S 0348 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFy` 11 NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V 0348
'BUILDING PROJECI' DEN'FIFICATION
BUILDINGG/A``DDRISS: _ - SANITARY NU. APPTLICAION SUB
SMIT AAL DATE
{.�
NE 'S NAME: HONE: C RACI'Ok'S NAME: LIC NO.
CC tz' -)97 �(k.d i'I r 05 NIC corITRGL«
•ARCHITECTIENGINC•ER! - LIC NO: 61)DRES n�� ❑
w'4s.. `
CONTACT, PHONE: BUILDING PI7RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ C9 ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECT'RICPERMIT FEE
1 hefchy aBlnn Thai I am licensed under prdvicinna.1 Chapter 9(commencing _ - JOB DESCRIPTION
a
FY with Svefim700(B of)ivisian3of the Rusinexs and Prnfcsxinnx Cnde,and niy license is RESIDENTIAL,
�� full Emmaus]dlbd, PF:RMI'1'ISSUANCFi
W F, '" ❑SPDWI. ❑KJTqIIF.N REMODEL
yVV License C1.ss LIC.IT APPLIANCES—RIES IDENTIAL [I ADDITION UMBING RE-PIPE
LDom Contractor
ARCHITECTS DECLARATION PANELS [_1 MULTI-UNIT UCTURAL
z O lin Z I undemmnd my plans shall be used as public records MODIFICATION
OZ`30 UPT02MAMPS [3 INTERIOR C3 CHIMNEY REPAIR
FBF,; Licensed Pmfiessi...I 2014000AMPS IMPROVEMENT C)SWIMMING POOLS
gSqgd OWNER-BUILDER DECLARATION OVER 1000 AMPS [3 BATH RF.MODEI/REPAIR [I DEMOLITION
C Q I herehy effimt that 1.m emmpt from rhe Cminacmr's License Low for the
C W V fallowing nomas(Section]031.5,Business and Professi...Cade:Any city or court SIGNS ELECTRICAL ❑OTHER
y¢ which requires a Permit to contact,alter.improve,demolish,or repair any s.ucore
F^��J prior,.its issuance.also requiresihev,plicaut for such peorchm BE...i,indmi,mamnt SPECIAL CIRCUIT/ -
j. tbar be is licensed prodomnothe provisions nfine Cominco/s License Law(Chapter 9
a�Op kommencing with Scction 91100)of Division3"fthe Business and Pmfessinns Code)of TEMP MFIER . I.ENST. COMMERCIAL:
4 o C that hxe
e is empt therefrom and the basis for the alleged exemption.Any vieliflam of ❑NEW BLDGIADDITION ❑DEMOLITION
-^,y Section 9031.5 by any applicant for a permil subjects the applicant o a civil p dmhy of POWERDEVI El TENANT ❑FOOD SERVICE
I.
not more man Ove hundred dollars 15500.
Y IMPROVEMENT
I�ia^S- 6 ❑I,asre own'
wurnfthe nd propenluuamyemployees with wagesrtheifwdecn......minn, SWIMMING POOLELE C
G andwildo The Professions
Codle: he Cont is tot intendedLicense
Law
do for apply to on owner
❑O'T'HER
m and eny who h Cale:The Contractor's themr's License Law does not apply o ilo owner of OUTLETS—SWITCHI!S—Irl 'U '
�' propcny who hnildx or improves thereon,and who rasa such work ulcil or or thrnngh
his awn anplay the provided that ssmh]mPos sold
thin not year of nr n0bred for NEW RESIDENTIAL ELECTR OITT.
sale.If.however,the building nrimmnvement is sad within nneyeundconipldinn,The SQ.IT.FL(lflk AREA $ISQ.t1'.
