S 1384 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF,tIT NO. 1384
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION'
-
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
0 o W L'oP � 338385 Igge
OWNER'S AME: �� PHONE: CONTRACTOR'S NAME:' L[C NO,
//e- NIC CONTROL#
ARCE I'I'13CTIP.NOINF.P.R: LIC NO: ADDRESS: - / ❑
_GI
CONTACT: PHONE: HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG BLEC'IPI MUCH
LICENSED CON TRAC'1'Ok'S DECLARATIONQTY ELECTRICPERMIT FEE
1 hereby alBnn that I am licensed under provisions of chanter 9 anmmencmg J09 DESCRIPTION
MW"W^IZ whhSoeuona000).Th,sion3onhe Unsinessxnd Pmfa.ion,Code,mace,license is RESIDENTIAL
O in roll ferry and effect PERMIT ISSUANCE
❑SFOWI. [_1 KITCHEN REMODEL
�UE" License Class Lic#
F L
Data-Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PII'13
ARCHITECT'S DECLARATION PANELS ❑MFINE-UNIT ❑STR UC Hit RAI,
O Z y � I understand my pWns shall he tried as public records MODIFICATION
UP TO 200 AMPS
0 El INTERIOR El CHIMNEY REPAIR
Fs+L�wq Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
❑��� OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEWREPAIR ❑D MOLITION
C ¢ 1 hereby anion mat 1 ma exempt from the Commmnr's Ltaeta
nse Law r the
eL U following reason.(Section 70315,Busmen and Prnfes. ns Glide:Any city or county ❑OTHER
W 3 0.y which squires u permit m construct,oilier,i0mprove,demolish,or repair any structure SIGNS[LECTRICAL
pflonolni" anee,aLmregalrstheappll,vm for Inch Parent o Ileo signed samrecal SPECIAL CIRCUrr/MISC. -
{ that he is licensed pumuam to the provisions of the Comranors la,mou Lav,(Chase,9
W 00 (cnntmencing wah Section]INN))of Division 31fte,Business and Professions Code)m TEMP METEROR POLE[NST. II�AL d
G ps o y' that he is exempt therefrom and the basis for mu alleged exemption.Any violation of ❑NEW BLD D i N ❑DEMOLITION
Xe6 Semon 71315 by any applicant Far a puraiLsuhjecu the upplicmno a civil penalty of POWER DEVICES
W^m ❑TENANT ❑FOOD SERVICE
more mon five hundreA delhtrs($SW).
Fx Od DLae nwnerof the progeny.nr myemploycea with wages as their sole compensation. SWIMMING POOL ELECTRIC IMP 1)� LNfi ^ eI
Fwilldo the wmkaril the structure isnot intended m offered I...ala(Seo.9044,Husiness ❑OTU � 1
and Professions Code The Coatfanam''s License Law docs not apply m an owner of OUTLETS-SWITCHES-FLXTURES /
^ property who mild,o,improves bureau.and who does such work himself-t--sh
his awn employees,provided the,such impeoureunts are not'mended or offered for NEW RESIDENT AL ELECT R SQ by,
sale.If,however the building orimprovement is sold within 0110 year 01froluderon.the SQ.FC FLOOR AREA $/SQ.PT.
n M1 w 111 theburden fproving that hdid not h Id p f p
pose I are.)
. IDEALL] I (m property, IY t f g with dcontractorstr
construct 1 t 7044 Business d P t Code:) Connector,Li-
come
e t d pry t nt p n)whon Id� pp ve, the ,and QTY. - PLUMBING PERMIT t PEP.
who tarts Corsucpmhprojectswith mcunn tor(s)I reused pursuant tothe Lommcm,s
Liters,Lew.
