B0668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY II
RTINOBUILDING-ELECTRICAL ;-ERNJ_ll
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MEDISoot)jc" �Yy'Uy+Lr+,�Sn-F1-nHv7V
BUILDING PROJECT IDENTIFICATION
Totri
BUILDINGADDRESS'. SANI'T'ARY NO, N'I'LICAII()NSUIiMI'1'1'ALr)xrE
'-27
OWNER'S NAME: I PONE: CONTRACT 'S NAME: LIC NO:
-. w _ O qp
NIC CONTROhp
4ARCHITECTTNGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
U-' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT - FEE. JOB IJH$CRIPTION
1 hereby affirm Nmat 1 am licensed under prwisioof Chapter 9(cammcncing '
O� w'it Stttion]WO)of Divisinn3of the Husiness and lhufexsimme Code and my license is RESIDENTIAL:'
w p Z PERMIT ISSUANCE
F-,2 in full force and effect. ❑SFDWL ❑KITCHENREMODEL
x U License F- ClLic.p
Q p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMPING RE-PIPE
1-Z W Date Cuntmcon
rn¢a ❑MULTI-UNIT [ISTRUCTURAL,
F-O y ARCHITECTS DECLARATION PANELS
Z I understand my plans shall he used as public records MODIFICATION
O Z UP TO 2(0 AMPS
❑INTERIOR ❑CHlht;glil'REPAIR
F4Fwj Licensed ProNlI mal 201-100 AMPS Ih1PROVENIFNIT 0SWIMMING POOLS
C C Q I hereby affirm OWNER-BUILDER I am exemptfromConvlON x nr'.c License Law for to OVER 1000 AMPS []BATH RF:MODEIJR'P. R UEMOhITION
yxj 3 LL F following reason.(Section 7031.5.Business amt Professions CWe:Any city or county SIGNS ELECTRICAL ❑OTfiER
m which regwres a permit m construct,cher.improve.demolish,or repair any ewmure X
OQ prior to its issuance,also requires the appiicam mr.och Toenail to rite a signed statement SPECIAL CIRCUIT/MISC, 1 It
That he it licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
1+10If
0 (commencing with Section 7018 of Division J of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL;
d 1=C that he is exempt therefrom and the basis lin the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
X-m Section 7031.5 by any applicant for a permit objects the applicant to a civil Penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
not more than five hundred dollars(S500). IMPROVEMENT
5� I]1.as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
F• willdothe wark,and tesauclum is not intended nuffered forole(Sa.9(94.Business ❑OTHER
W m and Po fessions Curb:The Cnmrennr's License Law docs nil apply to an owner of OUTLETS.-SWITCHES-FIXTUR
property who builds or improves thereon,and who dos such work him cif or through
his can employees,provided thin such i upowermus ore not intruded or offered for NEW RF,SIDEN'1'Lod.F,LECTR
sale.If,howevente handing or improvammn issold within one year ofeampletion.the SQ.PT.PL(IOH ARBA SISQ.IT.
