S0747 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICAT'IONAPERMIT PLUMBING.MECHANICAL O O /I I
BUILDING PROJECT IDENTIFICATION_ O 4i
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DNTF
le2o;7AK,
OWNER'S NAME: PHO RA )H'S IF LICK
NIC CONTROL#
(/L
ARCHITECT/ENGINEER, LIC No A DSS: / ❑
CONTACT. PHONE: BUILDING PERMIT INFO
Consultant can
Fees Paid by Applicant(Initial) BLDG G PLUMB MELD
D�, e,e ?7Z-/is o- ❑ ❑
LICENM DCONFRACIORS YEELARADON QTY. ELECTRIC PERMIT - 193E JOB DESCRIPTION
1 hereby affiml that I am licensed under provesitor,of Chapter 9(commencing
n=Z with Sen an 7000) fl)"", 3ofill Bmne dP dcoxion.G of my hccnex is RESIDENTIAL:
W p PERMIT'ISSUANCE.
an force an Z [A17.J�1 n ❑SFT)N'L El KITCHEN REMOUIiI.
QUU License Class Lie Or APPLIANCES-RESID1iN UAL ❑ADDITION EPLUMBINGRE-PIPE
yQL DaLJContrac�r�— EMUI:I'I-UNIT ESTkUCTURAL
''�//nJ ARCHI'TECT'S UL jSi ) W/ PANES MODIFICATION
OF-HZ l understand my plan...shall be used as public records I/IIt�1 UI'TO 100 AMPS
Z Sn G E INTERIOR YLTBh1 POINTY REPAIR
Fa t?f-ad Licensed Pmfiersinnal 2014000AMPS IMPROVEMENT C)SWIM M ING POOLS
CY C OWNER-BUILDER DECLARATION OVER I000AMPS E 13ATH REMODEURF,PAIR EDEMOLI RON
C Q 1 hereby affimt that I nm exempt from the Contractors IJ ense Law far the
Kii V following recam (Semion W).31 5,Baca...end Professions Codc:Any city It county SIGNS ELECTRICAL ❑(YfHIER
413 LL.h which reclines a permil m co mlract,alcor,improve,demolish,m repair any sanctum
F�O5 pon...wits issuance.alsorcyuiteslhuapplicant for.mch Permit file asignedsmtemeat SPECIAL CIRCUITIMISC.
fury that he is licensed pinsaanuo the provisions of the Contrenors License Uw(Chapter9
'C�p (commencing with Seninn lfXO)nf Division tof the Business and Prefnsslons Cdc)nr TF,MR METER OR POLE INST COMMENCIAI:
d athat he is exempt therefrom and the basis for the alleged exemption.Any violation of _ E NEW BLDG/ADDITION E DEMOLITION7f�_ Section 1031.5 by any applicmd for a remain snhjects the app licnm¢t ncivil penalty of POWER DEVICES E'I ENANT ❑FODU SERVICE
not more than live hundred dollars(S.NIO).
=0 IMPROVEMENT'
E]1,asowncr ofthe Propert,or my employees with wages as their sole cou-Nmatinn. SWIMMING POOL ELECTRIC
F. will do the work,and the structart is not intended or offered forsale(Sec.0011.Business El OTHER
6 3 m and Prnfessiom Cde:The Com-cwrs License Law does not apply m an owner of OUTIA TS-SWITCHES-FI%TURES
properly who builds or improves thereon,and who does such work hitnml[or tM1rnugh
his own employees,provided that such improvmncros arc rate intcndndfmmplm dTerd for NIEW RESIDENTIAL IELI:LTR SQ FF.
snle.IL hnwcwr.the building orimpmvemmit ix xulJ within
onyear oetion,pm SQ IT.FLOOR AREA $/SQ.FT.
