S 1209 (2) APPLICANT-:O FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHI n'No
BUILDING DIVISION APPIACXFION/PERMIT PLUMBING-MECHANICAL 1209
BUILDING PROJEC'C IDEN'IFICATION
BUILDINGADDRESS SANI'IARYNO7PI'I.ICAI'IONS(111MI'I-I'AI,UAH!
w 2 '3`?8
OWNI 'S NAM E: PHONE: 'ONBAC]OR'S NAME: LIC NO'.
NIC CON'IROI,a
irwrc
-�ARCHITECDENGINVER: LIC NO ADDRESS: El
CONTACT: PHONE. BUILDING P aRMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) 131.DG 13LEC PLUMB MI!CI I
❑ ❑ ❑
LICENSED CONftfile
TOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licender provisions of Chapter 9(commencing
0CZ with Section 7") 3ohbinessaod Professions Cale.and my license is RESIDENTIAL:
4:00 In PERMIT ISSUANCE
S 4:F full force and eRcen�b ❑tiPDWL ❑KITCIIISN REMODEL
QUU L¢ense Class a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REbPIPI?
F-ZW Dine maCIO,
vsQp, ❑MUl MULTI UNIT ❑STRUCTURAL.
R Ir CIOIiCLARATI(N
~NZ IO.dentandmY plart—ImIl has public records E`ANEIS MODIFICATION
0Z-- UP 10 AMPS [:1 INTERIOR ❑Cl IIMNI:Y REPAIR
17`�_'F-W Licenser]Pnfcesional201-II11111AMP5 IMPROVEMENT E)SWIMMINGPOOIS
�•1�� OWNER-RUR DECLARATION OVER IN)ANIPS ❑BATH REMODELREPAIR ❑DFMOLI'ETON
K Q 1 herebyffnn that E am exemptfrom the Contractors License Law for the
a ❑OI'11LR
3Cas F following mann.(Section 7151.5.[Business send Pndessions Calc:Any city or county SIGNS ELE6'I'HICAL 70
which requires a penin to construc ,improve,demolish,or repair any slncmn, e-f
Jprior m its issuance,also requites thecant losuch p mm filEle a.Ignedamtetnenl SPECIAL CIRCUIT(MISC.
ohm he is licensed puaumm ht the provisions ofthe Contractor's Livense Law(Chapter COMMERCIAL:
W CLpO (emmmencing with Sworn1001nof Eversion 3ofthc Rosner,and Professions Code)nr TEMP.METER OR POLE INST.
4 4 tY that he is exempt therefrom and IAe basis for the alleged exemption.Any violation of ❑NEW NLDG/ADDITION ❑DIiMO1,IT10N
W o m Section 7031.5 by any applicant Rt�r a Perim subjects the applicant set a civil penalty of POWER DEVICES ❑TENANT ❑1:001)SERVICE
me name than live hundred dollen($510). IMPROVEMENT
SpOa own
Ler Ofthe prnpeny.or my employees with wages as their solecon,cremiou SWIMMING POOL ELECTRIC OTHER
E., will Jo the work,and tho-anrmrc is not in adedorofend fin-Ie(Sce.0,14.Business ❑
L 3 m and Pmfessious Cale:;I he Commetor's I.ice-1.w Live J,ns mat apply to an Owner of OUTLETS-SWITCHES-FI%TURES
property who builds or impmvcs themon,and who does such work himself or Ihnugh
Inown employers,provided that such imprwenmmCl
n are not intended Or offered lie NEW RESIDENTIAL FI-ER SQ FT.
sale.If.however.the budding Or intprovammud is wld within one ye,rct , uprion.the SQ.IT,FLOOR AREA !sMy FI'.
towner-builder will have the burden of proving that he did rm1 build or imm
prove let p -
punsf
I] 1 f line pru,somyifuliorl, t i b 1 Kvialed I I I :Ill
construct h ployerN 9(94.Ra,ane,-and POAr,lion,L 1 ,)The L I' I"-
vcl.awdues not p,I,to an osvncrof pmlwny who buds or reproves darsm,md QTY PLUMBING PERMIT FEE
wh(, onrals Ea-,c,hpmjres with;.cnnln:oon,)ho,o,rd,. ...nose the Corindor'.
