S 0225 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO gRU�ILDING
ELEC'I'RICA6 PERMIT NO.
RU1LDING DIVISION APPLICATIONIPERMIT MECHANICAL 0225
T IDENTIFIL'ATION BUILDINGADDRFS$, SANITARY NO. APPLICATION SUBMITTAL DATI�44WQ
OWNS :S h NL: CONTRA1.1 ):�1� �/4 /A/�/J� � NIC CON'1ItOI.k
CHITCT/ENGINEIiR: LIC NrJ: ADL V !/`�V^-.�� ❑
CONTACp. L 'P/7JONJP, / BUILDING PERMIT INFO
1 (p ❑ Consultant Fuses Paid by Applicant(initial) BLDG 7PhUMI VIICH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEB
1 hereby mrrm that 1 our licensed under provisions of Chapter 9(commencing JOB DES IPTION
O=Z who Senmm�nu08 on)ivision lonbn Basinms and aro--sxions le, nil my❑cense i. RESIDENTIAL:
woo PERMIT ISSIJANCIi g
F�� in full force and ❑SFDWL ❑KITCHEN REMODEL
Q U License Claes Lie. APPLIANCES-RESIDENTIAL El AUDIT [I PLUMBING RE-I'll'li
F z WDam Commemr
wild '///7/ 77RCHIT'ECTS DECLAR 10 ❑MULTI-UNIT' El STRUCTURAL
Fmz I understand my plana shall he used as public records IANCIS MODIFICATION
UP TO 200 ANIPS I ❑INTERIOR ]CHIMN EY REPA IR
F4LW Licensed Pndesslonal 2014000AMPS IMPROVEMENT SWIMMING POOLS
; OWNER-BUILDER DECLARATION OVER 1010AMPS ❑BATH REMODEUREPAIR ❑DEMOLI' N
C C d I hereby affirm that 1 am exempt from he Contacmr's License haw fur the
X3'U InUtweitrieuom.(Section 7031.5,Rosier,and l'mm,drv,Ede:Any city or county SIGNS ELEi RICAL ❑OTHER
W LL y which requires a permit to conslrucl.alter.improve.demolish,or repair any structure
04 prior m e
its issuanc .1-acquiresthe aEq icon(fo,irrh permina file asigsamC
ncd mcr, SPECIAL CIRCU[TIM USe
1yY that he is Eeenscd porsuammlhc pnrvisi0ro of the Cnntrunnr's Gcensc Luw(Chapmr9
W EY02 (commencing with Section 7000)of Division 3 ofdte Business and Professions Crude)or TEMP.MUTEROR POLE INS'T I L
a d that he Is exempt therefrom and the basis for IM alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
W;N Serino70315 by any aii,hrmfor a permitsuhject.the applicant to a civil pennlry of POWER DEVICES ❑TENANT ❑fool)SERVICE
sol more than live hundred dollars(4510). IMPROVEMENT
f2� ❑ 1,as owner of the property,or my employees with wages as their sole compeer cion, SWIMMING POUL ELECTRIC
F will do the work,and the xtmctum is not intended or offered for sale(See JOg4.Huxlncss H
W m and Profession,Code:The Contractor's Liceme Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,and who docs such work himself or through
his own employees,provided nonsuch improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,howcvice the building lir improvement it sold within one year of completion,the FT.FLOOR AREA S/SQ.F1'.
ser-huilder will have the burden of proving Not he did not build or improve for pur-
pose of wle.).
