00020046 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �0 2p0 U In
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT vING PROJECT[CHAN'ICAI.
BUILDING BIND-M IDFINTIh'ICATIUN
HU ILDINGADDRESS'. SANITA NO. APITICATIONSUBMWI'ALDATI
20087 SOa7/m2,eSef 0"e% Z-/O-O a
WN1ER'S NAMIP PHONE CONTRACfOR'SNAME' LICNO:
(`A A[.Lf h I Y 'a6O'z Ow.`S Lt+%,�.L, N/C CONTROLN
7Z0with
CHITECfIENGINEER: LIC NO: ' ARDRESS: ❑
Y ,e 45, SAKaI�i �s
NEACE PHONE: BUILDING PERMIT INFO
❑ Consults nt Fecs Paid by Applicant(Initial) BLDG I!L,Cr PLUMB MUCH
Joe ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy err.f that 1.,a ecmwd trader p r,xims of chapter 9 E,min,encing JOB DESCRIP'T'ION
C Swim 7000)m`Di inion 3 oDhe Huwitur,cmd rrofeaai...Coic iu i my licenw is RESIDENTIAL'
nIRRMI1'ISSUANCIiCull Ruce and Ofcl1t. ❑SFDWL ❑KITCHEN REMODEL
n.w Clas. L- Lion ppPLIANCLS-RF_SIDENTIAL [I ADDITION C3 PLUMBING RE-PIPIT
t Qul Dme7- r f-tel—Contractor
F.Om ARCHITI-CS DIiCI ATIO PANELS ❑MULTI-UNIT []STRUCTURAL
zOyz I understand my plans chat]be used as public record. MODIFICATION
UPT02M AMPS [I INTERIOR 11 CHIMNEY REPAIR
F.4F„ty Licen,eJ l'mlessioaat 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AM15 ❑BATH RF.MODELREPAIR DEMOLITION
C C sc I hereby affirm that 1 um exempt from the Contractor's License Law for the
X 31 li U following remon.(Section 7831.5,Husincsw and Professions Calc:Any city or county SIGNS ELECTRICAL OTHE``R-- i? ®iaa.a- OM
tri ab- which requires a permit to c mnrrCt,alter,improve,demolish,or repair any%fracture 'A CFYl� 'da Loy Lys 4 fu
F�OQ Prior m its lwsuname,also requires the applicant for such permit file aligned statement SPECIAL CIRCUITIMISC.
ivy: ,bar In,,licensed panwm 10 the provisions Of be Contractor,License Law(Chnpter 9 /T
W o1 pC (commencing with Section V0brd Of Division 3 of the Business and Profession.,Code)or COMMERCIAL:
TEMP'ME4[R OR IM)LIi(NST.
Q.L c that he is exempt cercfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D1iMOLI'I']ON
_ Secdon 1031.5 by any nPP icmu err a permit.wbjecu the a,prenm u,a ave Penalty of POWER DEVICES
not mom than live hundred dollars($5001. El TENANT ❑FOOD SERVICE
Z Y MI'ROVEMENT
L �I.mowner k,the prolixity.
estmefor myenintende with wages il for their tale cnmpensiness SN'Ihih11NG POOL ELECTRIC
ESO and Prothe wons and er heCo eisnot s Livens O Law does sale
l(an Business )THfiR
I�il-m mM Professions Code:The Cmtram,,License Law does not apply toanowner of OUTLETS-SWITCHES-FI%TURCS
property who builds or improves thereon,and who dies or a.work idol mor through
hi,,,..oweverethe provided than such imrnwnnenw thin nut intended or oB'crcd Ibr NEW RIiSIDENTIAL ELIiCEN SQ 1'1'.
%ioner-bower will lave
burden
of proving
itat he mid noncildori provetionthe /�SO.Ij'. ' REA $ISQ.Ff.
