S0033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EI,ECrRICAI, PERMIT No,
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRIS'. SANITARY NO. APPLICATION SUBMITTAL DAIS
to 4G Limittl osz
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ARCHITEC ,ENGINEER: LIC NO. OJ,}) S$:� j 'vx I ❑
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CONTACT. PHONE: S �� 7X��� BUILDING PERMIT INFO
❑ Consul tant Fees aid By Applicant(Initial) BLD 1.1 PLUMB MECH
❑ ❑ ❑
LICFNSFDCONTRACTORSDECIARAI'ION QTY. ELECTRIC PERMIT FEE
I hereby tfrtm that I licensed e p n:of Chapter J(ct+ntt Its JOB DESCRIPTION
paZ mSecl +i 7000) lD 3 fife Bus and QmPo.gsir.'Cyk,pnd nyl arse l.v IDFNTIAI:
Dip /Y.J. / JyA� PERMIT ISSUANCE
I (!x
F+ w lull force and cftc ❑SFUWL ❑KITCHEN REMODBI,
aUU License Cl . Licx — ppPLIANCES-RESIDGNTIAI, ❑ADDITION El PLUMBING RE-PIPE
FZW Date Commaor
r�Q0. ARC ECFSDECLA ATION G PANELS ❑MULTI-UNIT' ❑STEDCICATIO
F']=i Z l is r. y plans s IHI u c as ld /', OUII9CATION
Z p'�— UP TO 200 Ah1PS
pZ-0 I\�"CiIN`O I ❑INTERIOR ISINEY REPAIR
FHF-W Limemed Ree"i...I 201-1000AMPS IMPROVEMENT L3 SW11+1ING POOLS
Q0.,y2; OWNER-B .DER DECLARATION OVER IOW AMPS El BATH REMODELIRf;PA1R ❑DEMOLITION
C 3 Q I hereby elRrtn that I am exempt form the Contraanr s License Law for the
X 3 a F following mason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
u: 0.m which construct,a Permit to consct,alter,improve,demolish,or repair any xtmeturc
pQ,
Prior mits issuance,also requires Ne applicant for such Permit o file asigneJ mamms..t SPECIAL CIRCUIT/A C.
that he ix licensed pumuant to the It...ionsof the Comranm's License Lia,(Chupter9
WEEp�0 (commencing with Senion]IXXp of Division Sof the Business mJ HofvsninnsCWe)nr TEMP.METERO VOLE INST COMMERCIAL:
d 0.o that he is exempt therefrom and the basis for the alleged exemption.Any violation of
El NEW BLDGIADDITION El DEMOLITION
W� Section]031.5 by any applicant for aproof subjects the applicant b)a civil Penalty of POWER DEV ES ❑TENANT ❑FOOD SERVICE
Cnut mom than live hundred dollar,($500). IMPROVEMENT
❑base owner of the prnpurtY,.r my empluyeez with wages us their sole compvnsu,i.n, SWIMM GPOOLELECTRIC
(.. will do the work,and theawcNre is nm mtended.n+Reme li,r xnlvlScc.]INy Rnxincxe ❑OTHER
,W 3 m and P (..Inns Code:'I'he Comractor's License Law Joe,noI apply e,;in owns,of OUT TS-SWITCHES-PIX'1'11R1iS
6i pmfedy who mild,m improves there...,and who doez.uch work him.df or tivough
his own employers,provided that such improvements are notionor alined for N RESIDENTIAL ELEC'I'R SO IT.
sale lf.hnwevcq the building nr improrcmmtis sold within nnc ycm nl'unnPldinn,the SQ,17.1'LUDR ANI3A 5/SQ.PT
wncomilder will have the burden of proving For be did not build or Improve I'or pur-
Weeofsale.).
