S 0012 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION DI �1I� n
BUILNG PROJECT IDENTIFICATION ' ' .6 J— 1
BUILDING ADDRESS: - SANI'T'ARY NO. APPL1CAl'[ON SCENT UJ'AL DATE
/0/6-/ �v- 'S-L%-q
ir 0 NER'SIS p1 ���- CO TB R' AME: LIC NO:
f41r+'n� SNI NIC CONTROL,
ICHITECT/ENGINEER: LIC No - ADDRESS: ❑
CONTAG'B - PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) RhDG ELECT PLUMB Is ECH
LICENSED CONTRACTOR'S DECLARATION QTY � ' ELECTRIC PERMIT) FEE
I hereby afrnln that I am licensed under provisions of chapter 9 o ommenle
ang _ ' - _ _^ I JOB DESCRIPTION
2 mSecion]nao of Divided 3 affair Business and Professions Code andmy license is ,
00 wl PERMI'I'ISSUANCE RESIDENTIAL:
y r m rw rnreo dna eBeoL
❑SFIJWI. El KITCHEN RF:MOUF,I.
�VZU License Clmx Lic# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RIi-PIPE
J y 6 u] Doe Contmemv
0. ARCHITECT' PANELS S DECLARATION MULTI El STRUCTURAL
Z p m z I understand my plans shall be used as Public records MODIFICATION
O'y�0 UP T02IX1AMPS
El INTERIOR [I CHIMNEY REPAIR
.G4G'/t Licensed Pmf..jobs[ 201-1000AMPS 1 PR0V1:MENT �SWhMMING POOLS
thatOWNER-BUILDER acsc,am DECLARATION OVER 1000 AMPS TH REMODEL/REPAIR ❑DEMOLITION
follaiyoy 0.W 6 ' I hereby whom on i um exempt from the Comtans Co A.,c Law forme
>e a d which ng massa. eranit t ]ensu Business and Professions Coda.Any can or county SIGNS ELECfRICAI. EIGHTIES
LLLL1I Iz. which requires a permit on coresthe aafterpplicant
improve,demolish, file.
i repair any slmnure
pdonolts laoance,.Ixn rWuirecthenpplienm for such,comb mtlle vslgned statement SPECIAL CIRCUIT/MING.
W� IhuAre is licensed Panama le'be provi,ear.Uhe Cmntrecmr s License Low(Chapc-9
(commencing with Sebom7000)orDiviomr3ofthe B.,iues,and Profo.mo,Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he Is exenlpl therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑IIP.MOLff10N
W"m
Section 7031.5 by any applicant for a,writ subjects me applicant n a civil penalty of POWER DEVICES
not more than five hundred dollars j$500).
- ❑TP.NANT ❑FOODSERVICE
5p ❑ Cas...e.of the property;onnycmployees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
y will dothe work,and the souclure is not intended omffered forsele tSec.904,Business ❑OTHER
0.a and Professions Code:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Is
property who build.lir improves meremn,and who docs such work himself or though -
his awn employees,,..tried that such haprnvemenl,are not intended or offered for NEW RES EN'f1AL ELECTR SQ IT
sale.If,howcvcr,the hulldingn,unmevcment is sold within one year of uvmpletionnhe SQ.FE FLOOR AREA $/SQ.Fn
owner-hrolder will have the burden of proving that he did not build or improve for put- A
Fee upside.). , - P� ,
❑1, f the property,am excI .' ly contracting with licensed comeacronsh, TOTAL: D
construct the p Jet(See,704 Business and Professions Code:)The Contractor L' - - ��
sato de tapply t fproperty h b 'Ids or improves thereon d QTY - ' 'PL13 IHRMIT' - - PE8•;Y ' Q
who c t t for such p lecturers with a correcmr(s)I ceased pu.munno v
License Law. - PERMIT ISSUANCE U
Q I am exempt not,Sec ,B&P C for this reason
Ownerpore ALTER-DRAIN&VENT-WATER(EA) llAT10N
�� WORKER'S COMPENSA'T'ION DECLARATION BACK FLOW PROTECT.DEVICE 1^ 1/VJ����J
i hereby union under penalty of perjury one of the following declarations:
❑ I asvcond will mammin.Cempencof Consemm self-Inane du Worker's Comm- DRAINS-FLOOR,ROOF,AREA.GOND. STOItI TYPE CONSTRUCTION
dm
to provided for by Section 3700 of the Laid,Code,fur the performance of the -
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37B)oRhe L.Mi-Code,forth,performance orhe work for which do,,t red is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Wmke',Com,sax.f.n Insinum.carrleraa Policy norther lire:
Cartier Policy N.- GAS'-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
NUB. 0 IyI510
(I hiseection need not be completed ifine pm
ermit is fortune hundred dollars($IUI) aREASCTRAP - _
�r less.) PLANCHECK FEE
o Loy any that in theoamin penfinany
so stworkfarmewGhdubjectiotheWrkesCoIball fer-
96WER-SANITARY-STORM EA.200 PI'.
