B 0624 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NY
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI 18n�2�=17� -1
BUILDING PROJECT IIIENTIPICATION
BUILDING ADDRESS: C SANITARY NO. APPLICATION SUBMITTAL DATI
0 o J So
OW ER'SNAME: P )NE: 'R C )R:S ME: LIC NO:
t N/C CONTROLN
RCHITECT/ENGINEGR: LIC NO: ADDRESSC:a: S ❑
coNTACI`��'� tAn.(y PHONE: �7, f BUILDING PERMIT INFO
S r$ N e ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED ONTRd under S DECLARATION QTy ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby uM.,d` that 1 am IimneW under provisions of Chapter 9 my licencing
OW
efZ withll(m and
Business and Pmfeaaiort Cale,anJ mylicense is El SFDW NTIALa
PERMIT ISSUANCE ILL-�� in full force atld eRat q El ❑KITCHEN REMODEL
Ia1...Z uatmse Class �' dQ Conwctnr n....f4 - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
V,<y ❑MULTI-UNIT ❑STRUCTURAL
Dry ARCHITECTS DECLARATION PANELS MODIFICATION
Z Z� I undersand my plans shall be used m public records
OZC UPTO2WAMPS INTERIOR 'CHIMNEY REPAIR
F=� m Licensed Professional 201-101)( PS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER ItIfI(IAMPS ❑BATH REM IJREPAIR ❑DEMOLITION
from ad PC Q I hereby affitno,1 am exempt from the Contractors Lima,,Low for the I r��I
L O y U following reason.(Section 7031.5.Business SIGNS Pmfcssions Cale:Any city or county SIGNS IiLECfRICAL F1 OTHER
LL O m which condos,a pcmtit to conswct,altar,improve,demolish,or repair any awcusa I n 4— INI �
��ysinto, it,Issuance,also require%the applicam formal rem in,file asigned satcmenI SPECIAL CIRCUIT/MISC.
F,�>. that he is licensed pursuant to the provisions ofthe Conuucmrs License Law(Chapter 9
(commencing with Section 7")of Division 3 oflhe Business and Professions Critic)at TEMP.METEROR POLEIN COMMERCIAL:
d o that he is exempt therefrom and the boats for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C1 DEMOLITION
Section 7031.5 hyony applicant for mpermit,.bja,,a the applicam 1.a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FW �, nm more than five hundred for..($100).
< Laowner ofthe Property employees with woes as their sole compensation. SWIMMING POOL F.CTRIC IMPROVEMENT
O ❑ the
PC Y Ye P Y B R"%° .OTHER
Tl Aothewons andde Fire Contractor's
notintended Law roffered
apply 7f W4.Rosiness
and A,who
Code:The Gmuucmr',License Law does not apply toll owner(ifgh OVTLEfS-S CHFS-FIXTLRNTWAL
pmpeny who huilJv or improve%thereon,nnA who doe,such wed himself or through _
his own employees,provided that such improvements are not intended or offered for
NEW RB. I'MIAL ELECTR
axle.If,however,the building at improvement is cold within one year of completion,the
SQ.ET.FLOOR AREA SISQ.14.
owner-builder will have die burden of proving Nat he did not build or improve for per-
lase,of vele].
