S 0091 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL Gw�LL
BUILDING PROJECT IDENTIFICATION
DING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
Gig/ BoGut/G�,� R d
NER'S NAME: PHONE. CONTRACTOR'S NAME: LIC NO:ARCl JCFrsr iftay ^&.a el�'/U.5 N/C CONTROLk
HITECT/ENGINEER: UCNADDRESS:
6ov� �ASsouf7t3O: E:] 9Lt?a'
CONTACT. PHONE: BUILDING PERMIT INFO
VI,bAldW/atwi 5{2 _pre/ ❑ Consultant Fees Paid by Applicant(Initial) BLDQ ELECT PLUMB MECH
4049, LICENSED CONTRACTOR' EJ RA!/ ((// Q '�,tC�7`' ❑ ❑ ❑
I hemhy.M,.Nal 1 am licensed under provlslom of Chapter 9(automation Qom' ELECTRIC PERMIT PEB
p g JOB DESCRIPTION
O1_ with SecrceanW)nf Divisien3of the Business and Professions Cnde,and mylicense is
�O� PERMIT ISSUANCE. RESIDENTIAL'
% in full force and effect.
CSF ❑SFDWI. [_J KITCHEN REMODEL
C U O License Class Lie.it
N6a Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
,z O >> ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
m q 1 understand my plans shall be used as public records MODIFICATION
OZ—, UP T0200AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Pmfessio..I a 201-IOWAMPS IMPROVEMENT' C]SWIMMING POOLS
G OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEL/RF.PAIR �DEMOLITION
nyd I hereby.(Siem on I am exempt[rem No Centimeters License law for the
F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to constmct,alteq impmve.demnli.h,or repair any s m one
�O prior to its issuance,also requires the aPPlicent for such permitmEleasigned smtemenl SPECIAL CIRCUIT/MISC.
setMW that he is licensed personal to Chep n,i.i.ne o❑he Comracmr's License Law(Chap.,9
f+I pO (commencing with Section 7")of'Division 3 ofthe Business and Professions Code)or TEMP.MEFEROR POLE INST. COMMERCIAL'
MRm C that he is exempt therefrom and the basis for the alleged exemption.Any violation of O NEW BLDG/ADDITION ❑DEMOLITION
i� YN. Section 7031.5 Fyany applicanl fora Pa.it,.bjao.the apillsomm a civil preallynf POWER DEVICES []TENANT F S VICE
i. not more than rive hundred dollars($500). RW"IMPROVE
S C E]1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended orelfered forsele(Sec.7044,Business EJ0
WM and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his we employee,,provided[hat such impmvetoenls are not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.ILhowever,the building or tmpmvemenl is sold within one yearefcempletion,the @6Q 6LOOR AREA $/SQ.IT.
ow wilder will have the burden of proving that he did not build or impmve for pur- T" ! S t
e of sale.).
I, owner of the property,am exclusively contracting with licensed centranors to TOTAL:
on
cons d the project(Sec.7044,Business and Professions Code:)'Ih �� ��e Convacmr's Li- @S REPD
cense Law does not apply to an owner of property who builds or improvas thereon,and QTY. PLUMBING PERMIT FEE {I
who contracts for such projects with a contractar(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE Uh Garth I INA
❑Ism exempt B&PC fo hi, Yen _ _, __ter - n ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S CON PENSATIO ARATION BACK FLOW PROTECT.DEVICE
1 hereby nation under Penalty of Perjury one of the following declamations:
••❑I have and will maintain a Carificare ofConsem to self-insum for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided for Section 37W of BeLabor Code,for the STORIES TYPE CONSTRUCTION
phis y perfeftwnce of the
work for which this permit is issued FIXTURES-PER TRAP -
❑1 have and will ode.for Workers Compensation Insurance,h required by Section
My othe LaborCnsationthsurance Performance ofthework for which this permit is issued. OAS-EA.$YSTBM-I INC.40I1TLBTS OCA,GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc: -
Cameo Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BU ]VISION FEES
isseetneed not hecotoplemforo
d if the permit is nGREASETRAP e hundred do[].loss.)(Thion PLANCHECK
]certify that inthe parrommanymannro ae a,1work for subject io parthe W ikersued.14mil
'Content- SEWER-SANITARY-STORM EA.200 PT.
not employ any Person in any manner so as to become subject m the Workers'Content- ENERGY FEE
,Z
Applicant
laws of California.Dam WATER HEATER WNENVELECTR
0 Applicant 1 GRADING FEF,
�-t NOTICETOAP.the Wors If,Cont a,... this Provisions
of Exemption.youshould
h 6 P WATER SYSTEM/TREATING
a become,comp y the Workers visions r avis provisions b the Labor Code you mon SOILS FEE
,W forthwith comply with such provisions onhis permit shall be deemed revoked. WATER SERVICE
�O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that hem iso construction lending agency ferric performance of Date M
LL f~ the work for which this permit is issued(Sec.3097.Civ.C.)
Q U Lender's Name TOTAL:
W Lender's Address TOTAL:
1 ri nify that 1 have mad this application and state that the above information is BUILDING FEEILACI 0-
r+Val correct I agree to comply with all city and county ordinances sort state laws relatiag to QTY. MECHANICAL PERMIT FEE
U 7a building cnnstmction.and hereby authorize representatives ofthis city to enter open the SEISMIC kFn7
.hove-mentioned property fur inspection purposes. PERMIT ISSUANCE
(We)agree In nave,indemnify and keep harmless the City of Cupertino against ELECTRIC E
liabilities,judgments,costs and expenses which may in any way a came against said City ALTERORADDTOMECH.
In consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P IN AIR HANDLING UNIT(TO 10,000 CFM)
SOURCERE 'IONS MECHANICAL FEE
9 1/ AIR HANDLING UNIT Ig000CFM) CONSTRUCTION TAX
SignTdr mApplicam/Coutim etc EXHAUST HOOD(W/DUCF)
HAZARDOUS MATERT&AINSCLOSURE HOUSING MITIGATION FE
Will No applicant or(uwrc bollding nceupanl store nr handle hazardous mamond HEATING UNIT CIO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes 7N VENTILATION FAN(SINGLE RES ID) PAID
Data Receipt M
zardsmsll air contaminancant or ts as
building by the ayse Area
Air Qut or ality Management
BOILER-COMP QHPOR IWpWB'rU)
emit ict? nus air conmminvms as defined by the Bey Area Air Quality Mutmgement
k Distria7 BOILER-COME(OVER 100.000 BTU) TOTAL-
District?
❑No
I have read the hazardous materials requirements antler Chapter 6,95 or are Coli- AIR CONDITIONER ISSUANCE DATE
f nein Health&Snfery Cade,Sections 25505.25533 and 25534.1 understand Nal if the NEW RESIDENTIAL MECH. SQ.FT.
building does net currently have u tenant,that it is my responsibility to notify the occupant
of the requirements which must be and prier to Issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY: IqZb
OFFICE