❑ Isreasonexampl under Sec. ,B&PCfor this reason PERMIT ISS UA
Owner Data ALTER-U ENT-WATER(EA) VALUATION
WORKER'S COM PF,NSA'I'[ON DECLA BATON BACK FLOW PRU!'.. )EW CH
1 hereby churn made,penalty 0f paymy ons of the following declarations '02A if mm
I have and willlnatnmina Ce,tiucam nr GnmClll lO self-ineureforWnrkere Grmpen- DRAINS-FLOOR,ROOP,A A,COND' STORIP.S 'I'YPECONSTRUCTION
smian,as provided fist by Section 39!X1 of the Latin Code,ronhe performance of the
work for which ihls permit is issued. FIX'I URES-PERT RAP
❑ 1 have and will midmain Workers Compereatien Insurance,as required by Section
3700 of the Labor Cade,for tire performance of the work for which this permit's issued CAS-EA.SYS'IUM-IINCAOUTLETS OCC.GROUP APN
MY Worker,C urvanatinn Lnunmce currier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIN DUSTRL WASTE INTERCEPTOR > t .
(TI' t ennead tot bo mntplxtad'1 tl 1 1's faro 1rangildollars($100) a + vBUIBDINUS IV1910N FEES -
GRHASETRAP
nr le:7 PLANCHHCK PPP.
1 cerfifyd tnthe ",or,".
ecofth kf hich tly p t -.uad,ishell SEWER-SANITARY-S'1'ORM EA.21X1 I7.
note pl yany p rens n ny nun rust h h GTt theW Ems Cooper ENERGY FEE
Z cation hawsAn(a)
Dara WATER HEATER W/VENJI ELECT HE
pplicam GRADING PEE
� OTICP.TA :If,after mnkin his Certificate of Exen"ems,you should WATER SYSTEM/TREATINO
(~ haenme
annker's Compansa nn previsions at the Labor Code,you must SOILS FEE
Lakl f-tforthwith comply with such provisions orthis permit shall adeemed revoked, WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY N13WRESIUENIJAL PLMB. SQ Up PAID
U 0 I hereby affirm that there ismw
aa, etion landin,agency fonrfm
he penrnnryof Receipt#
16s F the work for which this permit;.issued(Sea 3097,Civ.C.)
O U Lender's Nunn TOTAL: y
0.Wi Lander',Address TOTAL:
It
1 certify that have read this implication and sale that the above Infnrmatinn is BUILDING FEE It
�."m alined 1 agree Incurably with all ac,and rnamy ardinaeres aw sate laws unfair,In QTY. MECHANICAL PERMfI - . EEE
[J4 baildingenmtnnion,mad hereby not horao re"camentives.tons any'.am ripmothe SHISMICEnE if el
above damional Property for impectinn..pose., PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino agairsst ELECTRIC FEE
IiaNIities.jmd,mentnenme and expemes whfdunuy in any way reame,mart said City ALTER OR ADD Tn MECK
in asequence of the granting of this permit PLUMBING THE
APPLICANT UNDERSTANDS AND WILL COMPLY WE 111 ALL NON�POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE FIGUIATIC MECHANICALPs
C AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION
Sl,nm "buran Cnmmemr Dune 100 IAUS'I'1 IOOD(W/DUC19 - HOUSINOMIq'IOATION PEE
I1A`LARDOU MATE IALSDISCLOSURL
Will me applicamer future uilding`l0upantstorerrhandlehttzunlous Tttteriul IMA'I'INGUNEF(TO100,000BIU)
as defined by the Caperton Municipal Code,Chapter 9,12,and the Itenth and Safety
Code,Section 25532(x)^ HEATING UNIT(OVER 100,000 HTU)
❑Yes E]No
VENTILATION PAN(SINGLE RESID) PAID
Wapplicant obudding occupant eintot mint
Data Receip
emit haznrdous air commoners asdefined by the Bay Area AirQuality Management BOILER-COME(3111P OR 100,000 BTU)
DsuicR I 'PpU
PAL:
❑Per EjNe BOILER-COME(OVER 100,000 BTU)
I have read the huza,dom materials rerryiremems antler Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC TE
fornix Health&Safety Cede,Sections 25545,25533 trod 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.I7.
building does not currently have a tenant,that it is my responemility,to notify the receptor _
of the reeturemems which must be met train issuance of a Campania of Occupancy.
Owner.,amhnripe l agent Date TOTAL: ISSUED BN'
OFFICE