S0059 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
( CITY OF CUPERTINO BUILDING-ELECTRICAL. ( qPERMIT NO.
I� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 'G L
BUILDING PROJRCT IDENTIFICATION ���/WW�
BUILDING ADDRESS: SANITARY NO. APPLICATION SUtlMITTAI.UA'1'F:
11A) v— Cel i v �� 4 ( o -13
OWNER'S NAME:�� - I //z PI10NF.:s�L- /� CONTRACTOR'S NAME: LIC NO: NIC APE
CONTROLp
I CHI I'IiCfIGN INFER: /V (• LIC NO: ADDRESS ❑ y�/O
I O �/
C0 ACT. P8AN BUILDING PERl.11T INFO
. ' MJNA1 / ���`�l ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
} �yf7 28"
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,OZ pZp wird Seninn IIpO)ofDivism.3..fthelbeineseuWPrafessiom Cade.and mylicensc is PERMIT ISSUANCE RESIDENTIAL
V L1 KITCHEN
�ZU Licenlse rcc`nd t Liap APPLIANCES-RLSIDFNTIAL, OSF DITION [I PLUMBING RE PIPE
�6L Dam Contractor
- CUTI-UNIT ❑STRUCTURAL
RLHITECI'S DECLARATION PANELS
Z rr/x�Z I understand my plans shall W used as public seems UYTO 2W AMPS MODIFICATION
pZ—.� ❑INTERIOR El REPAIR
F�~ tensed Professional 20140MAMPS IMPROVEMENT E3SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 11100 AMT'S [I BATH RF.MODEIJkEI'AIR El OF TION
yy I hereby affnd not l sec exempt from the Contractor's License Law far the
`5<3 d F following reason.(Seclion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL LR •C
BB7I LL y which requires a permit to construct,alar,improve,deainlish,or repair any structure
F u'Oe pmrse its issuance,also recidaw,he applicant for such Permit to Ncasigncd sammenn SPECIAL CIRCUIT/MISC.
Nthat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
I� 00 commencing with Section]000)nf Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
d a that he is exempt merefrmn and the basis for the alleged exemption.Any violation M - ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant fora Permit subjects me epplicom macivil penalty of POWER DIiVICG9 ❑TENANT ❑FOOD SERVICE
t sort than five hundred dollars(8500). IMPROVEMENT
=0 ❑has owner of me pmpcny.or my employees with wages as their sole compensation. 'S. NG POOL ELECTRIC ❑OTHER
wdl Jo the work,and the structure is not intended oroffered forsole(Sec.]U44,Rosiness
and Professions Cade:The Commerce,1 iecom Law does not apply to on owner of )? 'TS ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nm intended or offered for - NE SID•NTIA ELECTR SQ IT.
sale.IL however.the Molding or improvement is told within one year..(completion,the SQ.FT.FLOOR AREA LSQ.FT.
er-builder will have the burden of proving that he did not Wild or improve for pur-
7pose of sale J. L:
1,its owner of the property,am exclusively caroming with licensed contractors 1. ✓ 9
censtrum the project(Sec.t)an Business and Professions Codas The Contractors Li- DO
c se et t does not appy to on owner of Business
and PY who builds d improves mere...,and QTY. PlbM B PERMIT FEF,
whor m rects for such peri with a comactods)licensed pursuant the Commeares .�A
License Law. PERMIT ISSUANCE M�_
1.m exempt under Sec. .B&P C for this reason
Owner Dae
ALTER-DRAIN&VENT-WATER(EA) VALUATION 35-
WORKERS
�� OD
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE CYJ O
I hereby aRrm under penalty of perjury one of me following doelamtamon
I have and will maintain.Certificate of Consent toself-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA, STORIES TYPE CON RUCf10N
,.tion,ev pmvideol for by Section 3](10 of the Labor Code,for the performance of the
wprk far which this pernal is issued. I'I%TURES-I'ER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3A)0of the Lbor Code.for the perforrranceofine work for which this .it is issued. GAS-IIA.SYSTEM-I INC.4 OUT!ETS OCC.GROUP APN
My Works xCost a macs.lnsumnce carrier and Policy a T GAS-EA.SYSTEM-OVER4(EA)
Currier: Policy No.
CE�OF EXEMPTION FROM ORKF,RS GRGSFlIND115TRL WAST Ii IN'fF.RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITHES
(Thisse,tionneWnotMcompleled ifthepemut is for-one hundred dollars(SIM) GREASETRAP
orless.) PLANCIfECK FEE Zl
(cenify than in me performance ofmc work forwhich this permit is issued,l shall SEWER-SANITARY-STORM IIA.2W FT.
not employ any person in any member so as m became subject to me Workery Compen- ENERGY FEE Ci
z
cam.Laws of California.Date WATER HEATER WNENT/BLECTR
OQ Applicant ) GRADING PEE ly%is
NM ICE TO APPLICANT.If,after making this Cenificam of Exemption,you,should WATERSYSTEMCREATING
E"' h Iacome subject to the Workers Compensation provisions of the Labor Code,you must SOILS fPl
forthwith comply withmch pmvisinmm this permit shall be deemed revoked. WATER SERVICE
O `:
].z CONSTRUCfIDN LENDING AGENCY NEW RESIDENf1AL?LMR. SQ.FT. pAIIJ pate Remild#
V O l hereby offirm net here iso cnnstmction lueningugency for the performaree-0f
Lis Ir the work for which this per mit is issued(Sec.3097,Cil C.)
QU Luddites Name TOME;
Hd tenders Address TOTAL'
0• l cenify that l have read this appliumi..n and state that the.b..ve information is BUILDING E
F00
VI correct l agree to comply with all city and county ordinances and state laws relating to Q1'Y. MECHANICAL.PERMIT FEE
SF:ISMI
V z building construction.and hereby robotic representatives of this city it)enter upon the O /tom✓
above-mentioned property for inspection pvgcesm. PERMIT ISSUANCEELE IC J ?y
(We)agree to save,indemnify and keep homeless the City of Convention against _
liabilities,judgments,costs and expletives which may in any way accrue against mid City ALTER OR ADD TO MECH. P II E
to onsequence of the gaming of this permit
A PPLICANT UNDERSTANDS AN U WILL COM PLY WITH ALL NON-POINT AIR HANDLI NO UNIT(TO 10,000 CFM) 'II LFERJ
S '�REGULATIG b
J /� 6 AIR HANDLING UNIT(OVIiR 101000 CPM1 "CO TRU ]ON A%
e
SammoAp
re analCommcmr ✓� Dam EXHAUST HOOD(WMUCD H U MITI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IMTM BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100.00 BTU) V
❑Yes VN. PAID
VENTILATION PAN(SINGLE RFSIDI Date Recti IX
Will the applicant or future building occupant use equipment or device,which BOILER-COMP(3HP OR 100TW BTU)
40 omit humardlos air connotations as defined by the Bay Are.Air Quality Management TO
District? BOILER-COMP(OVER I Wand BN) d
El Yes XN.. .
I have read me homed../us'mate rs requirements under Chapin 6.95 of the Cali- AIR CONDITIONER • ISSUANCE DATE
forma Health&Safety Gale,Sections 25505,25533 and 25534.1 undemand that if the NEW RESIDENTIAL MECH. SQ�Ill (� r1 O .-.O
Wildingrl nm cudrendy haveatenad.thm it is my resTomnibiliy to notify the occupant fit/ [ .
,dm nn which must et prior 'sa ofa Certificatlof --a'.. _
Ownermardimmied agent ate TOTAL: I ISSUEDBY:
OFFICE