t.l g I comply lh II ty unit ty rd' tIt I .mi ting to QTY. MECHANICAL PERMIT FP.P. .Z bold c 't lion, (hereby Ihori p an esOfth. ityt t rup ntheSEISMIC FF.E
ahove-mentioned property fonnspection purnusea PERMIT ISSUANCE(W,)agree m save,inomnily end keep ha arde„We City of Cupertino againstELECTRIC PP.P.I'nthililies,judgmants.cost,and expenses whichmay in any way scram ngaimsl said City AI:l ER OR ADD TO MECH.
in onsecuence of the granting of thin Permit. PLUMBING ITE
APPLICANT VLAIIOTANDS AND WI. COMPLY WITH ALL NON-POINT AIR HANDLING ON]TOO 10,000 CFM)
SOURCE RED LA'TIONS, MIiCHANICAI.FHE
I MISHANDLING UNI'T(OVER 10,OMCFM) CONSTRUCTION TAX
Signam 0 Ap it,, at Dore EXHAUST FOOD(W/DUCE) HOUSING MI'fICA'IlON PGR
HAZARDOUS MAI'HRIALS DISCLOSURE
illlh applicant or fmnru building occupant Into nr handl,hazardous material HEATING UNIT(TO 100,000 BTU)
as define by he Cupertino Municipal Coda.Change,9.12,and the Hasifth and Safely
Code.Sec 255J2(a)1 HEATING UNIT(OVP-R IIXI,IIW B'TU)
YCN Nt
❑ 'ENA'"ON CAN(SINGER RESID) PAID hale Receipt
(�
Will the applicant or farnc building Occupam use eyuipmcm Or devices which
mil homrdons air conmminams as AefineJ hY lhu Bay Area Air Quality Management BOILER-COMP(3HP OR 101,BIH1 BTU) TO L
Di,biaL BOILER-COMP(OV ER 100,010 RTU)
J
El Yea ❑No
Alli CONDITIONER
Ialth Safeal tyh odNou,maw25505,25533 as mm5534 1pmersta ofthe Calf- ^ ISSUAN AT
hernia Health Snfery Cnde,e,,four 25505,is.,and 255th 1 mnotify th lbw if Phe NEW RNSIUENTIALMECH. SQ.Pr y 5 (]l
bu eking doeenotcurrency must
met
itis ua ceoraC afte notify mepancy. �J
of the requirements which must be met prig to issuance or a Ccrtificam Of Occupancy.
Owner orrnnhorized agent Data TO ISSUED BY:,6 C171
OFFICE