S 2041 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL 2111
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(o / Ih0 V'S 7-4 d-u� 4Y
OWNER'S N ME'. PHONE: CO C R'S NAME: hIC NO:
ACS `vn Qlb ON Sic zs35•! N/c cord RGLx
ARCHITECOF. RNEER: LICNO DDRESS: ❑
-S�0 Ltyco fti A��
CONTACT: C PHONE PLALDING PERMITINFO Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MUCH
L7G- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEE
1 hereby affirm thus I am licensed antler,uwi,im,of Chapter 9(wmmencing JOB DESCRIPTION
Q%z with Section700goofDi,Nme Sof the Bnsines,.cd Profssies Code,and my li....ris R ENTIA :
WOO PERMITISSUANCE O
F W.. in full force and affect -Z(J - S" 3 "� l SPDWL ❑KITCHEN REMODEL
Out License Clas LieH APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F�W Dame—Con DELL
m ty ❑MUL')'1-UNIT ❑STRUCTURAL
O y ARCHITECT'S DECLARATION ATION PANELS MODIFICATION
zq`2z lander-rWnJ my plansxM1vll be used as puMie rwoMs UP TO 200 AMPS
pz..p ❑IST ERIOR El CHIMNEY REPAIR
[-+�E"W License)Pmfeasinnvl 201-IIKKIAMPS IMPROVEMENT (]SWIMMING POOLS
•.1 OWNER-BUILDER m Ce Conte ON OVER 1000 AMPS ❑BATH REMODEf PAHZ El DEMOLITION
{ 1 hereby nfRrm Net 1 vat..sept from the Cun¢mmf,License Law[n the
{ii1L55.O p�U following reason.(Section 7031.5,Beciness and Professions Code.Any city or county SIGNS ELECTRICAL
[-I OTHER ��na-�L..l>�T 16c,
u+3 W y which henries,v panel,to construct,alter,improve,demolish,or repair any structure
F,COQ
prior o its issuance,also requires the appl leant for such malit to fi le a signed darmarm SPECIAL CI RCU pDM ISC.
�ij•] that he is licensed mo-m,to Ill,pmvisions of he Comm ars License I..w(Chapter 9
W<� COMMERCIAL:
W�DO
(commencing with Setien 9000)or Division 3 of the Business and Professions Gods,)or TBMP.MUTER OR POLE INS'1'.
that he is exempt therefrom and the basis for the alloyed wo,smlon.Any venetian of ❑NEW BLDG/ADDITION ❑DEMOLITION
W..m Section 90315 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more them five hundred della,,($500). IMPROVEMENT
❑ 1,as owner of the popery,ornry employcex with wages es their sole compensmlom, SWIMMING POOL ELECTRIC
will do he work,and the structure is not intendedoroffered fini,me(Sec9044,Business ❑OTHER
1 ' and Profession Code:no Contractor's License Law docs net apply m an owner of OUTLETS-SWITCIINS-FIXTURUS / O
property who builds or improves thereun,and who does such work himself or through
his own employees,provided that,uch improvement.,me at intended or offered for NEW RESIDENTIAL ELECOI SQ FI:
sale.If,however,the building.,improvement issold wblut one year of enmpletina,1- SQ.Ff.FLOOR AREA $/SQ.FE
owner-boilder will have the burden of proving th ll he did not h tild or improve path,
pose of sale J. 07
E] 1,as ownernf the po pubS am exclusively.......fine with licensed coarrou,,te AL.
