S0640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAL PE U`NG
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 0640
IfUILDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS: SANI'1'ARl'NO. APPLICATION SUHh11TTA1.DAT[
2, ok-.?_q Coocr - 4/ Z-.
OWNER'S NAME: O'
PHONE: CONTRACTOR'S NAME: LIC N .
U5 _ 1\ Q -72-5--'63-79
NIC CON'Tk01,
�•,ARCHITECT/ENGINEER: LIC NO ADDRESS: ❑
CONTACT: / PHONE: DU ILDING PERMIT INFO
4--)f5c, ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
LICENSFDC RACnORS DECLARATIONQTY ELECTRIC PERMIT FEE El En' El
1 hereby affirm that l am licensed d provisions- of Chapter 1(commencing JOB DESCRIPTION
"Z with SecIkm7k)aofD' ^3sfthe Im,insandP fessions Code.and my licensees RESIDENTIAL:
w O O PERMIT ISSUANCE
Fly in full force and eRom. ❑WOW[. ❑KI'1'CHfiN REMODEL
¢UV Liccnsc Class J,# APPLIANCES-RESIDENTIAL ❑AUDI T]ON El PLUMBING RE-I'II'E
I yQ W Date Contractor
ARCH11 ECI'S DECLARATION' PANELS ❑MULTI-UNH ❑S"I RUCTURAL
F,7m
Z o h Z 1 understand my plans shall be used as public rensrds MODIFICATION
UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Profession.] 201-IWIIAMPS IMPROVEMENT LJ SWIMMING POOLS
C ¢ yfr I hereby affirm that I am exempt fmm he Connote License Law,for the OVER 1000AMPS -
El BATH REMOUEIIREPAIR 0 DEMOLITIONOWNER-BUILDER
1E
lKy 3 ci U following reason.(Section 7031.5.Husiness and Rofn,d...Cale:Any city or cnumy SIGNS ELECTRICAL ❑OTHE
y which requires a permit m construct,uller,improve.demolish,m repair any structure /L' V I t
prior to'its issuance,also requires the ppl' t for suchPermit file a signedsttement SPECIAL CI RCUIT/M ISC. - (PAS /YI
du i+
that he I'en.edp pursuant thep of the Contractor's L Law(Chapter9 �-1-/
r+1�ao (umun<ac'ng with Section 703D)olDvsion 3A he Busnessund lmfuss n esCodgor TEMP.MEI ER OR POLL INST. COMMERCIAL
y o C that he is exempt therefrom and Thu ha.ix or the alleged exem%inn,Any violation�n [I NEW BLDG/ADDITION El DEMOLITION
W rn Section 9031.5 by any applicant for a permit subjects the applicant ton civil penally of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
I Imre than five hundred dollars(S5k)), IMPROVEMENT
f*=p Las owner of the property,mnrycmployccs with wages as their snle eompensmi^n, SWIMMING POOL ELECTRIC
'yet w I do the work and theumcturc is nm imembedoroRewd for mle(See 9044,Rpsmce, ❑OTHER
send Professions Code:The Commemr's License Law does not apply-to an Owner of OUTLETS-SWITCHES-TEXTURES
pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SO FT.
