S 0775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BullD;NG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLumnlNc.nIHC,xANICAI. O 0775 7 C
BUILDING PR IECf'BEi I'IFICATION O 1 J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUpMIITAL DAT]
as
o 'ISN E: O P O E: k- CO 'IRAC ORS A Cyb/�LIC NO: 6 t�
` P NIC CONTROLJI
•f/ \ CHIITCUENGINEER: LIC NO: DA DRIiSS: �1 1 C _ - — ❑
CONTACT: PHONE: 1•n•„x'_SPJ�_/_/ •J`�" BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDU, PLUMB MECH
LTCENSEDCONTRACI'OR'SDECLARAI'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
0
I herebyllin
ao that[am licensed under provisions,,&Chapter 9(commencing
{� 0 with Secrion7000fofDivninn 3opbe Businessand Padmsion.a Gde.and my lievem ix RESIDENTIAL;
F� in full fmceand Inco-- +6 38x'665 M
PERfr ISSUANCFi GSPDWh [I KITCHEN REMODEL
ZDains,ne- Class Cumm•�• APPLIANCES-RIISIDEbfJAL ❑AUDITION [I PLUMBING RF.-PIPE
FIsl Dn
7i7 ARCHFIECT'S DECLARATION` PANELS - ❑MULTI-UNIT ❑STRUCTURAL.
z C)�z I undersmod my plae,,hull M1eused asprhlicecord
awards MODIFICATION
OZ4GEJPT02(MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F, I'f• " License)Professional 211-100EAMPS IMPROVEMENT []SWIMMING POOLS
-s! OWNER BUILDER DECLARATION VCR I(g1f1AMPS O BATH RF,MODEIIREPAIR El DEMOLITION
�
X 1 hereby aRrtn that I inn exempt from the Conuucier's License Law for the
X3�F- following mason.(Section 7031.5.Business unit Professions Code:Any city or county SIGNS ELECTRICAL
[]OTHER
which requires a permit m c...tr ,alter,improve,demolish,m repair any aNaeum
F.
prier lets issm.nccalso fairness meepplicant gained permit m tileusignedsommens SPECIAL CIRCUIT/MISC.
f�} mut he is licensed personal m the provisions of the Centimeters License Law(Chapter 9
��1z0 (commencing with Section WIXB.Ovifer,3ofthe Businessand Professions Cod)or TEMP.MFTCR OR POLE INST. COMMERCIAL'
a t4,o E that he is exempt therefrom trod the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
`r.of Section 7031.5 by may applicant far n permit subjects the applicam m acivil penalty of POWER DEVICES ❑TENAN'T ❑FOOD SERVICE
r>. not mot,than five hundred dollar,($5110).
F
,>.
❑ I,as owner of the proµny.nrnry employees with wages us their role<omµnsnrinn, SWIMMING POOL ELECTRIC IMPROVEMENT
Sa will do the work,and the,vuctrre Ivaco intended mooted for zeta(Seo.7094,Boom. 0OTH2R
a 3 aad Professions CNe:The Commcmr's License Low does not apply m an mvncr of OUTLISfS-SWTTCIIES-PIX RES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are mol intended or offem l for NEW RESIDENTIAL IiLECTR SQ
sate.If,bwe,m the buildingor improvement i,s.ld withlnone yearof complctine.the SQ.FT.FLOOR ARTA 5/SQ.fT.
now...ht,dder will have the horde.of proving Nat he did not build or impress,for par
pec crude.).
