S 0205 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'MICA L P13RMIT NO.
CAL
BUILDING DIVISION APPLICATIONIPERMIT PI.UMBINJECTG. IDIANIFIU 0205
NUILDING PROJIiCT IDFYI'IFIL'ATION
I SANITARY NO, APPLICA'f10N SUHMITi AI,DATIi
BUILDNO ADDRESS:
_- ,OWNER' NAME: ON' CO 'RACE R'S ME' �'f J'II�a NIC CONTROL#
IIT' f: GINEER: 1.1 01 f DD �S ! ^r� ❑
C 7q1 /
_
CONT y p : BUILDING PERMIT INFO
9/ ❑ Consultant Fees Paid by Applicant(Initial) B.UG u30' PLUMB MECH
�P ❑ ❑
LICENSED ONT CTOR'SI SCLARA'I'ION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licca under previsions of Chapter 9(commencing
O0Z with Section 90000of[ivision 3 ofthe Businessand PmfessimsCade.and my license is RFSIDFNTIALa
Yl O O PERMIT ISSUANCE
Fly all turreted effect. ❑bFDWL ❑KITCHEN REMODEh
,UU License Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
FZLL Dam Contractor
vz6 ❑MULTI-UNIT []STRUCTURAL
ARCHITECTS DECLARATION
PANELS MODIFICATION
Z 0 7 2 l understand my plans shall he used as public records
OZV�— UP TO 2(p AMPS 01001'1?RIOR ❑CHIMNEY REPAIR
F� I� Licensed Rnfesxional 201-HROAMPS IMPROVEMENT [ISWIMMING POOLS
Y .4 OWNER-BUILDER DECLARATIONAVER IIMgIAMI'G El BATH REMODEIIRHYAIR ❑DEMOLITION
CLL V I hereby ofm that I am exempt from the Contractors License law for the _ ❑OTHER
a following reaxon.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL.
3 LL rFra�r which requires a permit to cnn4mcl,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIMISC.
"y•.t thatheislicenadp muvnnnNepmvisionsoftheConuacmrsl.icen,eL w(Chapmr9
t�Q COMMERCIALS
aG0 (commencing with Secdonn and of basis
cegedexe andon.Any vi Code)or TEMP.METER OR POLE INST.
IlDEMOLITION
a asa that he is exempt therefrom and the bazis far the alleged exemption.Any violation of ❑NEW BLDCdQIIIBTIQND O FOOD SERVICE
I Section 103 L5 by any applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES �Tpf'ANT Y' A tl
m more than five hundred dollars($500). V IMPROVEMENT
1- 1.as owncrofthe norm employees with wages as lheirsolecam lion, SWIMMING POOL ELEM RIC
G ❑ Pn'Pe Y YemP Y g Penin OCT
will dothework.Co the he Contractors
License a.dofor salel in,to an Business f�
and progeny who
Cato:The Gm thereo License law sacs not work hi s if owner of OUTLETS-SWITCHES-FI%TURES rte_
his own who builds or improve..thereon, pr who Joss such ts himself m through
his own however,
the
provided that m such improvements is men0 um not intended or offered for NEW RESIDENTIAL F.LECTR SQ FT.
sale.If,however.the building or impmvhmvmis sold within one year of completion,the SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
D I,as owner of the progeny,am exclusively contracting with licensed comment,it, �`/'Led
��
conswct the pngect Se,7044,Busimss and Profcxsions Code)The Connecters Li- ,{
ase law does not apply to an owner of roughly who builds or improves thereon.and QTY. PLUMBING PERMIT FEF.
who contracts for such projects with aconuacmrts)licensed pursuantlo the Commences
License Levi. PERMIT ISSUANCE
D l amexemplunder Sec. ,B&PCIm Nis recon
Data
ALTER-DRAIN&VE - .R(EA VVALJU�ATI/ONN
Owner --
WORKER'S COMPENSATION DECLARATION BACK 11,0 R(YI'ECT.UEVICI.
