B 0447 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI I'NO 0447
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL SOOO] (pJfe(-
BUILDING PROJECT 1DEN1'IFICATION� + i
BUILDING ADDRESS: SANJIARY NO. APPLICATION SUBMITTAL DAII
�.�/S 9�
OWNER'ti A lw �/ I'IIQNIi CONTRACTOR'S NAMIi: LIC NO' �/
Y 7�. /�./V/J1,�.pp pp NIC CONTRULp ARCHITEC'DEIGINEF.R: LIC NO: ADDRESS: a /�sVFI J� 11
CONTACT: IT NB: BUII:UINC'1'1?RMI'PINFO'
- ❑ Cunsiillant Feca Paid by Applicant(Initial) BLDG IT I P.OM t Nil CH
ED
r. LICENSED CONTRACTORS DECIARAI IONQpg ,, t. ELECTRIC PERMIT IEE
I hcrchy aRrmtht l ami sed..do,Pori of Chapter 9(c:mme bb r '+ .,s./ ' - 'IDB DESCRIPTION
Qzz whh Sml on 9lNX))ol D' nT (d•Buv dl ndission,Code, nd rlry La . EDF 1'
WOO PERMIT ISSUANCE
CWF mftll fomeand effec SFDWL ❑KI'I THEN REMODEL
<UU l:cense Cl s. Lic.M APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
vP zw Dom Contract ❑AfULTI-UNIT ❑STRUCTURAL,
ARCHI'IUCT'S DECIARATION
I-5oe I'ANEI.fi MODIFICATION
z p h z I understand my plane shall he used as public mcoNs DP'1'O 20(1 AMPS
oz— ❑INTERIOR El CHIMNEY REPAIR
t—an F.; Licensed Pmfessienal 21)1-1000AMPS IMPROVEMFN'1' 0SWIMMING POOLS
^�^� OWNER-BUILDIA DECLARATION 11
^yam C w Q 1 hcrchy Affnn tem 1 am exempt from the Contract. License Law On the OVER I111N)AMI'S El BATH RGMODI'1 P�lL D�hj01.1'I'ION
p(Q 6 U following mason.(Section 90]1.5,Bushes and Professions Care:Any city or c army SIGNS EI.1,CTRICAI. YOTHG'R4�
W 3 k y .haft acyuiren a permit to,uninect.cher,improve,demolish,m repair any saucmre /71fC77�'r2-
,F„u'O� priortoits issuance,alsorequims theappllcant forsuch Permian files signed.ornmarm SPECIAL CIRCUTUMISC.
�yw that he is Incensed powisionsofthe Contractor's license Law(Chaining
purxu:muamoCOMMERCIAL:
W KG�O (nit he is exempt
Serchuml4nd of Uiviniofar he alleged nd P
An,vis Cnde)er 'fI?MI'.MI!I'ER OR POhB INST,
d W o c Sent io is exempt therefrom anJ the basis far the alleged emmptmn:Any violation of ❑NEW RLUC/ADDI'T'ION ❑FOOD SI RVI
W oe Section7031.5
Fee
any applicant
r,($5Permit subjects the applicant mucivil penalty ur POWER DEVICES ❑'IMPROV' ❑1'000 SERVICE
n marc wnn Ova handawl Jul ors y employees
IMPROVEMENT
FSQ ❑Las dw...ofthepmpcna nrmyempleaded with wages as their tale(94,Bovines, SWIMMING i'OOI.IiLEC'fRIC
$yip. wi 11 dathcairms andthcstmameisnm's License La a dolsall,appitely I.an ovore,.1 ❑QTIIER
{0`� and Professions CMe:'itis Cnntredofs License Law docs nm apply m an oiwner of OU'11,E'IS-SWI'fCIIHis-FIST'UN[is
property who builds nr improves thereon,and who docs such work himself or through
his own employees,provided!that such improvements are not intended or offered to NEW RESIDEN'I'IAI,ELF R SQ PT
sale.If, blacho,or improvement lssolA within one your of a,mpletiamtho SQ.FT.FLOOR AREA $/SQ.PI'.
ner-himMer will have the bunion of proving that he did not build or improve lot par-
. �1,aw ow).
❑I,as owner of the property,am cadmivdy contracting with licensed centrannn ht TOTAL:
onsma the project(Sec 91144.Bt s nexs 11 t Carlo)TT Claim
-
censelawdoesnotapplytoanownerofproperty h hills rimproves therePLUMLIIN P
who contracts for such projects with a conramo'(s)fiscri parsturt to the Commcwrs '
License Law. PERMIT ISSUANCE ' 3� SD
Ism exempt under Sec. ,B&P C fnr this rcasun
ALTER—GRAIN&VENT—WATER(F, ) VAI DATION
Owner Dan _\
WORKER'S COMPLNSjmr,rmECL follow ON BACK FLOW i'ROI'ECT.DEVICE.
