00040174 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIJILDING-ELECTRICAL, PERMIT NO
APPIACATION/PF.RMIT PLUMB NO-MECDANICAL
BUILDING DIVISION " .BUII:DING PROJECT IDENTIFICATION O O
BUILDING ADDRESS: SANITARYNO. APPLICAHONSUHMITTALDAIT
S Cu o
OWNER' N Py(JNJs:' O C T R' � e,
ir;LTY NIC CONTROL#
RCHITE./ EQ _ LI Q �Ss
' C � S� ❑
CONTAC'p rrlONc BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB. MECH
=1 ' L� ❑ C
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afforded 1 am licensed.,,de,previsions of Chapter 9(commencing " , . JOB DESCRIPTION
paZ ISSUANCE n with Section p000)ofOn"son 3ofthafmainelished Profession,code,and mPCRMI'1
ylcensei, RESIDENTIAL:
in full rce
fand offer�.o '
7� ❑ ❑
SCOWL KITCHEN REMODEL
�UV License Class Lh:# '— APPLIANCES-RESIDENTIAL. - [-]ADDITION ❑PLUMBING RE-PIPE
F 61 Dam l aclnr da�
F=y ARCHITECTS DECLARATI N PANELS - [_1 MULTI-UNIT El STRUCTURAL
w',� lunderxtand my plans shall be usedmpublic records MODIFICATION
OZ.^0 UP T0200 AMPS
[_1 INTERIOR 0CHIMNEY REPAIR
F f�E."li1 licensed Prof.Tonal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
u M.I OWNER BUILDER DECLARATION OVER Intel AMPS ❑BATH REMODEU EP ik ❑I3IiP LITION
C p�p�� 1 hereby affirm that 1 ran exempt from the Contractors License Law for the
7W5�C.0 following Paassrm.(Section 90315.Ousine,e and lhofesslons Code:Any dry nr umnty SIGNS ELECTRICAL ❑OTHER
I++a W F which hohdo s a camen to elue,hu ,uher,improve,demolish,or Parini.any...share -
�"�y� pno,to its Tonsure,also requireaflac.plicunt for such pe...it to file v signed,msmeai SPECIAL CIRCUITIMISC.
Cid tbut he is licensed pursuant to the pmvisionsof Ne Ctmlrador9 License Law(Chapter 9
tv�Q� (commencing with Section 9000)of Division 3 urine Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom end the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
�..y Section 9031.5 by any applicant for a permit mbjwR the applicant to a civil penahyof POWER DEVICES [I TENANT ❑FOOD SERVICE
F11111 more than rise bnndred dollars 0500).
< (]Las owner of the properly,or my employees with wages as lheirsole cempenwtien, SWIMMING POOL ELECTRICIMPROVF,Mh:NT
will dotwtum Is
he work,and thescnot inlwndedno
oRePaJ I .saIII(Site 70FL,Nosiness OTHE
3 ro and Potficoons Code: Use Comracters License Law dews hot apply to an owner of OUTLETS-SWITCHES-FIXI URES
properly who builds or improves(hereon,and who does such walk himself or through
his own employees,provided that such imp fmvemen¢arc not intended or offered for NEW RESIDENTIAL ELECTR SQ Pf.
sola if however,Ne huildingorimprovement i„old withlnoneyearof completion,the SQ.Ff.FLOOR ARBA $ISQ.Irl'.