sale.If.however the building m improvement is sold within one year ofsompletion.the
.00R AREA 5/SO.FE
builder II h' theburden f proving' th t b did t build p I per
/
p....of: ): T T,Ak q
1 r of the property. Ise' ly contracting with licensed contractors to ! (/
,ci,lountil project(S30A# lmoonc,, IP f.son,Code)TI C mase :Li' O
cxrsc Law does nut apply it,an owner urlrolicrty who build:or toprovestherc nd QTY.- - PLUMBING PERMIT FEE
who contracts for such projects with a comodent(s)licensed pursuant to the Commoor'v - '
License].a, PERM I'11 ISSUANCE 'r to
Imit esd di.Fs .B&P C for this reason
ALTER-DRAIN&VEN'T-WATER(EA) VALUATION
Owns Date
' ORKE 1PENSATION DECLARATION BACK FLAW PROTECT.DEVICE
[hereby affirm under penalty of perjury one of the finho,ing declarations
(]I have and will maintain a Certificate of Coment to self-insure for Worker's Crimper- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
svtion,as providW I by Section 3]1X1 of the Labor Code,for the performance of the
work for such this penon is iksuul FIXTURES-PER TRAP
0 I have and will maintain Workers Compensation Insurance,it,resound by Se,cionn �1
391X1 til the Labor Cada for perfnnnunce of the work for which abets penult is isaucd GAS-EA SYSTEM-I INCr#bU'T1.B'fS V (ICC.GROUP AM
My Workers Compensation Insurance ratio and Policy number are: E(R q IEA)
Carrier: Policy No.: GAS-EA.SYS"ITM-O Is
CERTIFICATE OFEXRMITION FROM WORKERSGREASE/I gLLTR € 1+1 EI
COMPENSATION INSURANCE BUILDING DI VISION ERRS
(This section need not ber
Ise completed if the pmit is for one hundred dollars IS 1W) GREASU TR'
m Ica) VLANCIIECK E'F,E
Icertifythatinthe performance of the work for x Inch this permit is issued.)shut[ SEWER-SA ARI'-STORM E3.200 FT.
not employ any person in any manner so as m become subject to the Workers'Compen- ENERGY FEE
Z cati on Laws{{f California.Dae WATER I11?A'I iN�
!z Q Applicant//X I GRADING F'
NOTICEIfO APPLICANT:If,a0cr making this Certificate of Lxemption,you should WATER SYSTEMG BEATING
F fire d .bj,l 10 the Workers O....pemaion provisions of the Labor Cale,you mu $OILS h['
limhwith camply with such pnorivinns nn bis permit shall be deemed resided. WATER SERVICE
0
Rs CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMR. SQ,tT. PAID
UQ Thereby affimt thus there is a conswctin^lending agency for We performance of Dal Rereiptp
the work for which this permit is issued(Sec.3099,Ci,C)
U Lera 'a Name ^ TOTAL:
c U Lenders Addresu f TOT L' lar
0. 1 certify that I have read this appliciamn and th
same at the move in is nformatioBUILDIN iE
.F. VO c iter.l agree in comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
IU 2 building consu enon.and hereby umorio,representatives or this city tocmer up the SEISMIC l' r
above-mentioned pperty for inspectionpurposes. PERMIT ISSUANCE fi1,hC1RIC4 '
(W) g t d fY IA ph I::'he Cy fC 1 t at - .�}
IlnNft .j Ig rents, r 1 pcn— litchniay inmyway raga nts-d Co, ACI'17R OR ADD'10 MECH. 7 YO
to y or mug t g ldo,M1 rot I'LIJMI{TNG 11,1: ✓
APPLICANT UNDERSTANDS AND WI LL COMPLY WITH ALI,NON-POINT. AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOUR IONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
efgp;' Data EXHAUSTHOOD(W/UUC) HOUSING MITIGATION FEE
IIAZARU S MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hasardous material HEATING UNIT(TO IW,OW RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Otte,Section 25532(ayt IIEATING UNIT(OVER I W.000 STIJ)
ElYes r VENI'ILA'1'[ON FAN(SINGLE RESID) PAID Uac Receipt#
Will the applicant or future building occupant use eyuipnanl or devices olodi
h Ih.eallous air ctrarromela defined by the Hay Area Air Onalit}Munagcment BOILER-COMP OHY OR[00,00)I3TI11
m
1fA
)carie.
�Ycs BOIL(?H-COMP IOV EN IW.IXNI R'I'll) _
I have read the hazvdom material,requiemenu under Chapter 495 of the Cali- AIR CONDITIONER ISSUANCE DATES
Immi.Health&Safety Cale,Sections 25505,25533 and 255X.1 undcrsmnd the if the NEW RESIDENTIAL MECH. SO.ET. 2n. 'X
building does not curemly have.tenant,that it is my ec,Nceibilkym notify the occupant f U
,if m^ei st ono issuance of a Cer ieaam nrOccupancy.
( e gent pill. 'RMAL: ISSUE[)BY.
OFFICE