cr,ale),will M1mt the burden of proving thm he did no,
hunt)or improve fur per-
po%c af.c:
C] 1.as owner of the Pec.704 atm Business
and contracting with licensed contractors I to TOTAL:
m,uma the es nor pdy ,, a.Bun,of and Processions ei d,C—)Or
r,m i its Comracmr', nd
wLaw dacrsuch plyman with
Prnpeny weemedd.c Orlmprothe Corcoa.ncl QTY PLUMBING PERMIT FEE
who.onsets fm such prmjma with a ttmtracmgs)IicenseJ pummm to the Contractor's
Liccnw law. PERMIT ISSUANCE
I am exempt under See B R P C for this reason
er ])areALTER-DRAIN&VENT-WXI ER(17A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECIf.DEVICE
1 hereby aflifm nuclei pmalty of perjury one of the following declarations:
❑I hmcmd willtnaimaina Ccnifaate ofComcal lowlf-inwfe for Worker'.Con"o- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TV PF,CONSTRUCf1Ot
smion.is Provided for by Section 3100 of the Labor Code,for the perlimmtunev of the
work lo,which this perrad is i,,imd. FIXTURES-PER TRAP
❑1 have and will maintain Worker's COmpemation Inwr,ncu,nu Cultured by Section
37W of the Labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' p o
My Workers C:p pensution Insurance curter and Policy numberam:
Canicn 1/)�/A-LCLn Policy N:a: GAS-F.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WOR WOR ER
COMPENSATION INSURANCE GRF.ASFJINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION
CIT'a vection need not becompteted ifthe permit is for one hundred dollar%($100) FEES
ar Icas.l GRF.ASE'fRAP PLANCHEiCK FEE
I,,mly thminthe purlianrancc Of the weak l'Orwhichthi%Permit isissued.I',WII SEWER-SANITARY-STORM EA.200 rr
z
not employ any prtnm in any manner so as to becomeuo Ompen-
subject the Worker.:CENERGY FEE
sation Lams of California.Date
Q WATER HEATER WNEN'f/EhLCI'E
NOTE am l GRADING FEE
ti NOTICE TO APPLICANT.If.after making this Cnimirs of of Exemption,you should WATER gYSTEAI/fR1iAi'ING
a , become subject m the WOrkcr'z Compensation this peanut
ons of the labor Croke,you must SOILS IEIi
�
forthwith comply wBM1 web pmvi-%rota nr this permit shall be Jcemed revoked. WATER SERVICE
Uz CONSTRUCTION LENDING AGENCY NEW RESIDF,NTNL PLMN. SQ,FT. PAID
UQ Ihn,whifpm l pnm1cisamnnmeti30 leading agency for the performance of Uvne ReeeipnM
� F the work Por which this permit i%iszued(See 3Wl.Civ.CJ
p U Lender's Name 'fpTAi.S
Lenders ABdros TOTAL: r 1
y1 certify that 1 have wad this application and state that above informminu is BUILDING FEE 1 1
ti
h stares].l agree to comply with all city and county ordinances and state laws mlalingm QTY. MECHANICAL PERMIT FEE
U Z building mnwwctinn,and M1umby truth mi.c rephCcentmivc%nffhlc city lm ether upon the SEL MIC FEE
shove-meminned property for inspection purprws.
PERMIT ISSUANCE
(we)agree to cast,indemnify and keep harmless the Circ ur Cupertino against F.LE +tIC 1 B I IJ 6M
I.exanies.judgments.costs expenses which may in any way nocme against said City ALTER OR ADD TO MECH.
I.cnmcyuence of the graining of this permit. PLU:�111 FEE LL
N'PLICAN'1'UNDIiRS'1'ANUS AND WILL COMPLY Wll'H All NON-POINT' AIN HANDLING UNIT(TV IO,IKKI CFM) t
SOURCE REGULATIONS. yJ
ate `nom®y�-6f.11-6f.11AIE HANDLING 11NITIDVF.R IILINNI CIMMECANICAL FEE
JR ) CON �
rR;DDb -���-�
thice Applic.nVCnntmcmr Dote EXHAUST HOOD IW/DUCT) HOUSING MITIGATION PER
MATERIALS DISCLOSURE
Will the applicant or(utum building Occupant store or handle hazardous material HEATING ON]IF(TO]W.q➢d BTU)
as defineA by the Cupertino Municipal Code,Chapter 9.12.:md the Health and Surety
Code.Section 25532(n)P HEADING UNIT(OVER 100,000 BTU)
❑Yee E]No VENTILATION FA N IS INGI.F.RESI D) PAID
Wil,'he t licann or future Wilding mention use e t or devices which Dale Receipt N
PP 6 P nAir Qu BOILER-COMP(3HP OR I00lNp UTU) n
emitict? nm oar cnnWminnnh aulcfncJ hY the 13aY Area Air Quality Management TOTA
Daunm^ BOILER-COM P(OVER 100.000 BTU) `
[-1 YC' NO
I havcre1the hvardnus minimal,requiwmems under Chapter b,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
loon.health&Safety Code,Sections 25505.25533 and 255.14.1 understand that if the NEW RESIDENTIAL MDO 1. SQ.FE
budding does not currently have a temmt.that it is my rcm xPOmibility unify the occupant ` V
of the myuiumm s which must W met prim to issuance ofa Cenifcate Of occupancy.
Ohneror sumorirtd ug,a, Date TOTAL ISSUED BY,
OFFICE