B 0374 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, t PERMIT NO 40374
IIUu,DING 111VItilON APPLICATION/PERMIT PLUMBING-MECHANICAL, SOOOI
BUILDING:PR(IJFICI'HMNI'UIC Iltol
BUILDINGADDRPSS: SANITARY NO. APPLICATION SUBMETAL DAI
CONTACCORLIC NO,
' OWNIiR'S NAME: PIIONL: 'S NAMIi
NIC CONTROL#
�ARCHIFEMIFN(IINE.Ek, LIC NO: ADDa"". ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Cunsul/anl frees Paid by Applicant(Initial) BLDG ELECT I'.UMB MUCH
ir)L' v ❑ �1 4
LICENSEil)CONTRACI'OR'SDECLARATION QTY ELECTRIC PERMIT FF.Ii JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
GCLz with Section 9000)of Dividon 3 ofgm ba,arssnnd l'n,fr,ions Cnde,mdnty).stew is RESIDENTIAL
W p I'IikMIT ISSUANCE
�W= in full force and a a! ❑SFDWL ❑KITCHEN REMODEL
aVV Live Lic.N APYLIANC6S-HF_SIDENTIA1. [1 ADDITION ❑PLUMBING RIiPIPE
<ZQa_Uarc Conmacmr
ARC]111 F:CFS DECLAItAI]ON PANELS ❑MULTI-UNIT ❑MODIFICAHO
F'=X I understand my plans shall tc a,rd as puhhe rccurds LL MODIFICAEION
02�� UPT0200AMPS ss,JO ❑INTERIOR [_1 CHIMNEY REPAIR
rsA. , Licensed Pmfnsionol 201-UKOAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IMOAMPS ❑BATH REMOUEL/REIVAIR ❑DEMOI.ITION
C 6 1 hereby uflinn that I an,aaentpt from the Carl.',,,,Liaeme Law for the ❑OTHER
following main.(Section 90315,Business and Professions Cde:Any city or county SIGNS ELECTRICAL
LL]3 LLF which m uims a l to consumer,alter.ire p it any demolish,or rc inich re V•Q L L J hdi>L'1C
11
z
F'LLOJ prinrr 9 .. ' 1. rh; ,plc tf hpe it it,II 'g dntmerman SPECIAL CIRCUIT/MISC. O V
that Joe Jpmoramn tl I - ❑M1 C11-1111'a"LL (Chapter 9 COMMERCIAL:
W (conmenemg with Section 7000)of Divtson 3 ofthe Business and Professions Cde)or TEMEMEItiH OR POLE INST.
E E e z that he is exept therefrom and Bic basis br the alleged exemption.Any violation of NIiW'BLDG/ADDITION I-]DEMOLITION
Sermon 70315 by any applicant for a penial subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
not tore than 11,c hnmrmd dollars 0500). IMI'ROVhMLNT
fS0 ❑ 1.as nwncr of rhe pmpcny.rnmy employees with wages as their tele compensation, SWIMMINGPOOLELEC'1'
b., will Jo the work.and thestructare is not intended oralBred for role(See 7o .Business ❑OTHER
a 3 and Professions Cade:The Contractor's License Taw does nm apply to an owner of QUILL-1'S-SWIICHFS- IL
propcny who builds or improves thereon,and who docs such work himself or through �...
his own empIr,ees,provided that such Improvements am not intended nr oftemd for NEW RESIDENTIA , I:C I I nA
sale.If,however,are building or improvement isseld within one yearn(completion.the IV .R.00 �29
IT.cohuilde,will have the barren of proving that he did not build or impreve for par- Uproms cl sale). 'I AI;❑ I,as nwncr ol'the poverty,am exclusively contracting with liceti camtrnslJ'1h�omumct rhe project(St,7044,Business and Pmfcasione Cak:)'rne Contrutnis Li- l//, 7p
c se law roes not apply in an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE IJ
who mmracts for such projens with a cnnlrucmr(s)licensed pueuant m rhe Coamircme, (�
Liccnsc Law. FERMI'I ISSUANCE •Sb Lay
I nm esempc under Site H&P C far this reason J
ACI ER-DRAIN&SENT-WATER(6\) OUAfLN
Owner Dec
WOHKBRSCOMPENSATIONlr , .,on DIiCe Ello ION HACK FLOW 1'Ii(YT IiCI'.UIiVICIi
1 hereby ufllrm under penalty of perjury one of the lallnef VAukel"do,claratCo
❑Ihavc andwie for by eCion370eof Com aj mCode.mmfor Worker's Campers- DRAINS-FL(X)N.HOOF AREA. OND. STORIES TYI'CCONSTHUCI'101
work(r provided for mi Section 3IIX)of the IaMsr Cadc,for the performance of Nor
work for which This punnit is iveurd. PIX'1'UHES-PER TRAP
I have and will maintain Wnrkcre Compensation Insurance.os required by Section
3700 ofthe labor PCrale.�((or the
�perrfor mance ofthe work for
Qw'hichh cchhi%�Permit
is kwaf GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.CROUP AVN
lor
Carrier Polcy
j"s'4 Y� Xs W^ncCc cartie rNo\Ja( r`h — GAS-BA.SYSTEM-OVER 4(EA)
cERI'IFLCAIEOI'EXIiMPT10Nl'HOMWORKEiRS' 3"%0Cik GdEFASMNDUSTRL WAS'1'Li INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PELS
(This section need nm Wcomp]eed ifche permit is torose humbcd dollars(SIM) GREASETRAP
PIdNC1fECK I§iE
ear ksa.)
