S0452 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
HUI ''E 'f'NO 0452
CAL
BUILDING DIVISION APPLICATIONIPERMIT PLUM Sic. CTIDENNIFIC
BUILDING PROJECT IDENTIFICATION
BUILDING ADIEt11 E� SANITARY NO. APPLICATION SUBMIT-IAL DATE
OWM 'S MF,: PHONE: CIA R'SN h1.: LIC NO:
�,1 ' ! 1 '� 1/r N/C �Q/('C�O�YfROLff
,ARCHITECT/F,NGINEER: LIC NO: ADDRESS: 'V W 'V`/ ❑
CONTACT:
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) Ill ELECT PLUMB MFCH
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT. FEE
I hereby affirm that I m licensed r provision f chapter 9(commencing JOB DESCRIPTION
Boz with5 i 7IX0) ID 'int?nf the Bus dPnde iooi Codeandmyla :e PERMIT ISSUANCE RESIDENTIAL
F��� in full here and chre, ❑SFDWL ❑KITCHEN REMODEL li
QUU Liccrmc Class Lick APPLIANCES-RESIDENTIAL ElADIA PION ❑PLUMBING RE-PIPE
F z n1 Doc Commcmr
'"ag' ARCHI'TECT'S DECLARATION ❑MULTI-UNIT' LJ STRUCTURAL
l.::)vi PANELS MODIFICATION
zOyz,� 1andetso dmyplansshall coved upublic mcordc
Oz�C If If 200AMPS, ❑INIPRIOR [I CHIMNEY REPAIR
w LirensN Professional 2nl-IIKKI A MPS IMPROVEMENT 0SWIMMING POOLS
(OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATIi kIiMOD[IJREI'Alk C1 DEMOLITION
CCC< I hereby offrm that I am exempt from the Cams,,.%',License].me for the �y
O c.U following terrain.(Section 9031.5.Business and Prom,sions Code Any city or county SIGNS L'LECI'RICAL ❑OD113R
W 3 U.`F which requires a panni to eonstrvcl,alter,improve,demolish,or repair any Umeare w
0oo
Q prior to its issuance.also requires 0e applicant for such permit to file a signed structural SPECIAL CIRCUITMISC. PQ
f y that he is licensed Pursuant m the provisions of the Contractor's License Law(Chapter 9
ayp0 (enmmencing with Scclion]UM))o[Uivizion3of the Business antl Professions CaJe)or TEMP METER OR I'OLF,INST. COMMF IwwIo�
d 1 e C that he is exempt themfrom sand the basis for the alleged exemption.Any%rotation of (] 14,FQ0C,,/ADDITION OHMOLITION
Xma Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWIiR DEVICES - :' NTVF (;UF' FOODSERVICE
4�N .c
FZ} nolmom'ban five hunJmddnllars(.SSDB). Ihtl'kOV1iS1ENT thITNO
Q ❑has axm<r of the property.mmy employees wiN sages as their sole compenutinn, SWIMMING POOh ELECTRIC
EFO will do the work.and the%wcture is not intended mothered forsate(Sec.7014,Business El OTHER
W 3 m and Professions Cure:The Cont actor's License Law does not apply to an owner of OUTLETS-SWITCH S-FIXTURES /e
pm,my who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or 0"' it for NEW RESIDENTIAL ELECfB SQ FT
sale.If.however,the builiinger imp eounent is soldwithin oneyearafcomple,ion.the SQ.Ff.FLOOR AREA 8/SQ.IT.