I hereby alarm under penalty of perjury enc of the fallowing dedact's Conn
❑Ihave and will maintainIf, eCion 37m of the Lalao sclf ,faltre Wmkefsen of
DRAINS-ItOOR,ROOP,AREA,GOND' STORIES TYPE C'ONS'I'HOC'I'IOD
moan•s provides for by Section J]00 of the halwr Ctdc,rqr She perfnrmuncc of Sha
work fnr which this permit is issued FIXTURES—PER TRAP
I have and will maintain Worker's Compete.ion Insurance,as 11.1.1 by Section
of the LpMla Cale.far theperform:mce Donee work for which this permit is issued. GAS—PA.SYSTEM1f-I INCA OUT LETS OCC.GNOUI' APN
My WalkJe��{s Ca��tppoo�//��' Insuron and Polio Leµ
Car"i r�fMrQlI�N/1 "Aicy Na, L�`"�IAf�e��/.ti� GAS—EA.SYSTEM OVER 41PA)
C17RTIFICXM OP EXEMPTION FROM WORKERSGREASEIINDUSTRL WASTE INI'IiRCFPI OR
COMPENSATION INSURANCE BUILDING DIVISION PEES
Thissection neednat becompletedlfthepetmit asfonmclummoeddollan($HSO) GREASETRAP
ur less.!
leenifYtbaintheperformancenf theworkfmwhlchthispermitix issued,Ishail SEWLR—SANITARY—S'1'ORM EA.21X1 FT.
not can't,an,"all in any'an no,so us or welane xahjecuo the Workers'Compcm - q� t
GY ',zsatian Laws ofCal&mia.Date WA'fGR ItEATLR WIVHNTIELF.C'Ht V 1/ ING PF.E2 Applicant .NOTICE TO APPLICANT:If,aper making this Ceotificate of Exemption,you should WATER SYS'I EMOKIL 1'INC,
a7 hoc... mbjrcun the Warkus Cnmpanmtian prnvininnx of the Luhor Gde,you must
W frrhwith comply with.such provisions or this peorm shall be deemed revoked WR'I'ER SERVICE
].z CONSTRUCTION LENDING AGENCY � NEW RESIDIiNTIALI'LMB. SQ.FT. PAID
I herebynflirm Sha,here is a consmeion lending agency fnr ihopatfomenccof B I�
the work for which this permit is issued(Sec.3091,Civ.C.)
Q U Lender's Name Tor IAL
_r
Lender's Address TOIAI"'
I comfy that I h 111 "ppl' f I (t p t' M f t ' , I BUILDING PEC
i... V1 via I:greemam ply to ll ly e ry N'n d.t ml If st QTY.i.' 'MECHANICAL PERMIT FEE
U z hailing eenitrachon andlorehy mihm' p stmufvesofthist'tyS enternp,t the '.r . SEISMIC PPE
'—: whase.mentioned propcny hnavpenian}amposn. PERMIT ISSUANCE
(We)agree le rove,indemnify and keep hamdass ten Cary or Cupertino against ELECTRIC IEE
l Adhi'm,pil,ment.c ,and expense,which may innerly wayaccme against said Ciry AI:MR OR ADD TO MECH. PLUMBING
ral
in onsehaenerof the gaantingof thispermit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'T OD N.000CFM)
SOUR F ' MECIIANICALh i
q AIR HANDLING UNIT(OVER 10.000 CFM) CONST RUCT10 TAX
a troof APPlicautlC tracer Dote EX HAUST I IOOD(W/DUCq HOUSING MITIG TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantnr fertile bmillingoccupant sure,handle hazardous martial BEATING UNIT CTO IIXI•(")BTU) '
as dcfinM by the Cupcnion Municipal Cale,Chapter 9.12,and She HealthSmd Sulety
Codes Semon 25532011 - HEATING UNIT(OVER I(B.0010 BTU)
E03 Yes ON. VENTILATION FAN(SINGLE RISID) PAID Doc Reccipt®
Will the applicant ar future huilding occupant use thimpment or devices which
emit hamnlons an oontiminems as thfierd by this Bay Area Air Quality Management BOILER—COMP(31111 OR 100.600 BTU)
TO fAL:
District? BOILER,_COMP 1(X6000 BTU) �-y
❑Yes ON. s (
I have anal the hamrdoes macrialx r is under Cha er h95 0l the Cul_ AIR CONDITIONER ISSUANCES DATE
cqulrumm� p
fomia Health&Safit ety Cade.Sec' 25505,25531 and 25531.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT,
building does mcri2ally h t t,it tit is Sny resgmslhiity to notify the owrupa,n .�/ S - 9
of the rcywraaral! t h Ica rmissuanebof n Cenificew of Occupancy.
Owner or authorized agent Dam TOTAL ISSUL011Y:
OFFICE