Loy any Heron the anyti mor so stworklorwhichthia the Wooer,'Co.,.-is owned, ehu0 SEWI?k-SAN I'IAHY-S'IORM EA.2(u,17,
not employ any person in any manner au as m heenrm whjen m the Wurkeri CnENIiRGY Rli
Z no.Laws of Califomia.Dam WATER HEATER WNEW&LECTLt GRADING FEE
O O Appfrvma 1
HI4, � NOT ICI:TO APPLICANT IL aHcnnakin,This Ccnifcntc of 1inwnptinnYo
. u should WN'17R SYSTpcFTRF.A1'ING SOILS FEE
7 Ranme subject In the Wn1v14 Campensadi n provi mm of the Labor Cede.yea mast
ficr ith comply with such provisions or this pmnitthail be deemed revoked. WATERSERVICH
PAID
CONSTItl1CTION LENDING AGENCY NIiW RESIDENTIAL PLMI1. SQ.lel'. Date Itcccipt#
U Thereby alHnn rhot theta isuamswalimn lending agency for rhe prrfonnunce of
the work for which this permit is issued(Sec 3891 Civ.C.) CI OTA L:Emcee,Name TOTAI,:lands(,Address Iy1 crony that I hoeread this application and scam thin the above lnformafmnisc cr.l agree nr comply web all city and coumyordirences andare laws relating m QTY. MECHANICAL PERMIT FF;Ii Zbuilding commune..and hereby aurhmim mpresenratives of this city m enter affair rhe aM�e-mcmionel propcny for inspection purlreel PERMIT ISSUANCE(We)age to save,indemnity and keep harmless the City of Cupertino ogalmtliabilities.judgments.costs and expemns which may in any way accme againsueid City ALTI7R OR ADD TO MECII.in sequenceofthe granting ofthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W'1'l11 ALL NON-POINT AIR HANDLING,UNIT(TO❑),000GFM) rfiE
Sd�ti(.li REGIII.A'L'IONS.
A- (w g. AIR HANDLING UNIT(OVER IL000CFM) CONSTRUCTION TAX
Signature or App lnanVCo actor •Firm EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA7JARDO(JS MAI E:RIALS DISCLOSURE
Will theapplicam or future building twcuptmt once or handle hazardous material HGA'FING UNIT(TO I M.nu,BTU)
as relined by the Cupertino Municipal C(de.Chapter Q.12.and the Health and Safety HEATING UNIT(OVER IW.000 BTU)
Ode,Section 25532(,)^
C Yca 1i'1 VE N'I'ILATION FAN ISINGLE RESI D) PAID
Dam Heccipr#
Will the applicant or future building corruptor use equipment or devices which BOILER-COME'(3HP OR 100.0(0 BTU)
emit hazardous air contaminants as defined by she Buy Arca Air Quality Management TUI'AI,
youicfl / BOILER-COMP(OVER I Wj)(()BI'U)
Vcs r�N"
AIR CONDITIONER ISSUANCE DATES
1 have mad dm h ookc,S s timet,2ls rcqulrcrmnu under Chapter o 95 of the Cali-
hrmin ficalrM1 Sa...e Cita Satins,25505,25533:mJ 25534.I undcteund thin if the NIiW HfSIDENI'IAI.MECII. SQ,FT.
hail Imes nrn currently hnveutemm�,that it is my reepnnaibilltymnmily the nccupam / v
Ow�I h 9mmmen whicM1 mus M met pnar to bsuanea of a Cenitical`T•E&
Q1> ) 0 lit, TOTAL: /LCg 7 r
3 agcnl Dom ISSUED BY:
OFFICE