S 0081 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '+ BUILDING-ELECTRICAL PEkM11'N0. /,t/'y 981 .8.�
BUILDING DIVISION APP(ICATION/PERMIT PING PROJECTBING- IDENTIFICATION �'il.1N/J_L�J_ 'JLJ�.�.
' BUILDING YIt(IJIiCT IDITNITPICA'TIUN
HUII.DING ADDRESS: SANITARY NO, APPLICATION SUBMI'I'I'AL DNU
levo
11-17
o eft' AMI:: - (NONE: Co " ACTOR'S NA ME: LIC NQ
99&I0LI7o NIC CON'11tULN
sHCHITECT/ENGINEER: - LIC NO: ADDRG,SS: 4-7 � '�� �� ❑
CONTACT: PHONE: L/� ❑UIIAING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUN111 MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMtr FEE
1 hereh,affirm Nal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWZ won scenon 7001E art Division3onne Husillcsx and Professions cak.and my license is RESIDENTIAL:
WOO PERMITLSSUANCE
F to full force and cBcct ❑SPUWI. ❑KITCHENREMODEL
�UU License Class Lica APPLIANCES--RESIDIIN'TIAL El ADDITION lIAMBING RCPII'li
sad Date Contractor
ARCHITECTS DECLARATION CMULTI-UNIT ❑STRUCTURAL
zc)i'a I understand my Ilam shall be useA vs public parents PANELS MODIFICATION
OZ4O UPT02MAMPS ❑INTERIOR 0c IMNEY REPA IS
Pa4t:M Licamed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Cmc; OWNBR-BUILDHR DECLARATION OVER IOIN1AMPg ❑BATH REMODEUREPAIR El DEMOLITION
C C Q I heresy affiml that 1 sal exemll from the Contractor's License Law far the
06 U fallowing reason. 71131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
n.(So
3Oy wh'sh require,"a permit Io cenxtfaa,n11c1:improve,demolish,or repair any am lama
al priori.it,i,m.rkp,alsoreym.a the appliwm Romehpernirm file socredsnamnnee SPECIAL CIRCUIT/MISC,
7 MyVt that he is licensed peromnl lolheprovisiorro fma Contractors Licence Law Uleol,t9
W 4�'0� (commencing with Section 90(X)).(Division Sof the Business and Professions Cale)or 'TEMP.METER OR FOUR INST. COMMERCIAL:
a WW yy�� that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NI?W BLDG/ADDITION ❑DEMOLITION
iCmisr Section 70315 by any applielon Brr a pemlit subjects the applicant e a civil pcnuliy of POWER DEVICES 'TENANT ❑FOOD SERVICE
nm moBonn n five handled dollars(5500),
Fl 1.as owner of the property.or my employees with wages as their sole compensation, SWIMMING I1001.ELECTRIC IMPROV13MIiN'I'
yf E.O willd.hework.enA theswmum is Ton imcnded ornffarexl for rale(Sce.JDW,Bminuu. OTHER
and Pr.fessiom Coup The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
4' property who builds or improves thereon,and who does such work himself or through
his owe employees,provided that soon impowealems are not intended or offered for NEW RESIDENTIAL.RLECTR SQ FT.
sale.If,however the building or improvement is sold within one year of completion,the SQLpP�'.PLOORAREA !oSQ.FU
w
oner-builder will have the burden of proving that he did not build or improve for par- # a ' D
pose of sale.).
❑ 1.as owner of the propery,am exclusively contraming with licensed contmmrrs to TOTAL J 1
c.nGalct the protect(Sac.71194.Business and Prooa.
