49100121 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9 11 I O
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING:DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PHOJE(:T imbrrIFICA'CION
BUILDINGADDRESS: SANITARY NO APPLICATION SUBMITCAI.DATE
fBR9 NAM` ONCONTRACfS ME6
NIC CONTROLp^ GOA V 95 4�0111.1
CHITECiIEN N":
LICNO'. ADDRESS � ; O El
ct
CONTACT PHONE: BUILDING P' MIT INFO
A&. -e ❑ Consultant Few Paid by Applicant(Initial) BLDG ELECT NISCH
Li �ac��s 83 3� 5133 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'r ELECTRIC PERMIT FEE
o Iz z 1 harChy al irltt mat 1 am rleen.rd ander pmni.iam mf chapter 9(commencing JOB DESCRI ION
'00 with Secmnn]g0)of ilivision}ofthe Bnsinax and Professions Coda.amdmylicerseis PERMIT ISSUANCE
E+-_. in erose eve unJ clfcm. a SFDWL ❑KITCHEN REMODEL
Fa+UgU License CP-s Lica 405 ia-h!g AM
APPLIANCES-RESIDENTIAL pUUIT10N El PLUMBING RfiPIPli
N Z G Dam Conwemr
E,<m ARCHITECTS DECLARATION PANELS [-I MULTI-UNG ❑STRUCTURAL.
Z O�,Z„ I tmderdund my plena shall be used as public records MODIFICATION
OZ—n UP 102MAMPS JIM PRIOR E5 CHIMNEY REPAIR
Licrnsad Professional 2011-11X0AMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION
Kaz- OVER I"AMPS BATH REMODEIJREPAIR ❑DEMOLI'TION
C I beery°(firm the I am exempt from the C°nlm°t°r's License Law for the
X G C.U following reason.(Section 7031.5.Business and Prafec ions Code:Any city or county SIGNS ELECTRICAL []OTHER
y which mquims a permit m ourvine,alter,hnpooe,dcmorsh.or rcpmr any,tmeure Q A/d
C, which
prior to issuance.also requires me applicant for such perminofleosigncJ statement SPECIAL CIRCUIT/MISC.
fly that he is licerved pursuant the provisions of the Contractor's License Law(Chapter9
W (commencing with Section TINE of Division]of the Business and Professions Gyle)or 'I ENM METFR OR POLE 1NST. COMMERCIAL'
11 a c Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
M or, Section 7031.5 by any applicant lin a Permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENAN'C ❑FOOD SERVICE
not,ere than roa hundred d°ltam(S5UU).
H Z Y IMPROVEMENT
L MLothe work.theprnproadur myemntendes withwagcsaNile w,704tpcnsiness SWIMMING POOL E?LI?CTR .
W F,C will da(kale k.and the he Cao i%notn,ou',Lieneeed Law
red dos not apply
to an Business ❑OTHER
L 3 w and I'mfeshob Cale:The Cummctore License 1<w'dies not apply to owner of OGI'LIiTS_SWI S gXTURES
popery mpl builds or impmvc thereon,i and who d°ca such work e deedohimself or through
his awn o ever,the provided that such tent ivsold w are mol:year UL v or uif d fur NI?W RESIDENTIA R SQ FT.
sale.If,hwvevcr.the building or improvement ivsold within one year of completion,the SQ.FT.1'LDDR AREA SISQ.IT.
owner-builder will have the burden of proving that he did not build or Improve torpor- :72.
pume.f
inpar-
pom.f sale).
Fl 1.as owner of the proper,,an exclusively contracting with Iicenxed Contractors to MAL:
construct the project(Sec.7044,Business and Professions Coda)The Contractor's Li-
,hocausc d.1,iow sn°tapplre mansithaofon,a),property whosedPtsds or...I improves tharcCiamo^.unJ Q'CY. PI,UMBI FEE
who contracu for such pmjec¢with a rnnlracmKs)licensed pursuam to me Comramors
License Law. PC
RMIT ISSUANCE
❑I.mesempl under Sec .B&P C far this reason
Data
ALTER-DRAIN&V 1?N'I'-WATER(EAJ VALUATION
COM T'l
WORKER'S Penalty
parjorION Uf the f following
MACK FLOW PROTECT DEVICf?
