B 0187 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMONO
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL _ 50001
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL PACT
0`71/ R!`►oc.._ �Jr. �-zs-4�
WN R'S NAME: PHONE: C9!J�'RACT0R'S NAME: LIC NO:
r ti Fra.t<»� _39a-7 -Prix P/ E%? Ods NIC CONTRDLN
.ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
`37 S' �M1s.� glw.11
CONTACT: PHONE: p dU1LUING PERMIT INTO
167 Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB nBGu
LICENSED CONTRAC'TOR'S DECLARATION QT'y. ELECTRIC PERMIT FEE
I hereby n0hed that I am licensed under provisions of Cham"9(co charreing JOB DESCRIPTION
aaZ with Soctlrn]Ilgd ofDivleirn3 of the Business and Professionx Code and myllcensc ie RESIDENTIAL:
�� ' Cullf rcr and aRee. PERMIT ISSUANCE
aW '^ ❑SFDWL ❑KITCHEN REMODEL.
6V License Class Lie.#
yV APPLIANCES-RESIDENTIAL ❑ADDITION BFC6MBING RE-PIPE
yd,o Dam Com ECL
AkCfI1TELT'9 DECLARATION ❑MULTI-UNIT ❑S"fRUCTURAI.
(. .N PANELS
oz4- Iundenwnd my plans shall he meA us public records MODIFICATION
pp ❑P T021MIAMPS L1 INTERIOR El CHIMNEY REPAIR
F�,F"W Lie ens ad Professional 201-1000AMPS IMPROVEMENT ElSWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER I"AMPS ❑BATH REMODEL/REFAIR ❑DIiMOIXf ION
d 1 hereby affirm that 1 nm exempt from the Commcmrs License Law fertile
L50=u following reason.(Section 70.11 5,Business and Prof admas Cede:Any city or county SIGNS ELECTRICAL ❑OTI16R
W 3 fL F" which requires a permit to conduct,after,improve,demolish,or repair any snu.are
prior to its issuance,aisereyuir..the applicant fee such mentor file samordswlenent SPECIAL CIRCUIT/MISC.
that he is licensed farmen,1.the pmmvions off the Connector's License Law(Chapter 9
X 00 (commencing with Section 7000)cdDivisi.n 3or I he Busdnes and Pmfassirnx Cheaper TEMP.METER OR POL� ST L:
COMMERCIA
OGc eG Ihvt be is exempt therefrom and the basix for the alleged exemption.Any violndnn.1 El NEW BLDG/ADDITION EIDHM01.1'I'ION
I• Section 7031.5 by any applicant for a permit subjects the applicant ton civil penalty if POWER DEVICES
m
nmo
t re Than five hundred dnllart(&500).
❑TENANT ❑FOOD SERVICE
F p" IMPROVEMENT
d ❑1,as owner(if the property,or my employee with wages as their side e.mprnsvrn
d , SWIMMING POOL ELECTRIC
Q will do Nr work.and[lie structure is not intended or offered for sale(Sec.90M,.n......
❑OTHER
. and Pr.fessionx e:The CoandUld v License Law duration apply to an owner of OUTLETS-SWITCHES-FIXTURES
Ed
property who,builds or improves thereon,and wbn does such work himself. l rough
his own candayeea,presided Ihot such i..pnrvencre,are not intended or.flered for NEW RESIDENTIAL ELECTR SQ PT.
sale.It,h.weveq the building or improvement mount wiflumone yen,ofcometh no the SQ.FC FLOOR AREA 5/SQ.FT.
minee,builder will have the burden of proving that he did not build or improve for put-
protectorate.).