-I hereby ill mai under Certify oeperjury one of the following dcdams Cor
s/ iman: as
,I have and will maintain aCenifcmmol Consent.[sell-insure for Worker's Cnmpem DRAINS-FLOOR, OOF,AREA,CO gTORIES TYPE CONSTRUCTION
1+ 'mtion,as provided for by Section 3700 of the Labor Code,for the performance of the
work ferom NifPa. isissued. FIXTURES-PER TRAP
O'l have and will maintain Worker's Compensation Insurance,as rtyubeit by Section
. 3700of me Loan,Code,for the perfamamceof the work for which this pennil is issued. GAS-❑A.SYST - C.4 LET. OCC.GROUT' AI'N
My Workers Compensation Insurance carer and Policy number am:
Carrier: Policy Nn: GAS-E:A.SY. 'R 41EA)
AV Sr"THICAT130F EXEMPTION FROM WORKERS' GREASFANDUSTRL WA INTERCElvT
/Ya�11. COMPENSATION INSURANCE BUILD 'C ) ISION IT,
(Ibis section nced nor b,completed ifthe pemul is forme hundred dollars(SIM) GRBASETRAP
or less.) PLANCHECK FEE
I certify that in the performance afore work forwhich this Permit is issued.)shall SEWER-SANITAR S
not employ any person in any manner so as to become subject m the Workeri Compen- ENERGY FBI:
O Applicant x of California.Date WATER HEATER WIVI:NIF: . i
T
7 GRAVING 1.
r7 y NO CE TO APPLICANT:IL after making his Certificate of Exemption,you should WATER SYSTEMIfREATING SOUS
abecome subject to the Workers Compensation provisions of the Labor Code,you must
UJ fonhwidi comply with such provisions or this pumilsholl he deemed revoked. WATT:H SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V 2 l herchy affirm that them is a cmmthection lending agency for the performance of Dat Receiptq
wor
(~ the k for which this permit w issued(Sec.3119].Civ.C.) TOTAL:
Lender's Name
} fJa Lenders Addrehti TOTAL:
0. 1 cenify that I have read this application end 'am Thal the above information is BUILDING iE
rH.x Vi comer l agree to comply with all city unit county ordinances and...minwsmlatingto QTY. MECHANICAL PERMIT FEE
V Z building emismaeion,and hereby authorize m,00,rmtivesofthis city hernmrupm,lhe
SF.ISMICF.Ii
F-r above mentioned property for inspcctirn purposes. PERMIT ISSUANCE ELECfRI FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,assts and expenses which may In any way accmh agamslsnal City ALTER OR ADD TO M ECR. - PLUMBING
in consequence of the granting of this permit.
APPLIC TLINEF:MSTANDS WILL COMP Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(100 CFM) MECHANICALFEE
5 F;GULA'I'IONS. a I# w
IN AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signmurc ol'App icanUCommcmr Ilam EXHAUST HOOD OYMUC!) HOUSING MITIGATION FF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occup:mtstore or hamlle hazardous material HEATING UNIT LTO 100,000 H'1'U)
as refired by the Catoctin.Municipal Code,Chapter 9.12,end the Health cad Safety
Code.Section 25532(a)1 HEATING UNIT(OVER 101,100)BTI)
❑Yes DNo VENTILATION FAN(SINGLE RFSID) PAID
Dale Receipt
Will the applies.[or future harbor,occupant use equipment tar devices which BOILER (]III'UK 1011,1X)0 BTU)
nit hazardous air ornamentals u defined by the Bay Area Air Quality Management701l.:
.District,! BOILER-COMP(OVER IM,100BTU)
ED Yet ON.
I have read the hazardous materials requirements under Chapter 6.95 of me Culi- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Scv ioax 25505,2593 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
hoilding does not currently have a tenant,that it is my responsibility to notify the occup nt
of the requirements which must be mel prior to issuance of a Certificate of Occupancy,
Owner m authorized agent Date TOTAL.: ISSUED BY:
OFFICE