S 0968 (2)+' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - Bun.nwc.ELecrRlcM• P 'D NO 0968
BUILDING DIVISION APPLICATION/PERMIT r1.uMn NG-MECHANICAL.
_ BUII,UING I'ROJELT IUENCIF'ICATION
BUILDING ADDRESS - SANITARY NO. AI'PLICAI'ION SUBh1fFFAL UAIT
OWNSNAM1IEc IIUN� CO R )R'S NAM:. LIC NIC CONTROL#
ARadut'ECf/ENG TER: L,IC � AD E,SS:D ❑
DD !!bb
CANT cr: PHONE: c - BUILDING PERMIT INFO'
v r ^ '336
LICENSED
❑ Consultant Fees Paid by Applicant(Initial) eO ELECT PLUMB/ MOH
LICENSED CON IRACfORS DECLARATION !/l (2TY. 1 ELEC'IRICPERMPI� I • 'FEE
I herchy union that 1 amlicensed uJ pnnimof Chapter 9 onamm g _ t JOA DE$CRIP'1lON
OmZ with Sa iorr7 00)mDioa, 1 f[it,Bust dP f '... Codv.md lice RERE 1
tk1 OO - I'ERMI'I ISSUANCE
F full force and a
WF n C Q S / ❑SFDWL O KITCIILN REMODId, -
�UU L.fansc CTSD _ APPLIANCES-RLSN[NL'IAI, ❑ADDITION ❑SFRU II URAL PIPIT
Zd Date Contmdor
tn66 ❑MUL'I'6UNIT ❑STRUC FUkAI.
ZS�,� Cnall b Use DECLARATION PANELS MODIFICATION
v�7, lundetamnd nyplamshnll nc Used as public rcrorAx, - CHIMNYRF'A
OZ—O UP TO 200 AMPS ❑IN'I'IiRlOk []CHIMNEY kIiI'AIR
I.M,,, � Licensed Pmfecsi...I 201-1000AMPS IMPROVEMENT 05WIMMINGPOAS
gygFq", OWNER-BUILDER DECLARA'L'ION OVER 1000AMPS [I BATH RIiMOUIiUREPA ❑DEMOLITION
gem, I hereby aRmh that 1 am exempt from the Contractor's License Law for the fp m
[I OTHER
y U folowiny mason.(Smtiou 911315.Brains,and Prafcssio I,Codi Any city or cnunry SIGNS ELECFkLCN.
Y11 t N whish onfa ms a permit m construct,aIle,,improve,demali.vh,m repair Try immure
fCC".u,at rt
prioo its issuance,also requires the applicant for.such pemtit m file a signed statement SPECIAL CIRCUIT/MISC.
222 that he is licensed pursuanno thepmvisioncof mr,Contractor's Lieuum Luw(Claue,Y - COMMERCIAL:
W�'C� (conu,¢ncingwith Secti.n71 B)of Division3ofthc Busiressand Professions Gxle)or TEMP.METER OR POLE INS T.
d y M C that her%exempt therefrom and the basis or the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION ❑DF.MOLH'ION
4%1 4• Section 9031.5 by any applicant for a permit subjects the applicant to a civil penuhy of POWER DEVICES ❑*117NAN'I' ❑1'001)SERVICE
not mom lhmfvehundreddollars(35W).
Lux awnerrd the I SWIMMING POOL ELECTRIC IAIPROVF:MEN'1'
❑ pn,at y.or is notipindexwilhered puxalle r sole compensation,
y' and dothewmk'Tend Cork: he Contiwots License awdosnot apply in
Boniness ❑O'1'HIiR
Ly�� and Ymfcssinm G,Jo:The Contractor's License Law does not apply ut an owner of OfIT1.IT5-SWITCIIES-PI%TURES
3�' property who builds or Improves thereon,and who does Such work hhdsulf or through P
his own empluyess,provided that such improvements am not intended or olTered far NEW RESIDENTIAL EI-ECFR SQ PI'.