0 1,as owner of the property am exclusively contracting with licensed contractors to 1i
,int rucl the prove,(Sec.7044,Business and Professor ons..de:)'In.Coabacmr'I LI-
sense Law does not apply of an owner of progeny who builds or improves lherean,and QTY. PLUMBING PERMIT -
who contracts for such projects with a conm,etrts)licensed personal,,the Contractors
License Law. P17RMIT ISSUANCE
1 am exempt under Sce. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Orifice Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE
I hereby if,.under pvmhy of perjuryane of the following declamtime,
I have and will maintain a Cenifter,ofConsenuo self-iname far Workers Confiner- DRAINS-FLOOR.ROOF,AREA.COND, STORIES TYPE CONSTRUCfIO
scion.as provided far by Section 3710 of the Labor Code,fur the performance of t th
work for which this permit i,issued. FIXTURES-PER TRAP
0 I have and will maintain Workers Compensation Insurance,as required by Section
3710o1fthe Labor Care,f.rtheµTharmnce of,he Werk for which this permit is issued. GAS-EA.SYSTEM-1 INC.S OUTLETS OCC.GROUT' APN
My ns nlnmmnce and Policynumfl ',! I
mer s y Policy No
cornerla I`��Y Oh 5 GAS-IA.SYSTIiM-OVER J(EA)
"It RTIPICATE oft[xppTiON FROM WORKERS' GREASF/INDUS'1'RI.WASTE INTfiRCfiPfOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need no,be completed Rom .It is prone hundred dollars(SI WI GREASE'[RAP
PLANCHECK PEE
or less.)
I really beat inthe perfuramem of the work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.2001T.
not employ anyµmom in any manner se as to become subject to the WorkersCompel- ENERGY FEL
QZ cation Laws of California.Dart WATER HEATER WNENT/ELEM R GRADING ITE
Z Q Applicant
(-'^ NOTICE TO APPLICANT:If.after making this Cembodue of Esempa.n,you should WATER SYSTE An REATI NO SOILS FEE
hmears subject m the Workers Compemntmn provisine,of the Labor Core,you must
a ti forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
a Q011Y � .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID £'
V OThereby nthrm thauhere isaconslmetirn lending agency for theµrformunce of Um 1k 4
the work for which this permit is issued(Sec.3097,Civ.C.) /TOTAL:
ULender,Name
Lender's Addres, TO'T'AL:
If
l4, 1 certify Nat 1 have mad this application and stare thin the above information is BUILDING I 'F:
F'N correct.l agree to comply with all city and county ordinance,and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FE'
V building constmction,and hereby authonureps,s,frativesoRhis cirymemmr uponthe
above-memi.ned Employ for inspection parimsex. PERMIT ISSUANCE ELECTRIC ITE
ee
(We)agrto save,indemnify and keep harmless tho City of Cupertino against
liabilities,judgments,emitted expenses which may in any way accmeugaimnedd City ALTER OR ADD TO MECH.
PLUMBING F
A APPLICANT
of Negaming Ithis permit.
APPLICANT I ERSTANOS AND WILL COMPLY WITH AL1,NON-POINT AIR IIANOLING UNIT(TO 10.000 CFM) MECHANIC L PEIi is
SOURCE "CATIONS.`
l,� AIR HANDLING UNIT(OVER 10,10(IGFM) CONSTR ;TION TAXro
el
StgnatureofA plicuaVC.I1-1-1 �/Df••mt EXHAUST HOOD(W/DUCD HOUSING MI AU NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapliarent I,future building occupant store or handle ha..Mo.,material HEATING ON IT ITO 100,100 BTU)
as defined by the Cuµniner Municipal Cole,Chapter 912,and the IIea11h and Safety
Cod.,Section 2553200/ HEATING UNIT(OVER 100,D00 BTU)
❑Yc, GNo VENT]I.ATION FAN(SINGLE RESIDE PAID
Dae RecciptM
N9a Ne applicant or future buildmiloccupam use equtpmem.r devices which BOILER-COMI'THIP OR INMIW BTU)
mit haaerdous air conmmirems as defined by the Bay Area Air Quality Management TOTAL:
Disuba? BOILER-COMP(OVER 100,001 BTU)
[:1 Y. r7 No
I have read the hammousmaterials cauiremcros under Chapter Ads ofthe Caii- AIR CONDITIONER ISSUANCE:DATE
brain Health&Safety Core,Sections 255115,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.EL
building does not emrently have o¢nam,that i,is my responsibility to notify the reentrant
of the requirements which must he met prior to issuance of a Cenific.ro.f Occupancy.
Owner or auth.nmd.,I., Date TOTAL'. ISSU BY:
OFFICE