owner-huilder will have the harden of proving that he did not buil)m improve for par- D�C 16
you of sale.,. To' C{/ RECD
E,as owner of the Property,am exclusively contracting with licensed council td
constrict the projmt(Sec.11441,Business and Professions toxic The Contmnoh Li- - CII Y
slaw does notopply ut nnowacr afpnlm,who builds or impmsea thereon.and QTY. PLUMBING PER T V!' ka Vf"CPI(lipu
who wmmem fur such p,ojeul,with a ematelo ls)licensed prrsnanftd the Comnamnr'x
License l,aw. PF,RMI IISSUANCE
E l am exempt under See ,B&P C for this reason
ALTER-DRAIN&VIiNT-WATER(EA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O 7/A �-
I hereby alarm Inde,Penalty of perimy oncof the fallowing dmlamtidm Q oo
❑I have and will moon, i Cendinsecol'Conselam,,df--insure lira Wink-,Compcm DRAINS-FLOOR,ROOF,AREA,CDN D. STORIES 'I'YITE CONSTRUCT ION
smart,as provided for by Sevin..3900 of the labor Code,for the Performance of the
ter which Ibis permit is issued. FIXTURF_S-PER TRAIT
o I have and will maintain WorkcR Compensation Insumnee.as requined by Section
3 Mthe lahorCde,for the rertormance of the work for which this permit is issued GAS-EA.SYSTEhLI INC.JOffi'LETS (KC.GROUT' APN
MfyW m lousy o:
Currieroau PollOndey Na.: GAS-f3A.SVSTEMOVIiN J[EA)
CERTIFICATEOFE) PfION FROM WORKERS GREASUINDUSTRLWASTE INTERCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION PEGS
(Thissectionnmd not becompletedifihe Permit isfornnchundrddollars(5110) GRIEASETRAP
PLrMaCf{ICK FEL
Ioyanylhm...a.peHdmmearso the work
accomewInch this Permit mooned.Ca'al all SEWER-SANITARY-S'IORM EA.?l()IT.
not employ any person in wry stunner so m w hmnme subject ret the Workers'Gmtpcm ENERGY FEE
Z satins Laws of California.Date WA'I'171t HEATER WIVENTIELECTR GRADING FEE
Z O Applicant
. NOTICE TO APPLICANT:If,after making this Cenifieaw of Exemption,you should WATER SYSTEMITREATING SOILS FEE
Femme.subject to the WoOcr s Compensation pmvixion,of the Labor Cods,you must
ai forthwith comply with such provisions or this permit shall b:dmmed revoked WATI7R SERVICE
aQ
7z CONS]RUC LENDING AGENCY NIiW HIiS11JF,M'IA1,I'hMN. SQ.FT PAIDPAI
l hemby .tbahere is.rmietion landing agency for the Pen
rfnnmtee of [)am Or ipn#
afftmnm
Ne work far which this pemtit is issued(Sec.3097.Civ.C.) TOTAL:
O V Lender's Name
Lender'..Address TOTAL:
G BUILDING
I candy that I have mad this application and state that the above information is
h correct.l agree to comply wall all city and county ordinances mad slate laws relating dt QTY. MECHANICAL PERMIT HE SEISMIC FEE
V Z building.....al on,and hereby vutbmiv<rcpre...an"xold'iscity¢t emerupon the
above mentioned Properly for inspection purptsc.s. PERMIT ISSUANCE ELECTRIC FEE
Al agree to save,indemnify and keep M1amtless die City of Cupertino against
liabilities ' Jyyytena.cmts and expenses wh' oym any way are.against said City' ALTER OR ADD TO MECH. PLUMBING FEE
value
Ne gmming of this permit. -
APd (CAN UND STAN S AND WILL CO (PLY WIT ALL NON-POINT AIR HANDLING UNI'1'CFO 10.000 CFM) MIECfIANICAL Ji
S G G 1
AIR IIANDLING UNI'i'(OVF.R IB,dfN)CFM) CONS'rHUCTI( '
n turco pplicanVContr�c tr_ ate E%HAUS'T HOOD(WNUCfJ HOUSING MITIGATION PEE
HAZAI{ US MATERIALS DISCLOSURE
Will the upplicont ort uture btaddingoccuranr nmol handle haaorddoa mmerial HEATING UNIT(TO H0.000 BTU)
as defined by the Crpenind Municipal GMs,Chi p lir 9.12,and he Health and Safety 1{i?APING UNIT IOVI'A lUl),IXO H'lll l
Code,Section 255121a)'!
❑Yes a4o VEN'1'l1.ATION FAN(SINGLE RESID) PAID
Dale Receipt#
Will the aPPlicamor ban 0,building tscupent use equipment or devices which. BOILER-COMP CIHPOR 1110.0X0 BTU)�emit hazardous air commainints' defined by the Day Area Air Quality Management TOTAL:
DiatricB BOILFR-COMP(OVER 1001000F'1'lD
❑Yes No
Ili h as the hmA oust a rials requimmc t under Chapter 6,95 of the if he
AIR CONDITIONER ISSUANCE DATE
fornix allh Safety Me.S n 3505,easy M 25511.1 understand that if the NEW RFSIUF,NTIAI.MIiCH. SQ.FT
buil ngd no,cu I ha as Lthm it is my sponsih" nt Motif the mcupant
of _ in- r?nrm issu c 'meas
rizW
agent
I ate TOTAL: ISSUED BY'.
OFFICE