Professions Code:)She Conurs Li- UN_ 4
c Trow docs not apply to an owner of property who milds or improves thereon,and QTY. PLUMBING PERMIT FEE
wh contracts lin such project,with a contractor(s)liecired pursuant,,,the Contractor's �'`
License Law. PERMIT ISSUANCE f Y
Iamexemplunder Sec. ,B&PCfodhvmaam Ur ��f CNllly
AI.TF.R-DRAIN&VENT-WATF,R(EA) VALUATION
Owner Date
WORKER COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I herehy illi ai under panolD of of Coy no of the fnllowing do rker's o
❑(have and will maintainstion 37M ofthe Labor Code,for for Workers Coal the DRAINS-ILOOR,ROOF,AREA,CDND. STORIES TYI'ECONSTRUCTIUN
vond,I , provided for by Section d. of the labor Code,for the perfnmwnce of the
work for which this permit in issued F'I%TURKS-PER TRAP
❑ 1 have and will lode.fonhe red's Cone.fthi w rk For Whiax ai lkpr by issued of the laMn Code,for the ry:rtormnncc of the end for which Ibis permit is issuer GAS-EA.SYSTEM-1 INC.401l1'LETS UCC.GROUP AI's
My Wn tion lnsu�au�ncarrier and Policypp �
Camier�_L�—Policy No,Ila d )B � GAS-EA.SYSTEMOVER 4(EA)
CER IPICA'I'E OF F.%EM(TION FROM WORK HRS'
COMPENSAI'I ON LNSU RA NCE GREASE/I NDUSTRL,WASTE IN'I ERCEP YOk
BUILDING DIVISION
i.csectionneed not becompletedifthepernal iafatnehundreddollan SHNH GREASE TRAP
or less.)(ThPLANCHECK PER
I verily that in the performance ofthe work for which this permit is issued l.shall SEWER-SANITARY-STORM EA.21%1 FT
not employ any person in any manner as Ira m heaome subject to lie Workers'Compen. ENERGY PER
OZ action Laws of California.Dale WATER I]RATES W/VPNT/ELEC'I'R
Z Appficam GRADING FELE.O
NOTICE TO APPLICANT.If,after making this Certi5cae of Esenlpni.e.you should WATER SYSTEM/(RENTING
a ? become sabjccl nr the Workers C.alpcmmian provlvloam ofthe Labor Cale,you(nam SOILS FTE
millionth comply with such provision"or this pennil shall he deemed revoked. WATER SHRVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RGSIOFMIALPhhf B. SQ.PI', PAID
UO Date Receipt#
I hereby affirm ohm there is e (Ser.on lending agency for the perfornance of
14 .
Rbc work for which this permit is issued(Ser.3897,Civ.CJ
0 F" Lcndar' Name TOTAL
U Lcndaes Add.,, T T
BUILDING PER
Fg1 cmee that 1 have mad this city
and coup and store that the stove iws rmatinn is
to
Z coredlorrectacomply
and with all rebycillenu represty entatince%ves
and smmhenteru upon
QTY. MECHANICAL PERMIT FEE
U Z nullding tonstrnmion,and htrehy vulM1uri'r.e rupresentutivea of phi"ally n)anter open the SEISMIC F'EH
i mwe-membined property tis inspection purposes. PERMIT ISSUANCE
(W'e)agree to save,indemnify and keep hamllcss Ne City of Cuperiou against ELIiCTRIC Ilii?
A
ems, which may in any way acerae against and City ALTERORADDTOMECH.f Noglomi n hi"pennil. PLUMBING FHII ERS', S AN I WILL COMPLY WITH At.I,NON-POINT AIR HANDLING LINE I'LTO Ilk(NNICFMIATI h11iCHANICAl.14iF.—g� AIRHANDLINGUNH(OVER 10.000CFM) CONSTRUCTION TAX
li n nna,ar Dula EXHAUST HOLD(W/DUCT) HOUSING MI'I'IOA'IION FEE
HAZARDOUS MAEHRIAI S DISCLOSURE
Will the applicant or future Wilding ovcupant store or handle hazardous instead TREATING UNIT(ID 100,003 BTU)
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety
Code,Section 25532(,)7 HEATING UNIT(OVER 103,000 BTU)
Ycs El No
VENT fA'I']ON PAN(SINGLE RES IDJ PAID - --
Will the applicant or future building occupaal use equipment or devices which Date Receipt p
enutb ohm,air contaminants as de6nedn be Ba Ams Air Quality Mona talent BOILER-COME OFF OR IOO,gXI BTU)
Y Y Y g TOIAI.:
Ilivtrici t
❑Yes ❑No BOILER-COMP(OVER 100,000 B Uf
I have read the haanlous material.,requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25531 and 25534.1 understand than if the NEW RESIDENTIAL MECH. - SQ.UL
buildingmronor
t, Well muse aterant,Illmhbmyrespnmirafurnotifyccupies,m
e(themquimmontvwhieh museautiot.is mon,y,eeom Calif nofOmupnncy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE