B 0148 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL 1 PERMITNO.�O148
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10 3 L EAVE (� -(�-fig
NIiR'S NA E: E' LIC NO
eco 1 Pall L �RIJ�-I:: ,"ACIDIVS MCAWSI WC, 56S0Z6
NIC C(0)NTROL#
JCHITECTIP GIN LIC NO: ADDRESS: w� O ❑ }� ,('
1!5
S 44MI-TICAr 150
CONTACT: PHONE: W BUILDING PERMIT INFO
ed l�.t1V, r 4#0 A ye-2,5657 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH 1
ry`y/
LICENSED I CONTRACfOR'S(DECLARATION QTY ELECTRIC PERMIT f°EE L3 tT
I hereby aBirm that 1 am licensed under provisions of Chapter 9(commenting JOB DESCRIPTION
DMZ with Section 7000)mfDivision 3 ofthe Buxiness and Professions Cale,and my license is R SID NIIAL:
OO b4 n aa� PERMIT ISSUANCE
CWr in lull force and clT SC�SO2so ❑SFDWL El KITCHEN REMODEL
QUZ(, License Claa Lic.py /.f APPLIANCES-RESIDENTIAL TION [I PLUMBING RE-PIPE
F-G W Datc Contras n�
ARCHITECTS DECLARATION C1 MULTI-UNIT ❑STRUCTURAL
Z FO tt2 Z I understand my plans shall be used as public reeorda PANELS MODIFICATION
oz— / UPTO 200 AMPS ( [I INTERIOR ❑CHIMNEY REPAIR
Licensed Prof essintral 201-1(NOAMPS IMPROVEMENT SWIMMING POOLS
555 OWNER-BUILDER DECLARATION OVER IWAMPS [I BATH REMODEVREPAIR El DEMOLITION
Y
LL 6 I hereby eliirm That 1 am exempt from the Comrnttnra License Law for the
bd o C.V following reason.(Section]031.5,Business end Professions Coda:Any city or county SIGNS ' ICAL ❑OTHER r!-
uull Out which requires a permit to consw0.alter,improve.demolish,or repair any swcture r
F�OQ
poor its issuance,also regain the applicant for such Permit file a signed statement SPECIA RCUIT-E
that he is licensed pursuant m the previsions of the Contractor's License Low(Chapter 9
p0 (commencing with Section900nof Division 3 ci Business and Professions Code)ot TEMP,METE OLE INST COMMERCIAL:
6 ax c C that he is exempt therefrom and are basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
W^ Section 2031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
N nut more Nan five hundred dollors($51g0.
==C
[I I'm owne'd the property,or my employees with wages as their sole compensation, SWIMMING L CfRI IMPROVEMENT
will do the work,and the structure is not intended or offered forsale(Sec.9044,Business []OTHER
and Professions Core:*the Contractor',License Law does not apply to an .act of .'"� OUT ITCHES-FIXTURES f
S property 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 R IiLEM SQ FT.
sale.If,however,the building or improvement is sold within ane year nfcompletion,theSQ.FT.FLOOR AREA $/SQ.Ff.
weaver-builder will have the burden of proving that he did not build or improve for put-
ofsalt.) A f / L—/S'-7 Q f
❑h as owner of the property,am exclusively contracting with licensed contractors to —
summer the project(Sec.9049.Business and Professions Code:)The Contractors Li-
sc low does not apply m an owner of property who builds ro
or impves thereon,and QTY. PLU IT FEE
who contracts for such projects with a enmmemr(c)Iiwnsed pursuant to the Comraemis III
License Law. PERMIT ISSUANCE Q
❑ I am exempt under Sm. ,B&PCforthisre on
ALTER-DRAIN&VENT-WATER(EA) 3 O /l VALUATION
Owner Date r/ L� OO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE \/-E�
I hereby offimn under Penalty of pepory one of the following Worker into:
m have and will maintain aCertiOcam of Consent mulGinsure far WoRer'x Cooper. DRAINS-FLOOR,RWF,ARIiA.COND. STORIES 'TYPE CONSTRUCTION
cation,us provided for by Section 39(1(1 of are Labor Cade,for the performance of the O
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,ns required by Serino
9(N)o(the loot Csde.Bothe perf�o{rmance of the work f�of—wh�irchptthgisCpermit is is�sue1d. I GAS-EA.SYSTEM-IINCAOUTLETS OCC.GROUP APN
CurrWark<00V I I !T atand
No.: `�11,S*Z GAS-EA.SYS9'EM-OVER 4(BA)
CERTIFICATE OF EXIIMPTION FROM W
COMPENSATION INSURANCEO F^ MOI wi \ GRFASEJINDUSTRL WAaV INTERCEPTOR IL ING DIVISION FEES _
(This section need not be completed ifthe pectin is for one hurdox nllan($1f01 GRP.ASETRAP r pQ
orless.) - PLANC Z(CK (/
I certify that in the performance ofthe workforwhich this permit is issued,l shall SEWER-SANITARY MEA..(0
nm employ any person in any manner an as lu become subject m the Workers'Compen- F.NE iF
,x satitm laws of California.Date 602 r
Q Applicant I WATER HEATER W L GRA LE
NOTICE TO APPLICANT:If,ulcer looking this Cerri0a4e of Exemption,you small -WATER SYSI'EMiTR ING
become subject m the Workers Compensation provisions of the"Ire r Code,you must SOIhS nE
Wti forthwith comply with such provisions or this permit shall be domed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Ff. PNiI
V 0 (herchy affirm Oauherc isaconstralending nding agency for performance
the of --- Dae Re<ciptp
(•-' the work for which this permit is issued(Sec.3097,Civ.Cd
0 Lenders Nome OI li•
L) lenders Address I
TA"
d acesandBUILD( G 'EE
I certify that I have rent this city
and application and state that the shove information relating is
DIIZ mildin.Ioustrawcn.andhrebyaall ity and countyordinancesmndsta Eocrorclain the QTY. -MECHANICAL PERMIT FP,E 0
V z huilJing cnnnmetion.and hereby authorise representatives of this city to en¢r upon the SETS C
move-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Catarina against ELf�C�RIC •E
liabilities,judgments,costs and ex,mods%hich may in my way accrue against said City } ALTER OR ADD TO MECH. Z 20 P BI GME
in asequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECH ICAL FEE
SOURCE Fr IONS
/�.-. 1-.23, 9 - AIR HANDLING UNIT(OVER 10,000 CFM) CON UCIION TAX
SlgnatureofA IimaddC ntra J Dare O I EXHAUST HOOD IW/DUCT) HO NG MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazaNnus material I HEATING UNIT(TO 100,000 BTU)
as defined pert
by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)^ I HEATING UNIT(OVER 100,100 BTY)—
❑Yes XNa VENTILATION FAN RESIDI PAID
3 Dom Rcceipt x
Will the applicant or arm ubuilding by the Bt use equipment or devices which BOILER-COMP OHPOR 100,000 BTI(
t hazardous air nmmminunts as defined by the Bay Area Air Quality Munngement zitD L.,
nsnet' BOILER-COMP(OVER IOg000 BTI)
❑Yes kiNo
I have bead the hmardous mamtials requirements under Chapter 6.95 of the Cali- AIRCONDOIONERISS DANCE DATE
forma Health&Safety Code,Serious 25505,25533 end 25534.1 uMerstaM that if the NEW RESIDENTIAL MECH. SQ.ET.
huilJingde cvtremlyho, tenant,that it is my resPmsibilitymnotify the axupmn \p el ( 000•••"'"'
of there mus p' noissuance ofmCmif¢ate of ups y. \
\ y�
Own ge to 1 ISSUED BY:
OFFICE