S 1973 ! —APP,LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEgIT NO. 1973
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL `v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
q7 449
OWNER S NAME: 6PfIllN,: _ CONTRACTOR'S NAME: LIC NO:
C& EAMAJD /NUt J.LJ �Cc. - 7,-E� $�j .AnN N/cCONTROL#
ARC ITECDENGINEER: LIC NO: 'ADDRESS: E]
CONTACT: PHONE: BUILDING PERMIT'INFO
�YNY � �g'� ue-o ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MOB
LICENSED CONTRACTOR'S DECLARATION QTY. " ELECTRIC PERMIT, FEE
' I hereby affirm that I at Rermad andel provisions of cbamtet v mon,men=n,g _ - JOB DESCRIPTION
wC with Section 7BB0)OTS,remn3afire Business and Professions Code.snit my license a, PERMIT ISSUANCE RESIDENTIAL:
. in full force and effect [ISFDWL ElKITCHEN REMODEL
1Z�u License Class - Lia.
7y ES
APPLIANCES-RIDENTIAL El ADDITION El PLUMBING RE-PIPE
til Dam Conlmcmr
1„5m ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
"ZOOZ l understand my plans shall he used as public records MODIFICATION
OZ�� OTTO 20)AMPS ❑INTERIOR El CHIMNEY REPAIR
F4 W Licensed Professional 201-IOMAMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDHR DECLARATION OVER 1000AMPS
❑BATH REMODEUREPAIR ❑DEMOLITION
94 W 1 hereby affirm the,1 nm exempt from the Contra=Inf's License Law for me
iCS� M U following awarem (Section 7011.5,Business end Professions Cod,Any city nr enmity SIGNS ELECTRICAL ❑OTHER
ywhish reclaims a permit la consumer,alter,Improve,darolisb,m femur any Nmcwre - -
prion t '.. no I. y :❑ ppL t[ by 'u fl v6 titcement SPECIALCIRCUIT/MISC.
shy that he is licensed amarm to the provisions ofthContractors Limense Low Chapter 9 - 4E 0
WWWQn (w tete n6 with Section 70W)at Divisi Sof he Business d P ofessions Code)or TEM P.MET ER OR POLE INST
but he is exempt therefrom and he brae,far he alleged exm
sine at Any Actinium of ., O ❑NEW BLDG/ADDITION ❑DEMOLITION
W..y Section 7031.5 by any applicant fora permn subjecls,be upplicannaa civil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICE
FZJ+ of more than five handled dollars 6500). IMPROVEMENT
q d D Lss owner of the pmpwty,nr my employeev whb wvges as their role tompensmim, SWIMMING POOL ELECTRIC
qZ`a will do the work,and the strtmemm is not intended or offered for sale(Sea 7044,Business - ❑OTHER
W and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIX'IU RES
Q' property who builds or impmvcs thereon,and who does such work himself or hough
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTR SQ FT _
sale.If,bootee,the building or improvement is sold within one year oPoompleticn.the - SQ.Ff.FLOOR AREA SISQ.FI'.
-builder will have the burden opausing that he did not hand or improve for par-' '
pterrof sole). /'- -
❑ 1,as owner of the property,am exclmively emulating with licensed,oarsman,to OTAL'
om muct the project(Sec 7044,Business and Professions Code)The Contractor's Li- -
copse-Lawdoesnotapplytoanownerofpmperry who builds or improves thereon,and QTY. PLUMBINGPERMIT .-FEE '
whocontract,forsuch projects wimam imcloo(s)licensed pursaanne the Coneram,
License Law. PERMIT ISSUANCE
nmas
I am exempt under Sec. ,B&PCfohistin
ALTER-DRAIN&VENT-41filt ) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROfEC'1'.DEVICE
• I hereby offiren under penalty ofperjury one of the following declarations:
I move and will maintain a Cemificale of Consent to sell-insure for Worker's Carmen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TY PE CONSTRUCTION
nation,as provided for by Section 3700 of the Labor CcaL.for the pertommreo aria,
walk far which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Code,firths,perfonnaneeofine work for which this permit is Issued. GAS-EA.SYSTEM-I INC 4 OUTIF FS OCC.GROUP APN
My Works,/n Compensmion Insure v u r vnd Policy numh
Carrico C{ �L1�/u/ cmcPoli=yNo: O ,slec.-aJ 7PA GAS-EA.SYSTEM-OVER 4TDG -
CERTIFICATE OF EXEMPTION FROM WORKERS' GkEASE/INDUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE. BUILDING DIV] PGE$
(This station need not be completed lithe permit is Lattice hundred doll ars($100) GREASETRAP
m less) PLANCHECK FEE
I cemifythm mile,peimueetifihe walk farwhich this permit is issued,Isbell SEWER-SANITARY-STORM EA.200 Il'.