I.m owner of the property,an+exclmively ruminating with licensed contractors to,,,,start the project(Sec.7M0.optima.,and Professions CWeOThe—aa.xa's L-
amseLawdoesnotapplymanownerefprogeny who builds or improves Nereou,and y, PLUMBING PERM
Of
who contracts for such projects with a contactors)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
1 am eacrept under Sec. .B&P C for Nis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARXRON BACK FLOW PROTECT,DEVICE I (y 0 oyx
. 1 hereby efV_/'
ftrm under Penalty of perjury one of the following decimations: JA r J V
❑ [have and will maintain a Cenificme of Con,entto self-insure for Workers Compete- DRAINS-FLOOR,EDGE,AREA,COND. STORIES TYPECON T cTIOI
,at.,ms provided for by Section 37W of the labor Cade,for the perfar mance of Ne 1
work hu which thi,permit is issued. FIXTURES-PGR TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Cale,for the performance of the work for which this pctmil is issued. GAS-EA.SYSTEM-I INC.4 OUTLEISROUP 'If
rti
My Wnrke' C�ra�pQnsalion Insurance and Policy nu he pm: 4//`7 (O
Came Policy No: �yL - tR GAS-EA.SYSTEM-OVER4(EA) 3
CERTIFICAT OF EXEMPTION FROM WORKERS'Eep. 1 ODD GREASMNDUSTRLWASTEI ERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sada,,need not W completed Edo,permit is(.,..a hundred Russ,($100) GREASETRAP
or less) FICHE 'H
I certify that in the perfomwnceofthe work for which this permit is issued,Ishall SEWER-SANITARY TORM EA.201 FT !
not employ any parse"in any manner so es 1.heoome subject 1.the Wmkeci Co.,.- ORGY FEE 0 +�
O ZBanco Lsws,,f Cidifomia.lone WATER HEATER ENT/ELECTR RA IiE� 6 1999 11 i0
Q Applicant
y NOTICE TO APPLICANT.If,after making this Cenificam of Gxemption.you should WATER SYSTP /TREATING SDI LS FEE
a ; become subject m the Workers Compensation provisions of the Labor Calc,you must
L$I r-i forthwith comply with such provisions or this permit shall be deemed revoked. WA'[ERSE ICE
QID
CONSTRUCTION LENDING AGENCY NEW SIOENTIAI.PLMB. SQ.FT.
V 0 l hereby affirm that here is a construction leading agency for the perforamm of
W the were for which this Permit i,issued(Sec.3097,Civ,CJ
0 Lender's Name TOTALLU$I Lender's Address TOTAL:
I retry that I have read this application and mile that Ne above information is
BUILDING PEE N 1
LCis) correct.l agree to comply with all city and county ordinances and state laws relating to MECHANICAL PERMIT FEE SEISMIC PEE
V Z huildingconswetion.and hereby aWtorive repreaenletive%nf this citymemeruptmthe
'-' abovc-mentioned progeny for inspection purposes. PERMIT ISSUANCE' ELECTRICF
(We)agree to save,indeamify and keep hem leas the City of Cupertino again,,
liabilities,judgments,costs and expenses which may in any way amme against said City ALTER OR ADDTO MECH. PLUMBI
in consequence of the granting of this parr t t.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL TiH
SOURCE REGULATION .
AIR HANDLING UNIT(OVER IQWO CI> CONSTRUCfI TAX
Signatureof Ap licanucimrnnor Date EXHAUST FOOD(W/DUCD HOUSING MITIGA
RN FEE
HAZARDOUS MATERIALS DISCLOSU.i
Will co,applicant nr future building aa...nt,mte or h. diel azinhimmaterial HEATING UNIT(10 I01).000 )
as JcfinW M1y the CupeniW Municipal Cale,Chapter 9.12,as he eallh and Safety
Cala Sectloo 25532(x)? ms�ss HEATING UNIT(OVER ,1X10 BTU)
❑ ..tl
Yes N" VENTILATIONFA .INGLE RESID) PAID
Data ReceiptN
Will the applicant or far..building tampon use equipment or devices which BOILER-CO UHPOR 100,000 BTU)
area haaardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Distrix^ BOILER- MP(OVER I00,000 BTU)
E]Yet No
I have read the hominess materials requirements under Chapter 6.95 of the Cali- AIR DFDONER ISSUANCE DATE
Tania Health&Safety Code,Sections 25505,23533 and 25534.I madecomal that if the RESIDENTIAL MUCH. SQ.FT.
Wilding does not currently have a stand,Nm it I%my responsibility to notify the occupant t�
of the require no which must be met prior to issuance of a Cenificme ofac
Ou mcy.
4 44
Owner or authonae .gen ate TOTAL: ISSUED BY:
OFFICE