S0001B0185 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CIPS OP CUPERTINO BUII.DING-ELECTRICAL PERMIT'NO
Bl51OFDIVISION APPLICATIONIPERMIT PI,UMRING-MECHANICAI, S00010185
BUMMING PROJECT IDENTIFICATION
BUMPING ADDRESS: /
. SANITARY NO. API'I.ICATION SUBMI'FI'AI.DATI
I Aj Wog
OWNF.R'SNAN E: PHONE: CU.YTRA ORIS NAh is LIC plyy'141N/C CONTROL,a
Dfill ECTIENGINEER: LIC NO. A 2 e AI/y. SJ .� ❑
CONTACE PHONE: BUILDING P iRMIT INFO
r W ��O ❑ Consultant Fces Paid by Applicant(Initial) BI❑DC LIiCT BPuO H MECCH
/✓/W/ LICHISSED CON]RACfOR'S DECLARATION QTY, EI,HCT'RIC PERMIT FEE JOB DESCRIPTION
I hereby allirm that I am licensed under provisions oil'Chapter 9(commencing
O'YZ with Seclion 7OAR Of Division 3nftbe Business and Prnressinns Code..and my licenttis RESIDENTIAL'
W p PERMIT ISSUANCE
in full force and e0ect _ �QS� ❑SFDWL ❑KITCIIIiN REMODEL
aU(~j Liccnm Clp: Lica pPPL1ANCE5-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
h2 U Dae Connombor
g.Dh ARCHITECTS DECLARATION 1'ANEIS ❑MULTI-UNIT [I STRUCTURAL,
H Z I understand my plans shall W used as public necmd. MODIPICKTION
OZ-o UPTO200AMPS [I INTERIOR 11 CHIMNEY REPAIR
F4F'LLl Licensed l'mfessional 201-I(kO AMUS IMPROVEMENT E]SWIMMING pools
CYz; OWNER-BUILDER DECLARATION OVER HxHIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
ft�=16 1 hereby affirm that 1 am exempt form the Contrecmr's License Law for the !�!77
�xm O6•U following reason.(Section 7031.5.Business and Promi,sio e,Calc:Any city or county SIGNS EI.ECTRICAI, L •Z O OTHER
W 3LL y which requires a perand to construct.alter,improve,demolish.or repair any amcmre
as C)
prior to its issuance,alsorequires the ppl' t for suchq i to rile a signedstatement SPECIAL CI RCUIT/M ISG
Sr�rg
that he is joca,edp.,.,art be f n- l'he Contractor',License Un,(Chapter 9 COMMERCIAL
�p'�� (usn me ms ng x'Ih Swt nm70a0)m(DVFinn3mfthu 1p;' s.. II I'.msCalC)m 'I EM M1.111:lt OR l'OI,I:INS I'.
d rya o pL Ihat he Is crcmpt therefrom and the basis for the dlelmd use prion.Any violmien Of ❑NEW BLDG/ADDITION 0 DEM(ll.l'I'ION
Sort 17031.5 by ony opplicom for ape.it subjects the mi,li,md to a civil perad,of %MINGSE�)I.
❑TENANT ❑FQOD,S'1?RVICE
nm nmom than live hundred d011ms($500). IMPROVEMENT
=0 ]Lvsawncr ofthe prnpcmy.or mYemployeeswith wagxasmhcir solecompensation. .1?CTRICwill Jo the work.andmheswcmreis not imcndedonmRemd Rnwle(See 7W4,fasincs OTUER
1 B m and Profeslons Cede The Conuai Lienu law Jens not apply to an owner of CS-FIXTURESproperty who builds or improves thereon,and who does such work himselfor throughhi.s own employees,provided that such improvements am not intended or offered for ELECTS SQ FT.sale.If.hneever,the building or improvement issuld within one year ofcompledon.the SQ.FT FLOOR AREA $SQ.IT.
owner builder will haw the burden of proving that he did nt Wild or improve for pur-
pose of Nola.).❑1,as owner of the property,am exclusively convuating with licensed contractors to 'AL:
ennenuct the project(Sea.]041.Business and Professions CiWc:)ThC Contractor's Li-
censeLawdoes not apply to an owner Of pnmperty who builds or improves thereon.and QTY. IN PERMIT FEF,
who c urracis for such projects with a con recua(s)licensed pursumn to the Convector's'
licence Law. P17RMIT ISSUANC.