AID
sale.Ii,howeve,the hoildingorintprovement is sold within one you ofanrpletim,the SQ.IT.FLUOR AREA VSQ.C-C
owns,buildr, have the burlenof Towing that he did not build o,in.pnwe for par- 'U 10
pose of sm ve 'JUL ro
[3owne
1,un r of the prapeny,am exclusively contracting with licensed cmtrucmrs To rOTAI„
construct rhe pm)em(Sec ]BW.Business and 1 f.:orx Code)the Comment.Li- t y CITU
cemo l.aw Joe,,not apply to an owner alp pent h'M1 Ids or nprove%Barren J QTY E' 'lit Pl-UhIBING PERMIT' I. FEE 1. Lip:lL'PCfl1 II1(�
who contracts for such psjors with a comruotor(s)licensed pursuant the Contractors '' ' -
LicenseLaw. PER Ur ISSUANCE
❑I ran exempt muter Sec ,B&P C lbr this rcrson
ALTER-DRAIN&VENT'-WATER(EA) VNAA'I']ON
Owner Date
'WORKERS COMPENSATION DECLARATION BACK FLOW PRO]ECT DEVICE
L - I hereby affirm under penalty of perjure one of the following declarations:
❑I havered will muinmin it Cenitientcol'Consmn toeell'-insure liar Warkrr'sCnmpen- DRAINS-FLOOR,ROOF,AREA.GOND, S TYPE CONST RUCTION
moon,as provided lir by Section 3900 of the Labor Code,for the performance of the
work
birth this permit is issued. FIXED RES-PERI'RAP
(have and will alantin Worker's Conq,nation Insmunce,is requ lred by Section
3700 of the labor Cada,for theperfnmrance of the work for which this permit is issued GAS-ITA.S YSTEM-I INC.0011'I'LETS - C.GROUP AI'N
MYWarkcre IF omryrtc mEnsu mcaalcrrnd Policy nuenx wc:n'/b07 GAq-1'A SYSTEM-OVEIRa(HA)
Caster. - Yoliry No.:_L�-�o-S-L
C R"1'LFICATF,Op EXEMPTION FROM WORKIiRS' GREASUINDUSTRI.WAS It IsO ERCEFFOR
COMPHNSA'I'ION INSURANCE BUILDING DIVISION 17I7I1S
This weli0n need not Mcompleted ifthe permit is krone hundmal dollars(SIW) GREASETRAP
PLANCHIiCK THE
or le".)
Ii,olly that In the performance of the work l or which this permit is issued,[,bull SEWI7R-SANITARY-STORM ITA.210 FT.
not employ any person in any manner so as to became subjauo the Workers Contains- ENIiRGY]TE
Z satin.Laws of Calirornis.Outs WA'I'lilt Hl!ATEk WIVF.MfIHLECTR
Z Applicant t • GRADING FEE
NOTICE TO APPLICANT.If,after n,kin,this CcrtifirnT of Viabrition,you should WNrER SYS'IEMGREAI'ING
- a ; becume subject to the Workers Cmnpensution provisions of m
the Labor Cole,You mt, SOILS FEL
Lia forthwith comply with such provisions or peanut shall be denned revoked. WATER SERVICE:
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PUMP. SQ.I'Il PAID
V0 I hereby affirm that there is a connmorion lending agency for the perfonrance of [)—are Receipt#
1"t the work far which this penn.I is i...N(Sou.3099,Civ.C.)
U Lenders Name 'I OTA L:
H.1 Lenders Address IDEAL:
A. 1 cenify that I have mad this application and state thal the above infonn:nu m is BUILDING FEE
h
correct.Iagree l comply with allcity and c appy ord an
ansate laws relating i QTY'a. MECHANICALFERMIT I FEE'
U xt huIIJ' gemhxtmd h.andl crcby echo,ry p nc nnl vcX of lhsmty¢,enter upon the SEISMIC FEE
aMve-mentioned Dmpcny for mallonar prnTus. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hmmlcss the City of Cupertino against ELECTRIC FEE
liabilities.judgments.costs and expenses which may in any way room,against slid City ALI'I!R OR ADD To M ECI I. "'�
in asequence of tn
he granting of this panni. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(XX)CFM)
MECHANICAL ItE
SOURCE REGULATIONS.
AIR HANDLING 11NIT(OVER 10.00t)CFM) CONSTRUCTION'fAX
Signatureof Applicam/Corractor - Dam EXHAUST I1001)(W/DUCT) HOUSING MITIGSI'[ON THE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Fuildng occapunt store or handle M1vurd...maternal HEA1 ISO UNIT(To 100,000 B I'BE
as definbl by the Cupertino Municipal Code,Chapter 9.13,and the Men Ina and Safety HEATING UNIT IOVER 100,0113 TO)
Gdc.Seen a 25532(a)'1
❑Yee No VENTILATION PAN(SINGLE RESID) PAID
Date Receito
Will the applicant ser Poore builJlny occnpaul ave oquipnmntnr devlucu whirl
innit haurdous air contaminants as defined by the Buy Arca Air Quality Management BOILER-COME'(3HP oN 11XI,IXX1 B'I'U) -
D strict' ',oral.: 6
❑Yes 11 No Hf111.P,R-GDMPfpV1?R IIXI,IIIXI BT'U) ' P
I hso,m. Ilio It...o1m. nimeritt1, tx ands,Clan -GJ$nf the Ghli AIR CONUITIONER
hcyn000en pa't ISSUANCE LINE 1:
ballsHealth& a me Cute,Sare 8505.25533 and 255Jq,1 anJentun tlmt if the NEW RE.SIUENI'IAL MIiCH. SQ.Fr. L
hullJing does cartem havyate :111.1 It is my resrymeibility to Mcmm mhmeh vat
.I,hc{ui mus Mtn(prior lhiihanceal'e Ccnitran '1mann Y.
Owns r art,nn,ad conn Uulc TOTAL: ISSUED BY:
OFFICE