construct he project(Sec,7ROL Business and pmfesslons Cale:)The Gmmuemr,LI-
se Law does not arcane,of property who brild,or improves lherum,oad QTY, PLUMBING PERMIT FEE
who contracts for such projects with a eontmeor(s)licensed precom in the Ctmwemds
License Law. PERMIT ISSUANCE
❑ Imo warard un der Sec. ,B&P C for this reu,on
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aFnn under penvl,y of perjury one of the following declnulars:
El I haveand will nmintroa Certificoe of Conseetwielf-insure far Worker's Ceenpen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
le.,as pmvided for by Section 3900 of the Labor Code,for the perfmmencc of,be
µor k r which this permit is issued FIXTURES-PER TRAP
It
ave and will nmimein Worker'.,Cnmpensmien Inxumnee as requited by Section
37")of the labor Code,for the performance of the work for which this Perini,is issued. GAS-EA.SYSTEM-I INC,4OUTLE-1'S OCC.GROUP APN
MY Worker')C{M�1p�! mo ather vad Polis b�(
Carrier.7J(,[Lsv' }J�s^angpc Policy Nny��(L� ?_";J GAS-BA.SYSTEM-OVER4(EA)
CERTIFICCAATEOPQEXEMPI'ION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BU_IL_DING DI ISIO_N FEES
(This section need not he completed if the perm,is femme hundred dollars($100) GREASETRAP
or le.va-) PLANCHECK PEP
I amifythat in the performance of the work forwhich Fepennd is issued,l shall SEWER-SANITARY-STORM EA 200 FLnot employ any person in any maiden so as to become subject m the Workers'Cooper- ENERGY PEE
,z s quay L,wsof California.Date WATER HEATER W/VBNTrELECTR
z O Applicant l GRADING FEE
r M NOTICE TO APPLICANT.If,af¢r making this Certificate of Exemption,you should WATER SYSTEMOREATINC
L^ become afflict,to the Worker.Cmd,shomion pmvlvions of the Lahnr Code,you must WFEEg
forthwith comply with such pmvi,ions or this permit.,hull be deemed revoked. WATER SERVICE
Q
(1e CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. JU/SQ.Ffceip,a
1 hereby affirm that Fere is a construction lending agency for the performance of
W ,hev kto,which this permit is issued(Sir,3099,Cie C.) TOTAV
Lender's Name I IJ
{>a Lender's Address TOTAL:
1 certify that I have read this appliemum and dle,that the above information ix ��r�
L-I h correct.I agree to comply with all city and county ordinances and state laws relining w QTY. MECHANICAL PE '9)Y-�.building wnswetion,and hereby nutherize representatives of this city to enter upon tireabove mentioned property for inspection Purposes, PERMIT ISSUANCE(We)agreein save,indemniy and keep harmless the City of Cupertino against
jrdgm� o,tsandexpen,es which may in any wayaccmoagainst said City AITERORADDTOMECIT=HAZARDOUS
min ofthis permit.T DS AND WILL COMPLY WITH ALL NON-POINT qIR HANDLINGUNIT(TO 111,001CFM)Z AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTIONX
entracmr D e EXHAUSTHOOD(W/DUC`U HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE ,,
Will the applicant or future building occupant store or handle h.zarmst material HFBTING ON IT(TO 100,00 BTU) s W,
as defined by theCupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)p =(OVER
T(OVER 100,0011 BTU)
❑Yes ( o FAN(SINGLE RESID) PAID
Data Recciptk
Will the applicant or future building occupant use equipment or devices which P(3HPOR IU0,000 BTU) T
"cavi,hazrems, it contaminants as defined by the Hay Area Air Quality Maregemer, D T 1l./1
Dis..im% E(OVER 111.(110 BTU)
❑Yex
'd the h;vurdnus at lots requirement.,unJer Chapter G.95 of the Call- ONER ISSUANCE DATEform ealthfetyCod2,Sce�io 2550 frJ5533 and 25534.1 undermm�d Nat if the TIAL MECII. SQ.Ff. tel) �✓
buijdingdces ocerentlytftaveaie nµ fif ismy renponvihillry,e notify the occvpnn
6f the renal • naw must bs etp to issuance o[a Ccnifent uupnncy.
Owner or aohnriacd ogee l Date
TC61 y r ISSUED BY:
OFFICE