I,Iccnsu Luw. PERMIT ISSUANCE
Ian event pl un der Sec. ,II h P C or this nvnon
AUFER-DRAIN&VE ER(EA) VALUATION
ownDalc
WOItKI:R;S G.OMI'I1NSA1'I(IN bIiCLAItAIan, HACK FLOW 1'R(YCEC'C
I herehy.1 inn mals,penally of perjely 11-11 OI'Iha 1bduwde
ing clamdon
❑ er Ihuve and wilhnamuin a Ccrlifrtulrol Cunsanuo strlf-Insure tar Worker's Contprn- DRAINS-
IlAO P. A, S'IUIIIpS 'I'V IT CONST fill(,IION
vatior.as providedlio hySection 370ol la,Ltk,,Code. or tire allornalue,of the
work f..whichd',pet I, 11X'CIIRLS PEN'fH
7 1 have Oil voillnn I nW kcr,Cn nlwtsmat hnconale,.,c,mocdhySee on
3701 of the Lvhor Code,for lire perhmname of the work for whish lhspmut lv,,surd. CAS EA SYSTEM-1 INCA '1' S OCC.GROUP AI-N
My Wa C"1111
nsui-1" 'on ycmm artier and Policy r
}}�b rc �f
Curtler: Pnliry Nod-1JQ �o ` GAS-EA.SYSTEM"OVLR4fEA)
1 1'll'1CALOPE%IiMI`IION FROM WORKIiKS' GREASITNDUSTRL WASTE INTERCEPrR
(Ttiswnion neeAn OMPENSAI ION INSURANCE BUILDING DIVISION PI!LS
cA it he pen:ut is husme hundred dollms(SIM) GREASETRAP
or Icss.) PfANCI IIeCK PI!E
I certify lira in be perftnnnee offlework for which this l<rmit I,issued.I shall SEWER-SAN]'CARY-SI ORM EA.200 FT.
not employ any peaors in any manner so as m m
faccoe subject as the WrakcN Contain- LNIiRGY PEI;
Z smiorl Laws of Califomia.Date WATER HEATER WN111,TCF,LECfR GRADING ITE.
Z O Applicant
rM SOILS Igili
NOTICE TO APPLICANT:IL'afmr making thin CerifcaH of Lxemption,you should WATER SYSTEMn"RENTING
Fes , become subject o the Worker's Compensation previsions of the Labor C(Ae.you must
Qhmhwith comply with such provj,iup,o,,hi,permit shall Be droo revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.F2 PAID
U Z' Doe Receipt
(hereby turner,that then in a construction lending agency for the perfommnce of
[ULE the work for which this permit is iauold Sec 3(P)1,Civ.C.) "r(YrAI.:
O Lender's Name TOI'A L.
E
} LU[1 Letlder's Address BUILDINGIT
y E certify that I have mad this application and state tom the shove information is
E y corcd.lagnc mcumply with all coy and county nNiwnccs and sure lax.rclaing en QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building constriction.and hereby authorize representatives of this City ht enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC ITT
(We)agree nn wve,indemnity and keep hornless the City or Cupertino against
Iiubilities.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER I0.000CFM) CONSTRUCION'E'AN
Signature of ApplicnnUCOnmsat Dam EXHAUST HOOD(W IDUC) HOUSING MITIGATION PLL
HAYAROOUS MATI!RIAI S DISCLOSURE!
Will the,applicant or future building occupant smru or bundle haz.0...mmrrid HEATING UNI"r LTO 100.0001 BTU)
as defined by the Cupertino Municlpal Code,Chapter 9.12,and the Health and S.@ty HEATING UNIT(OVER W.(010 BTU)
Cale,Section 255321.)7
C]Yes E]No VEIN'I ILATION PAN(SINGLE RESID) PAID
Due
Ruziplp ��
Will the appftcam ser future hadding Occupant sew equinvolt or de we, bush I1UIhBR-COMP(3HP OR IfM),WII BTU)
mit hvurJnus sir unnaminnntx us def inrJ by the 11 y Arca Air Qanlify Mnnugcment
DE,vic11 ROLLER-COMP(OVER IW.000BTU)
❑Ycs ❑Nn
1 hour rcuJ Om hneunlnus m:neri. yni r a t under Ch:gner 695 of the Cali- AIR CONDI'1'IONL'R ISSl1�ANC$uljfl?
!Irma llcallh.4 Safety Cndc.Safi. 16, 125534.1 andcotanJ dol If Iha NI!W RI!SIDIiN'rIN,MI?CH. SQ.FTI'. Y/�C�l/
huildingJcesnotcurrenlly ill ono IY u 'Itylnnotifylbcnacnpnt
of thercl nrcnmle whir sl le nmll a Ccu 'ala Of Once, . A
Owner ser uodmriacd.gem D ILL
TOTAE.: ISSUI3D HY:
OFFICE