B0391 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERI TNO. w
API'LICATION/PERMIT PLUMB NG-MECHANICAL 11 ��lJ
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION SOOO1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT¢
/0cl,3 1 ZansdoJe— S - 1'3-9?
OW :R'S 'AMF: PHONE: CO ACTOR'S NAME: LIC NO.
"rel —0938 �)no 010 U U N/c coXTRol.a
•'ARCHITECT/:NGINEER: LIC NO DDKE S. �• ^ �2� I t ❑
CONTACT; PHONE: VV i111(_t BUILDING I'hRM1T INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PWM. ECH
M
F(-C,A� as3-�I I 1:1 L] d� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions Of Chapter 9(ommmencing JOB DESCRIPTION
meet with Seq[on](XXII of Division 3oftre Busincssand Pmfeseions Crdc.and on,license is PERMIT ISSUANCE RESIDENTIAL
C)0Fes_ in full force and effect. ❑SPDWL ❑KITCHEN REMODEL
Class IY U F Liecarm Jr
6 U APPLIANCES-RESIDENTIAL ❑AUDITION I�}PCHAIBING RE-PIPE
F z m Datc Contractor
Inion ❑MULTI-UNIT L1 STRUCTURAL
ARCHITECT"S DECLARATION
F-Z I understand my piens.shall be used as public records PANELS MODIFICATION
OZ`-nC UPT0200AMPS El INTERIOR ❑CHIMNEYREPAIR
W Licensed Pfofe,,amod 201-10RAMPS IMPROVEMENT [ISWIMMING POOLS
OWNER-BUILDER DECLARATION
C C Q 1 herchy Fri. bar 1 am exempt
-floor Contract License I.aw for the OVER 1000AMPS ❑IiATII REMODEL/REPAIR ❑DEMOLITION
3 LLU fallowing rev on.(Section 7031.5,Business and ProlHsions Curie:Any cin of county SIGNS ELECTRICAL ❑(YfHCR
y which requires a permit to construct,alter,imprme.demolish,or repair any structure
,E„�0; prior to its issuance,also requires the applicantfor suet,permit to file a signed statement SPECIAL CIRCUIT/MISC.
E p. 'hat he is licensed pumuant to the provisions A me Contractors license Law(Chapter 9 -
ca: (commencing with Section 7000)of Division 3 of the Business and Professions Cook)or TEMP.METER OR POLE,INST. COMMERCIAL;
1 L CIO 'hat he is exempt therefrom and the basis for the alleged exemption.Any'relative.of ❑NEW BLDG/ADDITION ❑DEMOLITION
^vi Syrian]031,5by.ny npplicam torn Penni.mbja:tsthe vpplicanl m'er'it q:nnlry of POWER DEVICGS ❑'TENANT ❑FOOD SERVICE
=0 at,,marc than five hundred dollars($51X), IMPROVEMENT
❑1.as owner of the property.or my employees with wages to their sole compcvauon. SWIMMING POOL ELECTRIC []OTHER
F will do the work.and lhestracmrc is not intended or l(ered forsile(Sec.]01J,Business
W ro art Pro essions Cade:The Commorm's License Low does not apply to an owner of OVT'LETS-SWITCHES-FIXTURES
Of—
property who builds or improves'here ar,and who docs act,work him if nr Through
his own employees,provided that such impmvemcnts am no'intended or mored for NIiW RFSIDEN'I'IAL ELEC'I'R S
t fel
sale If.ho evegthe building or impinmencnt is sold witvn one ytatofeorpledion.the 71 SQ.ET.II"DOR AREA SISQ.1'I.
owner-builder will have the burden of proving that he did not build or fop r".for Per,
,ay it sale).