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL -
cnM1xBucl the Bell(Sec.MITI,Business and Professions Code:)The Co anche's Lo-
cerise Law dees not imply to an owner of property who bands or improves thereon,and QTY.. PLUMBING PERMITFEE
who contracts for such projects with a conmacmr(s)licensed pursuantI.the Crnhnmm's
License l.aw. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner DoneALTER-DRAIN&VENT-WATER(EM VALUATION
'
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT..DEVICE
I hereby affirm under penalty of perjury,one of the following declanaiens:
❑ Ihme and will meimaimuCeniOmtc.PC.nsentto self-insure for Week,,s Coepen- DRAINS-FLOOR,ROOF,AREA,GOND. S'TOklES TY PE CONSTRUCTION
varied,as provided for by Section 3700 of the Labor Code,for the performance of the
L 6
k for which this permit is issued. FIXTURES-PER TRAP D
®-tdayEand will maintain Worker'x Compensation Insurance,as moci ired by Secondioi A
IN
3700ef the Eaton,Cole,let lhd performance of the work err,which this Nona,is issued. GAS-EA.SYSTEM-I INC.I OU'I LH9'S OCCOR P. APN
My Wnrk .Cr enaa�n In umnd]�arrirr and Popcy
Carrie.KrV � Paltry Na: g`�� GAS-
EA SYSTEM-OVER 4(EA) pNS'0
CERTIF CATE OF G) TMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE LNG B VISION ITTS
(Thiseuti.n nein Morita complHed if the permit is fonmehnndred dollms(Si00) GRHASE'1'RAP
m he".) I'LANCHF. EE
I employ
any pen in in anyperformance
man n r sof s to become ch
to perthe Wo kers ed'Cont shall
V t
SEWER-SANITARY-STORM EA.21N1 R.
not employ any pension In any manner run as 1.become subject m rite Workers'Comped- ENERGY FEE
,Z uti.m Laws of California.Date WATER I IEMERW/VGNT/ELECTR
z O Apparent ( GRADING FEE
Uj NOTICE TO APPLICANT:If,oder making,Fls Cenificam of Exemption,you should WATER SYSTEM/TREATING
abecome snhject to the Workers Gampensatlnm pmvisiomx of the Lab Cover,you mus, SOILS PEE
Wl forthwith comply with such previsions or this permit shall be deemed merged. WA'T'ER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAID. SQ.P. PAID
l hereby affirm thin there is a construction lending agency for the performance of Dwe ceipl
w� the work for which this permit is issued(Sec.3097,Civ.C,)
Lend,ex Name TOTAL:
V Leaders Add.... IDA(:
I certify that I have rend this application and state that the above information is BUILDING FEE
o-E'i h
caused,I agree ma comply with all city and county ordinances and state laws relating a QTY MECHANICAL PERMIT FEE
V Z building conswcdnn,and hereby canonize representatives of(his city to nnerup.n rho i SEISMIC FEE
abrvnmentionr l property for inspection purposes.mlPERMIT ISSUANCEISSUANCE -
Vm)ance to save,indemnify and keep haress the City of Cupertino against ELECTRIC FEE
r Ilibilltiev,judgmems,costs and expenses which may in any way name against solid City ALTER OR ADD TO MF,CUPLUMBING NIiB
. O
suryedcc of the granting of this permit. t
APPLICANT UNDERS'T'ANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,11110 CFM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC'T'ION TAX
SignatteenfApplicanVCo podoo, Dam EXHAUST HOOD(W/DUCT) a HOUSING MIT'IGA'TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future haildingdecapmnlxumnr handl huzaNnuvmm,etal HEATING UNIT(TO 1011,0011 BTU)
as detinet by the Cr,ma.Mani_aipod Code,Chapter 9.12,and the Health and Safety
Code,Sermon 25532(^)'! HEATING UNIT(OVER 100.000 BTI])
El Yes ❑No, PAID
VENTILATION FAN(SINGLE RESID) Tom Receipt#
Willthe applicant irfummbuilding by
nt use Bay Area
Air Qualitment or y
devices BOILER-COST(311P OR 100,000 BTU)
.�emit hmardnm sir cnntamin;mb ns detinet by the Pay Area Alr Quality Mvnagomen! TOT •l
❑Yes ❑Nn
District? BOILER-COMP(OVER 104000 BTU) V
1 have rend(liehacartlnas malenals reyuirement,undo Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
Trona Health&Safely Cade,Sections 25 5,25533 end 25534.l eade...ma tum if da, NEW RESIDENTIAL MECIL SQ.TC r n
building does nut camenly teats at it is my mp.ns'bility in notify the occupant
There at
nk w most mote ce.i v C rtlticute rf icy. l.[
"& �� p ip
O nation ahem Data TOTAL ISSUED BY:
OFFICE