I henry affirm under Canifiy oe perjury one of the following Worker decimations:
1 have pand wrovided
(or bynetion 7M of Comemmnost,for the Performa Compem DRAINS-FLOOR.ROOM AREA.COND. STORIES TYPE:CONSTRUCTION
min°,as provided for by Section 3](0 of the hMr,Cost,for the performance of the
work forwhich mix pantie is orW, FIXTURES-PER TRAP
❑Ihave and wiltode.(ase parrs Compensation Insurance.for which
dnt Section
PlNl of the l.uMn Gala tin ere perfannuncc ofthe work larwhich this prnnim In issued. GAS-EA.SYSTEM-]INCA OUTLETS OCC.GROUP 2 N
My WorkG�c CAoryp{n5atiyn hourance cmricra^J Yulicyn bur ate
Caner: 15 LX PnliryNty: 1417 �Q�'I GAS-PA.SYSTEM"OVERS(fiA) O 6 3 Z�
CERTIFl�CAT Ii OPT..MPDON FROM N'OHKERS' GREASE%INDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is forone hundred Jollars(SIM) GREASETRAP
or less) PLANCHECK EEE
I ecrify thud^the tertmovar.ofthe work forwhichthis permirix i...ad.lsrall SEWER-SAN]TARY-STORMEA.200 ET.
tot employ.an,par tanyn nu xoas to becmou subject m the Workers' ENERGY FEE
Z safe.lows of Califomia.Data all WATER BEATER W/VENT(ELECTR
zO Applicant GRADING FEE
z NOTICE TO APPLICAN'C If,ager making this Certificate of Exemption,you should WATER SYSTEMOKEATING
(✓ , beconm xubjeauo the Wnikc Cotnpensmion Fmvi.inns or the Labor Code,you nasi SOILS FEE
�+ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
JQ
Q. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FI'. PAID
z Ihcrehy.fbnn that there is aconstraction lending agency for the performance of Data Receipts
�' F the work for which this Permit is issued(Sec.3097.Civ.C.)
' Lender's Name TOTAL
OULender'.Address TOTAI;
6. I arli,Nal 1 have repl
d this^ ication and state that the above information is BUILDING FEE
h Cortef l agree to comply with all City and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE
U 2 hulldingcnnmruction,and hereby cal n,anam.,anatives Ufdo,anyloenterup°n the SEISMIC FEE
°Mrvermntiorod popery for inspection purposes. PERMIT ISSUANCE
(Wc)agac m save.inde �nnnity and keep hikess the City of Cupertino against L'LE:CfRIC FEE
liahiIiirs,jm,ftmms.co,ts and expenses whichntay,inany way mcoc.gainn said City ALTER OR ADD TO MECH.
PLUMBING FEF
InCANT Uf thegnlTAN Sthis permit.
SOURC1AN'CULATIONANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALhEE
SOURCIi REGULATIONS.
AIR HANDLING UNI'P(OVER IU,IMYJ CPM) CONtiI'RUCPIUN TAX
Simulate NApplicanVComracmr Date EXHAUST HOOD DVMUCT) HOUSING MI'I IGATION THE
HAZARDOUS MATERIALS DISCLOSURE
Will mheapplicant or future building aecupanl storem handl.hasardoas material H17A ONG ON I'PTTD I Wane)11'1'U)
as earned by Thr Cupertino MericiFil Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ 1117ATING UNI"f(OVER I Minot BTU)
❑Ye. 0N VENTILATIONFAN(SINGLI?RESID) PAID
Dine Reaeiptp
Will he.,,fix; ( ,,[Marc buildingoccupant use equipment or device,which
.it hazardous air camtamirmet,as defined by the Buy Art.Air Quality Managetnem BOILER-cUMP(3 HP OR IW."BTU)
T01'AI,:
inrixll BOILER-COMP(OVER 100,000 BTU)
ClYea Fl No
1 have mad the Indianians bra mals requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
femme Health&Sufcty Core,Seat iuns 23505.25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECH. SQ.IT.
buddingdxcsnot merit,ravcaten.nLthar it is my respon.cibilltym many rite occupant
of ate req v, ,t be tom prior to issuance of n CeninraI OecuP I y.
Ow c an t eJ agent ate TOTAL: ISSUED BY:
OFFICE