lint employ any Canon i a any Imnncr so as to b«emir subject to the Workers Conifer- ENERGY FEE st
0 Z .mini Laws of California.Date WATER HEATER W/VENT/ELECUR
z
NOTICE
nl 1 GRADING FE
NOTICETO APPLICANT.rsafterpensatinnp provisions
of Exemption,you would WATER SYSTRM/fREA'IINC
Glume subject y the Workefa Compensation provisions of the Labor Code,you man SOILS PEE
{La [nnhwilh wmply who such provisions or this permit shall bo deemed invoked. WATER SERVICE
Q
UO - Cm(therRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
I�ar whichIN,pet there--.aed(Seeconstruction30 lending agumy far Cer(o.mamce of Dale Reocipt#
w H
the work for which this permit is issued(See 301 Civ.Cd -
Lenders Name - T(YIpL.
WLender's Address - TIYI'AL.
FG. 1ccnee that 1help adthiscity andcounanddina the anired
abovewstotaling is � BUILDING FEE �
.-1 (n mrtoc[.Ivgreent.amply with all city and county ordinances and vote laws inleting to QTy, MECHANICAL'PERMIT -FEE
O building conxWetion,and hereby authorize rcprasenmtives of this cl[y to enter upon rho SEISMIC FEE
starve-mentioned property for.inspection proposes.
(We)agree w rave,indemnify and keep M1armleys IM10 CIIy of Cupertino.geinst PERMIT ISSUANCE ELECTRIC
lialubliee,judgments,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO SUCH. PLUMBING EE
in suryuse of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO Ig000 CFM)
S l .F:REGULA'I' S MF.CHANI ALFER
' AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRH.TION TAX
'ignition,of ApplianVCmaraa..r Date EXHAUST HOOD(W/DUCT) HOUSING TIONFE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant...future hoilein,occupant node or handle hazunions material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safely
Code,Section 25532mC HEATING UNI'p(OVER 100,000 BTU)
❑Yes El No - VF.NTILXJION PAN SINGLE RESIU) PAID --
DateRceeipt
Will the applicant an future building occupanl use equipmenl or device,which BOILERCOMP(}HP OR 100,000 BTU)
',nit Incaution,air restaurants,vs defined by the you,ny Arco Air Giddily Manage -
ment TOI,A
istricC
❑Yes F1 No BOILER-COMP(OVER 100,000 BTU)
I have read the hamolons minuials AIR CONDITIONER _
requirements under Chirac.695 ttme Cal ISSUANCE DATE
balite Healthgdoes&Safety Core,Sciences atena 255(15,25533 and 25534.Ito notify
th Thal if We NEW RESIDENTIA I.MECH. SQ,FP
holding does not currently na.aa tenant,mat it j%my responsibility m nobly me nccup.nt
o[me reyuirernerts whicM1 mull he mer prieneissmnce ofd Certificate ofOecupancy..
Owner ormthoized agent Date TOTAL: ISSUED BY:
OFFICE