ow nt
er-builder will have the burden of proving that he did not buildor improve for put- • 00 ) `1
poof sale.). 7 (,•Aj\,
as of the property,a smear and
c Professions
with Ikons Ccvmtmenm m
construct does not appl(Secy
]lair,weer of and property
who
Cade:i no Contr...... n - I '
cess haw docs not apply fU un owner of properly who builds or improves thereon,and QTY. � •PLUMBING PERMIT. FF.P,
who contracts(or such projects with o con me or(x)a,r.we puwuant to Oe Contractor's
Lice,,Law. VERMIT ISSUANCE O
tant lo
s cx nde Bk PC for lhi-%%sass
ACrER-DRAIN As VENT'-WATER(LA) VAL A'1' N
COM PHNSN'ION DF,CIARATION El 1! I - BACK FLAW PROTECT DEVICE
1 bushy off"an under,penalty df perjury one of the following declarations:
❑IhaveanJ willawamainu Ccni&ate of Cansem ursdf-insurefn.Workers C,wrNm- DRAINS-FLOOR.ROOF,AREA,COND, STORIES TYPE CONSTRUCT ION
cation,as Provided for by Sermon 3700 of IM1e Labor Code,bertha Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,u"arirW by Section
3700ofthc labor Code,for the Nomarrmnceof the work for which this permiue issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCP GROUP APN
Aly Worker's Compensation Insurance carrier and Policy number am:
Carrico PNicy No.: GAS-EA.SYSTEM OVER J(FA)
CERTIFICATE OF EXEMPTION FRONI WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE IN 'ISION FEES
(Thi%section need not tscompicted ifthe Permit is forooe hundrtddellars H UXb GRIiASE TRAP
or lard PLANCHECK :E 69
I ccnifythm intbe pmance of IM1e work to,which this permit is i...cd,I shall SEWER-SANITARY-STFT
ORM EA.200 .
not employ any person in any manner so as m become subject to the War4rf Compo.- ENERGY FE
Z .anon Laws of California.Done WATER HEATER WNENT/ELECTR
GRADIN
Z Applicant
NOTICE 10 Al-PLICANT.If,after making this CeNficam of Exemption,you should WATI7R SYSTEMC REATING
NSGII ti P
F become subject m the Wnrknr'x Compervcation provisiom of the Lebon Corte,yon emit
Lat•1 r�i forthwith comply with such provisions or this permit shall be deemed revoked WAIERSERVICE
Q
CONS I'RUCTION LENDING AGENCY NEW BESIDES TIAL PI.MPND B. SQ.lT. per Recelplk-
1 much,omuha there Is.. motion lending agency for me performance of
V. . ff'he work lin which Ibis prrmil,,invued(See 3007.Cia C)
T(YIAL:
O Lender's Name TO'I'AI.
N W Truest's Address
LL BUILDING I iii
1 certthat I have read .na
this application and e Thal the above infounonhm is
ify
N corred.Iagreefo comply with all city and county ordinances and state lairs relating it) QTY. MECHANICAL PERMIT 'E SEISMIC I:T
Uz building eo..Moon,and hembyraft iaesprescvtam,,idmis city ,,enter upon the
above-mcmioned propcny for inspection PuTsccs. PERMIT ISSUANCE ELELTRI .FIE
(We)agree to save,indemnify and keep harmless the City of CUPe.ino uFranw
liabilities.judgmcnn,I....is and ca,enms which may in any way"""againctzuid City ALTER OR ADD TO MF,CH. PI.UMBI GFEE
a. nmquence of the 6rraming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO]Q000 CFXy MI?CII ICAI,IEE
SOURCREGULA — -
AIR HANDLING UNIT(OVER 10.000 CFaD CDNIT ACTION TAX
Sig wrcaf ApplicanU ont )a EXHAUSTHOOD(W/DUCT) HOUNINGNIIT 'NTIONFEE
/ARDOUS MAITRIALS DISCLOSURE:
Will the applicant or future building occupant store or handle h...nimmmaerial HFA'I'INC,UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and IM1e Health and Safety
Code,Section 25532(a)? HEATING ONIT(OVER 100.000 RTU)
E3 Yl, 0 N VENTHATION PAN(SINGLE RESID) PAID [)am ceipl9
Will the applicant or future building uecupant use equipment or Devices which
C emir humrduus air conantinants as defined by the Bay Area Air Quality Managentenl BOILI:H-COMP f311P OR IU0.0(10 BTU)
( T AL:
District' BOILER-COMP(OVER 100,000 B U)
Yes ❑No
I have rend the larmrd..ux mmcrialxm,mmmcrosualChupar(as of ahs Culi- AIR CONDITIONER ISSUANCE DATE
Tutu I Indlh k Safety Coac,Seem) 25505,25533 and 5534. undmsnnA Iha If the NEW RI?NIDF;NTIAL MECH. SQ.Ff.
building does net currently haven towel,that it is my res,msibility m notify the cecnpanf
at the mquirnnents which mull be inclprior m Ismuncc of aCmtib in of(kcupnncy. /)
Ownerorauthorieed agent Dere °T ISSUIiD NY: I�J�//'
OFFICE