warobuilder will have the burden of proving that he did not build or improve for put-
❑p]I,as own,
.Las owner of the pmpeny,am exclusively Petitioners with licensed mmmees i- TOTAL:
onse Lm d product(Sec.904Q Business and Petny wh has ds or i The es thereon,
Li- -
use Law t,f not apply m an owner of progeny who omit,.or improves thereon,and QTY. PLUMBiNGiPERMIT FEF. '
who wmrncs for such projects with n amwctor(,)licensed pursuvm to he Cemmc(wre
License Law. PERMITISSUANCE
❑I am exempt under Sec. .B&P C for this reason _
Owner DateAEGIR-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECf.DEVICE 0�
I hereby affirm undo,penalty ofp jury one of Ne following dcelamtion,:
I have and wil l maintain a Certificate of Consent to self nesto for Workers Compm- DRAINS-FLOOR,ROOF,AREA,COND. STORIES IYPH CONST RUC'TION
inner,as provided for by Section 3900of the Labor Code,for the performance of the
k for which This permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
B of the Labor Godo f�r(hc performance of Ne work for which his perall is issued. GAS-EA.SYSTEM-I INC.4 OU'TLEI OCC.GROUP MIN
My Work C�."�/�;li�on J°ncfSSS camierand Palicyn117b"2647
le'
Currier:! Policy No GAS-BA.SYSTtM-OVER4(P,A) "�
CCR IFICA EOPEXEMPTIONFRO WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRI,WASTE INTERCEPT OR
('Phis sermon neW notbe compiwcd iFlhepe.mi(ie forone hundred dellars($Ij FBUII:DINO qIV I$1QN PBBS '
or less) GREASB'CRAP PLANCHLCK PPF. "
fcenify that in the performance oftle work forwhieh this permit is Issued,Ishall SEWBR-SANITARY'-STORMEA.200FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE,
Oz action Laws of California,Dam WATER HEATER WAVENTIELEC rR GRADING FEE
z 0 Applicant
r rNi NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you aheuld WATER SYS I'GMfrREA'1'ING a SOILS PEE become subject to the Worker,Compensation prevision,of the Labor Code,you most ,
fonhwbh comply with such pruhoore or this parmit,ml he aeemedreboked. WATER SERVICE'
Q
CONSTRUCTION LENDING AGENCY NEW RESIUEN'1'IAL PLMB. SQ,FT. PAID
IM1emby action hnt there isaconstruction tootling agency for the performance of _ Date Receipt#
V 0 the ,for which this permit is Issued(Sw.3fN9,Civ.CJ '
Ira F Leaders,Name TOTAL:
s V LenJcrs Address - TOTAL:
tir�'ys I sonify that I have read this application and stem Thal the move information is s BUILDING FEE
C0!) correct l agree to comply with allcity and county embrasures and stet,law,relating to QTy.. - MECHANICAL.PERMIT R FEE .
) ,"� baldingcommclion,and hereby withoriTonpPasenmdves of this city toenter uponthe SEISMIC FEE
above-mcn mmol properly f n ne,sction proposes.
(We)agree m save,indemnify and keep harmless the City in Cupertino against PERMIT ISSUANCE ELECT FET.
" liabilities.judgments,costs and expenses which may in any way seems agrinst said City ALTER OR ADD TO METH:
in
consequence of the granting of this pemet PLUMBING FEE
APPLICAN'I'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1010.00(1 CIM)
50 CP.REGULAriONS MECHANICAL FF.F. -
n�, A ' Lj,:, AIR HANDLING UNIT(OVER 10,gID CFSU CONSTRUCTION TAX
Signature of AppliennVCoitmetor, /!/`-- 1 Data EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PP.Ii
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous..,enol HEATING UNIT(TO 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? 1[EATING UNIT(OVER 100,000 Ir'I'U)
El Yes VENTILATION FAN(SINGLE RRSID) PAID
Dom Receipt#
Will the applicant or future building occupant ave equipment or devices which _
emit h:aardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR IIIU,000 BTU) TOTAL
District' BOILER-COME(OVER 100,000 BTU)
❑Yes
I have road the hazardous materials requirements under Chapter 6.95 ofthe Chh- AIR CONDITIONER - ISSUANCE DATE
forms Health&Safety Came,Section,25505,25533 and 8534,1 mchowand(bat if the NEW RFSIDENTIAI.MECH. SQ.IT
building dews nal currently have a tenant,that it is my respomibility to notify the eeeupant
ofthe ra, eta which meet net pri to iss neofaC Hitt le of pa ,
L
Owner or out oozed agent 'Date TOTAL: ISSUED BY:
OFFICE