owner-builder will have the burden of proving that he did not huild or improve for par,
Ton r of sale) TOTAL'
owner of the Pr eny,um exduaivaly cammcling with licenced contractors to
cont nh P o"
If ]044 B-' ..andI f::ion,C I )I he Contractors l -
n. Lwdoex nota yI r fp p ty I bid. P :Ihemot and i QTV PLUMBING PERMIT FEE
who contracts talon' Jc Id�n cummctim[sl liucnmA punuummOm Cnn¢umork
I.i,ePER MIT ISSUANCE
iceI,tpuI rS ,If A,PC for mi,maxca
r ALTF,R-DRAIN&VENI-WATER(EA) l VALUAIION
G Np —ly'�
• ` Them f1 Rnd pe by f"SAryOt/I li f911wiral I uons (SACK FLOW PROTLCI'.DEVICE 0001 OD
' Ih ll I Crif t IC n: ii If-in W k Cnntpen DRAINS-FLUOR.ROOF,AREA,COED. SUCluffs '1)PIT CONSTRIICIION
sou ca,ax ovidedfrby5 f 3700 f the I laaCcdc.forineparionnalaccul[hc
far Inch the pr n,is'.xs vd. FIXTURES-PER TRAP
I] c and will maintain Workcre Cumlansanon Inwmnce,as required by sr,tk n - V
370X7 if Em Labra Code,for thepuff rtmunecifthe work for which this permil is kvind. GAS-EA.SYSTEM-I INC.4 OUTLETS DCC GROUP MIN
My Worker's Compensation Insurance courtier and Policy number am: 43 3617
Cameo Policy No.: GAS-EA.SYSTEM-OVER 4(EA) /(
CERTII;ICATE OP EXEMPTION FROM WORKF-RSGREASEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
IThi"eclion need no, Gonne
he i,com,mol ifthe permit is hundred dollars(SUR) GREASETRAP
or less) I'LANCIIIiCK 1993
Icertifythat in the pedornancuof the work for which this penton is issued.is hall SEWER-SANITAR ORME
not employ any Person in any manner To)as to become subject m the Worker'Cnmpcn- ENERGY FTE
ZZ salimn Lows of Collision..Data WATER HEATER W/' LECTR GRADING THE
O A,,Ii.1 1 _
N NOTICE TO APPLICANT:If,after making this CcriGcme of Exemption,you should WATER SYSTEMIT G
f" ; become subject to the Worker's Compensation provisions,of the Labor Code,you most SOILS IFF.
forthwith comply wit such provisiom or this Permit diall The deemed revoked. WATER SERVICE
C Q PAID
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL LMB. SQ.i l pa . Rttcipt p
U O I hereby affirm that there is a constmetion lending agency fur the performance of
D. F- the work for which this permit is issued(Sec.3097,Civ.C.)
O Lendeh Name TOTAL.
V Leaded Address TOTAL:
} 00. 1 certify that 1 have read this application and state that the above information is BUILDING FEE
F` y correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FIiE
U Z building construction.and hereby automc representatives ofthis city to enter upon the
above-mentioned property for inspection purPuus. PERMIT ISSUANCE ELECTRIC FEE
(We)agrceo e,indemnify and keep harmless the City of Cupertino against
Iiabilitics.juJg ts,eos¢a expense1-
in
which may in any way accrue against said City ALTER OR ADD TO MECH. - PLUMBING ME
onaequence the gra of this pe.I'.
' APPLICANT DER. A DS AND WILT OMPLY WI'I'11ALL NON-POIN"1' AIRIIANDLINGIINIT(TO IBOOOCFM) MECIIANICV.19Ji
I ATI El
jt �-J_ /]q AIR HANDLING UNIT(OVER L000CFM) CONSTRUCTION'UOK
Signa ore f App icon on .curt tone / EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DI. 'LO.SURE
TIT the appllcunl or future building occupant store or handle h,mLm,ummrial HEATING UNIT I aft BTU)
us,def of by the Calcium.Municipal Code,Chupmr 9.12,and the Health and Safety
Calc Svr ion 25332(a)'I HF,A'fING UNIT(OVER 1 W,(00 BTU)
L]VITT; ]No VENTILATION FAN(SINGLE RESID) PAID
Ualc Ncccipt p
Will he applicant or Futon:buildingw<upunt use ccopmemor devices which BOILER-COMP OHP OR 1WINO BTU)
mit bamrnma air enmmmicano us Jdined by the Itey Area Air Quality Mnnagumenl '1(
Uisnicf.' BOILER-COMP(OVER I(V BTU)
❑Yu Fl No f
AIR CONDITIONER ISSUANCh DNIi
IIn 'dt I'" J 'tTil 4 munJ CI TI O5 nflh Cnll-. ^ 2
f S' tyU I x25511525533 t 255941 J vmdlki'fthe NI?WRESIDENTIAI.MECH. SQ.PT. �� X9
mkfir,d a cofatly .Iht 1. mM1llyt ilythc puce
fihere ich 1 Ccribummal'Orn cosy.
Own c vol a .cd egcm
Umc TOTAL: ISSUED fly.
OFFICE