I,as inner of the pmpeny,an exclusively contacting with licensed contractors 10 TOTAL:
construct the project(Sce.7011.Business and Professions Code.)The Contractor's Li-
censeLawdoesnotapplyloanownerofpropenywhobuildsorimpmvestheaean.and QTY. PLUMBING PERM IT FEE
who nmmoss[or such projects with a court r(.q licensed pursuant n the Commuter's
Licence law. PERMIT ISSUANCE
I]I am exemp under Seo. ,115 P C for this recon
Owner Date ALTER-DRAIN&VENT-WATER(EA) ///V�/((r//�LUAANOION
WORKER'S COMPENSATION DECLARATION HACK PLOW PROTECT.DEVICE 1' ✓��
11011 1 hereby affirm under penalty of perjury one.1 the following declmrumm:
]IM1ave and will mnimaina Ccnificme nfConsent to sell'-insure[nr Worker's Courtier- DRAINS-FLOOI.RODE.AREA,COND. S'I'ORI&S "TYPE CONSTRUCT 101
scion,as provided for by Section 37M of the Labor Cady home,performance of the
efor which this peit is issued. FIXTURES-PER'FRAP
w 1 have and wilrm
I orainain Workers Conpcmmion Unsmoom.us required by Section
3700 of Ne Labor Care.fonhc performance of the work for which Nis is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Work- 1lluncv-Limim and Policy n m
Crricn �r �IW%
Policy No.: pe it GAS-EA.SYSTEMOVER 4(EA)
(mai-'10E�R7/IITCATFO EXEMPTIONFROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCF;I'TOk
BUILDING plVl$ION I'EBS
(This section recd not be completed irthe permit is lumens hundreddollars(41W) GREASE TRAP
lir Iex'J PLANCHECK 17I7E
I eerily the in die pcnarmarceof the work for which this permit is issued.I shall SHOWER-SANITARY-STORM EA.21X1 IT.
not employ any person in any more!so as m become.subject to Ne Worker'Curative- ENERGY FEE
z ration Laws of Califnnia.Date WATER HEATER WNENT/GLECTR
z Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certifieme of Exemption,you should WATI7R SYSTEM/TREATING
F� ? become subject m the Worker's Compensation provisions of the Labor Code,you most
SOUS ITE
fonhwhh comply with such provisions nr this permit shall he deemed revoked. WATER SERVICE
0
CONSTRUCTION LHONDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI. PAID
U0 lhereby dfimUhathere isaco(Ser.3n lending agency fur Ne performance of Date Receipt)
F 'he work lin which Nis permit is iuued(Sec.J(197,Co.C.)
O
Lunde,,Name 'fOFA L
U :
r I CLI IFndcr' Address TOTAL:
� certify Nat 1 have read this application and sameNal he suave inl'nmmrnn is BUILDING FIiF,
FVI cosset.I time m comply with all city and county...containers and sten laws mlatingm QTY. MECHANICAL PERMIT FEE
U z building construction.and hereby amhorim representatives of ibis city to enter upr the SEISMIC FEF.
r aMwe-memmued property for inspection purposes. PERMIT ISSUANCEaI�
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FI7E Qew
inbildies.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECIL
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL.FEEiy K.
AIR HANDLING UNH(OVER 10.010 CFM) CONSTRUCTION TAX
Signature of Applicano/Commemr Dam EXHAUST FOOD(WTUCT) HOUSING MITIGATION WE
MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hazardous nmmrial MEATI NO UNIT(TO 100.000 RT
as defined by the Cupertino Municipy Code.Chapter 9.12,and the fleanh ad Sal cry
Care.See don 25532(a)^. HEATING UNIT(OVER I(p.Op HTU) /yyyp]�
�Ves PAID I __
VENTILATION PAN(SINGLE RI511» Dan Receipt M
Will the applicant or tore building occupant me ecoun e n or devise wM1lch
'mit hiscradmi, it emominams.,,turned by the Buy Aura Air Quality Management BOILER-COMP(3HP OR I BU.0A0 li'rU)
Uin cR
OTA,:
BOILER-COMP(OVER Ifp.tN10 BTU)
❑Yes /(y�°�.
I have mail the hvurdom min,neds m cents under Chapter 6.95 of the Cali- AIH CONDITIONER y
y 255 pISSUANCE DAl'E
frobuild He IibnSafsty Crude.Sections.that,25531and eq,25534.1 to notify
socaifane NEW RIiSID1iMIAl.MliCll. SQ.17,
buildingd sum armmlyhave be met prior
it i.anryreapmdbillty nrnotifythe resupamt
oft rwhic ysthmet prior ar isnuunce nfa Ccttific of(
Ow m g nt DAreI TOTA ISSUED By
SY
OFFICE ,