] I aT eaengmmnder Sec. ,B.Ys PC tis thisrcaam
N:I'Ick-DRAIN KVI7NT-WAR(EA) VALIIAI'ION
owner Dam
WORKER'S COMPENSATION DEC1.A RADON BACK V[.OW I'ROTI?CI'.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent In self-insure for Workers Compen- DRAINS-19.00R.ROOF,AREA.COND. STORIES 'TYPE CONST RUCTIOb
tion,as provided for by Section 37W of the Labor Calc,far the Performance of the
I for which this permit is issued. FIXTURES-E'ER TRAP
1 h 1 will maintain Workers Compensation Insurance.as required by Section
37f of the laWr Coda far the performance of the worA fm whteh this permit is issued. GAS-EA.SYSTI:M-1 INC 40lITLETS OCC.GROUP AI'N
Ca crdet�CJmnipytrsmiO sutancg'as^° ug
Entry NnYn � GAS-CA.SYSTEMOVCR 4(EA) Sf
CERTIFI ATE OF EXEMPTION FROM WORKERS' GREASE IINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('this section need not W completed ifthe Noma is for one hundreddollars($10o)
GREASE TRAP
or Icss.l PLANCI F
I cccily that in the performance of the work for which this permit is Issued,l shall SEWER-SANHAKY-STORM EA,200 FT.
not cnmplay any person In any manner so as to become xub)mt to the Wnrmus Compcn- r ' ENE�GV FEE
Z sauna lawsofCalifornia.Date WAFER IIFAr17R W/VENT/ELECTR ORADESOt r
O0 Appliconl )
fNOTICC'FO APPLICANT:If,slier making this Cunifantn of Ustru Lien,you should WSJ ER SYSI EMO REATING= SOILS FEE
� ' fcconm subject y the Workers Compensation adsprovision,ithal of rbc Labor Cadevole you must
� s forthwith comply with such provisions radius permit shall W deemed mvoAN. WAt1iR SERVICE
0PAID
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMtl. SQ.Ill Oeste Receipt of
I hcmhffi
y arm that Here is a cnnstmetion lending agency for the performance of
— the work for which this permit is issued Nec.3097,Civ,C.) TOTAL:
Q Lender's Name TOTAL:
LU lender's Address
r I 1 comity that I have mad this application and state that the arson,information is BUILDING FEE
rFi co) comet.l agteu nm comply with all city and county ordinances and state laws relating to QTY. MFCIfANICAI.PERMIT FEE SEISMIC FEE
C.) Z building constrvmion.and hereby authorize representatives of this city to enter upon the
above round wood properly far inspection purposes. I'ERAiI T ISSUANCE ELECTRIC PEE
We)agree to save,indemnify and keep harmless the City of Cupertino against
Iluhiliiie,,Jalgnems.crisis and expense,whrshavy inany wa,swam against said City ALTER OR ALAI TO MECIt PI.UMBING FEE
in cam
.snpmaw of the granting of this permit.
APPLICANT UNDIiRS'i'ANDS AND WILL C.OM WI'I'll ATI.NON-POINT AIR IIANULING IINI'I'('IT)IQgNI CFM) MIiCHANICAh FEI
SOU ^4ppl
NSsAIR HANDI,I NO UN1'1'(OVER 10,000 CFM) CONSTRUCTION TAX
Sig marcontmem, `Dam EXIIAUSTHOOD(W)DOCI) HOUSING MITIGATION FEEZ RDOUS MATERIALS DISCIASURiiWlnrfumm Wildingacupamsmrc, handlchaemolmsmamrial NIiN'ING UNI'1'(3D IIXLMO RTU)
us Jefned M1y mho CupcninO Municipal Csde.Chapter 9.12,and robe Health and Safety HGTING UNIT(OVER 100.000 BTU)
Code.Section 25532ho)?
❑Yes AN. VENTIAT10N["AN(SINGI.E RESID) PAID
Date Receipt -2 AMR 1 its,
""'the applicantur future Wilding occupant use e9uipmem or devices which BOILER-COME'OHP OR 10.100 BTU)
rut bcardous air ttmerchants as defined by the Bay Area Air Qua1'ny Management ;IY \L: or
evinP BOILER-COMP(OVER 110.00)BTU)
❑Yet No
I have madmc havmJous mmeriuls raryircnenu under Chupmrh.95of the Cali- AIR GDNDfHQNI'.R ISSUANCE DATEI'nmiu Ilcalla le Sately Codc,Sections 25505,25533 and 25594.1 rmdcrswnd that If the NEW RESH)EN'I'[A),MECH. SQ.F-r /
building Joerc nateurtaanlyhovcumnunt,Ihnlnamyrexpm...dulay b.notify the occupant (� -2- (/
of dic re oI roams hlth t st W tot prior to issuance Of a CcNiieo •Of(X pane.
Own re. ambo er,. g t I Dae TOTAL: ISSUED BY: r
OFFICE