1,as owner of are property,am am exclusively contracting with licensed contractors m TOTnI.:
consumer he projmt(Sec.](W1.Business and Pm4su nn Cei Tim Contractors Li-
cense Law dims not apply it)an owner of property who builds or improves menton,and QTY. PLUMBING PERMIT FEE
M commtlz finvuch pnjems wuhucontractions)licensed pursuant to the Contractor's
Licence Law. PERMIT ISSUANCE
I am exempt under Ste. .B&P C far Nis..,at
ALTER-DRAIN&VENT-WATER(IA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTCCI'.DEVICE
1 hereby affirm under penalty ol'perjray one of the following declarations:
Fl I have and will maintain a Certificate of Consent to self-imum for Workers Compen- DRAINS-FLUOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 39'X1 efthe Labor Code,for the performance of the
work for which this front,le iseaeal. FIXTURP_S-PFR TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ofine Lo1wrCWc.(.,,he perfomwnceofthe work fmwhich this pc.it.,issued. GAS-EA.SYS']I:M-I INC.q OUTLELS OCC.GROUP APN
My Wo SCnry nsaty nln. terse orderadPolicy nu h yT�`
Cnrricc 1 1��- 1 nrd Policy No GAS O CAS-EA.SYSTF.M-OVF.k<(BA)
CGRI'IFl ATE OPExit VTIONFROMWORI iRSGREASF%1NDUSTRL WAS 117 INTHRCEPI OR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
GTis section need not be completed ifine permit is for one hundred dollars IS 100) GREASETRAY
tar less) � PLANCHECK r+EE
I certify that to(lie performance of he work for which misperndt in l,,ovd.Ishall SEWL'R-SANITARY-N I ORM EA.211017.
not employ any Person in any manner w as m become-bilecue the Wnrtiers'Co.,.- ENIiHGY ILII
,Z indo®r Lawsnf Califemie.Dam WATER HEA'T'ER W/VENTMLECTR
GRADING I
Z Q Applicant I :EIi
NOTICE'r0 APPLICANT':If,vlie r.nuargon,COnifemc of lixcru,no ,yon should WATER SYST'17MG`REAIlNG
F ? become.object m the Worker's Comlm eomm la inions of the Lather Cede,you must SOILS FEE
forthwith comply with such pmvissonz ar this permit shall be deemed treated. WATER SERVICE
p
C CONSTRUCTION LENDING AGENCY NIiW RESIDEN-GAL PLMB. SQ FTPAID Hale I eccipt p
✓U Thereby vffrrn'hm there innumnwminn lending agency l'onhe perfannvuce of
H. F 'he work for ahich Itis permit is issued(Sec.309],Cir.CJ
TO L:
C)U Iwmder's Name
rLender's Address AL: Q
1 1 our thin I have read this application arid that[lie above I,. BUILDING FIB
F (n QTY. MECHANICAL,PERMIT FEE -
U Z building construction,and hereby authorize representatives ofthis city to enter upon'he
SIiISMIC FEE
above-mm�tioncd pmpeny forirlmctinn purpnen. PERMITISSDANCE
(We)agree nm save,indemnify and keep boneless me City of Cupuninu.gnimt ELECTRIC
liabilities,judgments.costs and expenses which may in anyway accrue against said Cin ALI'ERORADDTOMECII. PLtJhf BIND lgili
nscqucnecfinegmnting this to
APPLICANT UNDERST, S ILL COMPLY WITH ALL NON-POINT AIR HANDLING INITGO IBOMCFM) MECPIANICALFLE
SOURCE IN rl
_ NR HANDLING UNI'I'(OVER Il1.fX1U CPM) CONS'I'RUC fION'TAX
Signor - pPli mus: act Date EXHAUSTHOOD(W/DUCT) HOUSING MI'I'[CATION FEE
HA/'.A OUS MATERIALS DISCLOSURE
Will the applicant or future hudding oreupant.vmre or l andlct,mynhmz mmerinl 1117ATINCT t1Nl'I'(TO 10010()0 BTU)
as defied by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cede,Section 2592(')'! HEATING UNIT(OVER 10o"BTU)
.]Yes 5 V ENTILAT1oN FAN(SINGLE RES IDI PAID Dom But M
W II Ne applicant or future building occupant use equlpmem Or devices which BOILER-COMP(3HP OR 11110
.mit
nut hazardous air emo m earns m defined by the Bay Arca Air Quality Management TY"AL
Disvitlp BOILER-COMP(OVE:R 10.000 BTU)
E]Y" E]No
Ibase read the,condanis inamehiscoruncomas under Chapter 695 of me Cal A I R CONDI'1'IONER ISSUANCE Lost
fornia Health&Safety C Seelmor,4505.25533 ad 25534 I understand nd that Rum NEW RESIDENTIAL MECH. SQ 14. l(J
hu'Id' gd eel� fm�Cb�l't lt marry the occupant
n p
O rambori ag Uate TOTAL: ISSUED BY: 1
OFFICE