not employ any person in any manner so as to become suhjecuo the Workers Comete- I ENERGY FEE
svtitin laws of California.Data WATER HEATER W/VENT/ELECPR
z ppheare - - GRADING FEE
r.l 0 NOTICE TO APPLICANT:If,after making this Certificate t,1Exemption,you should WATER SYSTEMaREATING
H become som t to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith cmnply with such provisiam or this,pennitshall be dereadrevoked. WATER SERVICE.
a (�
� z
CONSTRUCTION LENDING AGENCY NEW RF.SIDF.NTIAI.PLACE. SQ.FT. - PAID DoleeTMAL:
I hereby affirm that rhos is s constmction lending agency forme performance of
the work for which this permit is issued(See.3097,Civ.CJ
Lender',Name
0 a Lenders Address - TOTAL BUILDING FEE
1 certify that I have fwd this applicatith
on and slate bertha above of manner is
iFi fin correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 4building conswction,and hereby authorize represeamiives ofthis city to enter upontho SP,ISMIC FEB
nhova-mendoned pmp,,Iy for inspection pu,p,11, PERMIT ISSUANCE
(We)agrcc m save indemnify and keep Jamul...me City of Cupcmino ogainn LECfkIC PEE
Iiahilities,judgments,costs and expenses which may in any way came against said City ALTER OR ADD TO MECH. , PLUMBINGFEE
00
ME!
e of the granting of this Factor.
' APPLIC rtes UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(10 IR"CFM) • ]CAL FEE
SOURCE ,'ILATIONS.
_
12�QAIR HANDLING UNIT(OVER 10,001)CFM)- CONSTRUCTION TAX
Signature mApphcantlContr tar Date EXHAUST HOOD(W/DUCT) - sHOUSI�G MITIGATION PEE
HAZA OUS MATERIALS DISCLOSURE s Jt- .�
Will the applicanmr future building omupant.xmre,or handle brutaltius material HEATING UNIT(TO 100,000 BTU) VAlf
as deanmd by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety -
Code,Secdtiu 25532m)p HEATING UNIT(OVER I010,0(10 BTU)•
❑Yes No VENTILA'T'ION FAN(SINGLE RESID) PAID --
Dvic ReaiptM
Will the applicant or future building by the Bt use .Ail a or devices which
emit hazardous air comaminvnts es defined by the Ray Arca Ail Quality Management BOILER-COME(311P OR 100,000 BTU) O
District',
❑Yw ❑No BOILER-COST(OVER I W.NN)BTU)
AIR CONDITIONER
I have recallsSafety
hazardous oda,Sectors
ials255 5.25533 a under .1 and S95 ofmoColie - ISSUANCE DATE
basis gdoes&Safery Qd,Sections 25hat i 2s my end 25534.I understand thatifme NEW RESIDENTIAL SUCH. SQ.Pp.
building does not currently must a met p that o Is ua ce of it Cahy to notify the Occupancy.location
a[the mqulmmom,ywhirlr must be met prior m issuance of n CemiOwte'of Oecupvncy. A
Ownwnr vmhmHzed agent Date TO'CAL: ISSUED BY: �� • �O
OFFICE