'1'OI'AL:
Fl 1.as owner of the property,am exclusively contracting with licensed contractors to
construct the Project(Sec.9DW.Business and professions Code:)The Contractor's Li-
came Law does not apply to an owner ofpropeny who builds or improves thereon.and QTY PLUMBING PERMIT FEE
wbusnnulectx for such projects with a rnnuacmrs,licensed pursuanuo the Contracmes
License Law. PERMIT ISSUANCE
❑ I am exempt umbar Sec. .B&P C fortbis mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dae 2 Jk D .�
Y WORKERS COMPENSATION DECLARATION BACK FLOW PROTECr.DEVICE 1�/{!V1
Thereby alum under penalty of perjury one of are following J Worker's
a:
❑ohms it will foi byatenilicam of Ce Lalmr Cade.for the Worker'sce of the DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONS'PRUCfION
sainn,as provided for by Section 3](X)of the)arbor CWe,for the pedi+mtvncs of the
forwhich l punnitis issued. FIXTURES-PER TRAP
w 1 M1uvc and will muinmin Workers Compenxatim+Insurance,m arryircJ by Section
31011 ofthe loath trCst ff�or t(1y�,perf.r ° the worklirrwphhich th'.pc mi....7J. GAS-EA.SYSTEM-I INC.40LYII.hll' OCC.GROUP APN
C:nWtt • �fl+_Vrr•r andP )icy Ci O CAS-EA.SYSTIiM-OVI3R 411iA
�cft
EItTIF + ON FROM WORKERS' GREASFJINDUSTRI,WASTE .'TERCITTOR
COM ENSATIONINSURANCE BUILDING DIVISION FEES
(Thi.-cti.n need not McompletW i[thcpemtil i,fnnme M1nndreJ dnllury[$I W) GREASETRAP
or less.) PLANCHIiCK hili
I ecrtily that in the performanec of the work forwhich this permit is i....LI erl SEWER-$nNITA -STORM EA.201 FT.
not employ any person in any manner so an m become subject to the Workers'Compen, ENERGY FEB
Z -tion Laws of Culifi+mia.Dore WATER HEAT WNIiNTIELECR
ZO Applicant 1 GRADING IIHi
N NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER IENI BEATING SOILS ME
become subject to the W.rkces Compensation provisions afire Labor CWe,you must
forthwith comply with such provisions or this permit shall he devoted revoked. WATER SERVICE
Q PAID
z CONSTRUCT[ON LENDING AGENCY NEW RESIDENTIAL PLMR QFr. Dare Recniptx
U 0 I hereby affirm that hcm,,a acarom stair lendmilmsency(.,,he parti+nnearsof
the work for which this permits i...ed(See 3090.Cie,C.)
Lender's Name 'I OTAL'.
W Lenders AJJms, '1'OTAh:
1 certify that 1 have read this application and state Nut the ubovc inforn+alon iz BUILDING PI[E
corms,.I nerve Io cnntry,with all city and county ordinances and state law,relating a QTY. MECHANICAL PERMIT jFEESEISMIC T9?I:
U z huilding....i•u'uainn,and hereby,uOhortt,em're,enmtivex oflhi,city ,,cnarupontbc
ahnvcnmull nncd propcay for Inspection purposes. PE3t I ISSUANCE Ii1.IiCfRIC 11313
(We)agree,,save,inasmoify and keap Iturmlvms the City of Cupertino again.t
liabilities,judgment,.cnl,and expenses which may in any way ucameaguin.a.aid City ALTER OR ADD TO MECH. PLUMBING FEE
in ennrquence of the granting of this permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WI'T'H ALL NON-POINT AIR HANDLING ONIT(r014tHro CF MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING"'IT
IBJ CPM) CONSTRUCTION TAX
Signmiie of AP,licoadCommnm Dmc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAP,ARDOUS MATERIALS DISCLOSURE
WSIlthe applicame,furore buildlag recepaotmom or handle baraNmvnamrial HEATING UNIT ITO IOOJ OUVID
as dc0mrl by rbc Capci inn Municipal CWe,Chapter 9.12,and the Health sod Safety HEATING UNIT(OV IIX).(Xln❑TUl
11 Code,Section 255321a7"
❑Yes ❑No VENTILATION" . SINGLE RESIDI PAID
nate Receipts
Will the applicant or furore building occupant use equipment.r daises which BOILER-C 1P(3HP OR Hxfovx)6'rU)
'emit heoardeas air contaminants as delinW by the Bay Arca Air Quality Management TOTAL: I
L
- BOILER COMP(OVER t10Jprof IIT)
ea ❑No nIR >ESIDENNER ISSIJANCIi DA'dIb 1 l a. t ' I q t. I Ch pt 695 t'heCalth&\f ty C I S i '25505 25533 125514 a 1 tlwt T the ,W RESIDENTIAI.MECH. SQ.FT.mnemxwhich mu.tbumetur t smnevio Cnhw,col a.cmpauy
uthnm<d seem
Date TOTAL: ISS UF,D BY:
OFFICE