owner-huilder will have the burden of pmving that he did not build or impose for pur-
pn ^ � '
ve.f".1 L D
❑ I,as owner of the propcny,am exclusively contracting with licensed contrucon to 1(yl'AL: Y-'
construct the project(Sec.904.Business and Professions Cade:)The Corin attor's Li-
ceres,Law does not apply to an owner of property who builds or improves iherenm unit QTY. PLUMBING PERMIT FEE pYJp 9 8 �(}qf
wcontracts t acts far such pmjems with acommctor(s)licensed pursuant to the Contreao's v Y
Liecme Lucs, PERMIT ISSUANCE
❑ Iain exempt under Sec. ,H&P C for this..anfZ�! Vf
Owner Dam ALTER—DRAIN&VENT—WATER(EA) N.UATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ti f rte under Penalty of perjury one of the following declarations:
❑ Ihave and will maintain a Ceniftcate of Consent to self-insure for Worker's CnmPvn- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
action,ox provided for by Section 3700 of the Iahm Code,fm per
the f cdrdwe of the
work for which this Permit is issued. FIXTURES—PER TRAP
El have and will maimain Workers Compensation Insurance,.aa required by Scrium
3701 of0m l.aMsrCnde,for prerhommum ofthe work for which this Permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLID OCC.GROUT' APN
My Wnr CnnTPens.1inn Ins im ce diamerand Policy nu56K
Curtiar: �. Policy Nn.: 925 GAS—P.A.SY53'f!M QYIiN 4(HA)
CIiRI'l1ICATH OF EXEMPTION FROM WORKERS'
COMP17NSATTON INSURANCE BUILDING WASTE INI'IiNCCPIY)It
❑UILDINO DIVISION IIIiE9
(This section need not he completed ifthe permit is for one hundred dollars(5110] GREASE TRAP
no IessJ PLANCIIECK PIAT
I ccnify that in the performance ofne work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.21X1 IT.
not employ any Peron in any manner so as to become subject to the Workers'Compen- ENERGY FEE
ZZ sai.n laws of California.Ilam WATER HEATER WNEIsENFLHCTR
Applicat, GRAVING ITE
y NOTICE TO APPLICANT.If,after making no,Cenihcate of Eeemptinn.you should WATER SYSTEMVTREATING
hecmo,subject In the Wnrkds Compensation provisions mitre LeNo C afu,you most SOILS ITE
W forthwith comply with such provisions or this p,orft shall be dared revoked. WATER SERVICE
D Q
7 Z CONSTRUCTION LENDING AGENCY NEW RFSIDENTIAI.PLh1B. SQ,t'r. PAID Date Receipt p
VO work
by whnffmithanutihem issued( ee 30lendin.agency for perhimmnce of P
the work for which this Permit is issued(Sec.J091.Civ.CJ
� E*' lander'e Name 'I'OTAI,:
O LUk1 Lcndcls Address TOTAL:
iL I ccnify That 1 have read this",plication and sate That the above information is BUILDING ITP.
h
correct.I agree o comply with all city and county ordinances and stale laws relining In QTY. MECHANICAL PI?RM IT FTE
building mnsinmi,m.and herehy raniumim representatives of this city In enter"Pon The SEISMICFEE
shove-niantioned propertyfaririoNel mpmposes, PERMIT ISSUANCE
(We)"gree to save,indeinnify and keep harmless the City of CoPertis againstELECTkIC FEE
liabilidus,judgnmons,costs and expenses which may in any way accrue again said City ALTER OR ADD TO MECH,
in consequence of the Irani ng of this pe PLUMBING FEE
APPLICANT UNDERNDS AN L C fPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CPM)
RF1il+ A S. MECHANICAL.PF.R
SOURCE
AIR HANDLING UNIT(OVER 10,000CPh) CONSTRUCTION TAX
Sig I
oTAp anUCmu / G Date EXHAUST GOOD(WMUCI')
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEC
Will the applicant or future building occupant more or handle hazardous mmerial HEAT]NO UNIT(TO 1(X1,000 BTU)
es defined by The Cupertino Municipal Code,Chapter 9.12, it the Health unit Safety
Code.Section 25532(m? HEATING UNIT(OVER 1(0,10(1 U TU)
E]yrs ON. VENTILATION FAN(SINGLE RESIDE PAID
Date Receipt p
Will the applicant orfairbuilding occupant use equipment or devices which
emit hmN
noucontaminantsv sircontaminants as defined by the Ray Area Air Quality Management ROLLER-COMP(1HP OR 100.000 BTU)
TOTAL:
UisvieT( ROLLER—COMP(OVER I W.000 BTU)
❑Yes 7 N '
I have read The ha armus materials requitumenm under Chirpier 695 of Tic Cali. AIR CONDITIONER ISSUANC17 DATE
f n is Hl uhh&Safety Cale,Sections 25505,25533 and 25534.1"ndentim l that IIThe NEW RES]DEM'IAL MECH. SQ.Ef.
build'mg docs not amrend,have.tenant,that it is my responsibility o nosily The ocrnpnnt
of the wqUircinerns which run M mat prim to issuance ofa Cenifcate"f Oce"pancy,
Owner inmidorirdl agent Dace DMAI^ ISSUED BY:
OFFICE