B 0470 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'ti
CITY OF CUPERTINO BUILDING-ELECTRICAL t PERMIT NO.
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL. SOOO1490470
BUILDING PROJECT IUEN'I IFICATION
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL.DAI
�S7RTS Ja . ��p�xn.ra CfJ S a�li� S -- �
OW 'S NAME: or/LclLilS -/__ P ��� CONTRACT(2N'S�NA2ME: '� LIC N0:
g(/D' o NIC CUNTHOh p
•ARCHITECT/GNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE r BUILIJINC PERMIT'INFO
1 ��/ ❑ Consultant Fees Paid by Applicant(Initial) NL❑DC ELECT r PLUMB MECH
Z"--1/7
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby efllrnt that 1 rte licensed under provisions of"Chapter 9(commencing PERMIT ISSUANCE JOB DESCRIPTION
ad'Z with Section 7000)of Uisision 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
WOO
FWD in full force and eOcel. ❑SI'UN'L C1 KITCHEN REMODEL
aUU License Class Lie.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING BE PIPE
v G L Dae Contractor
ARCHITIiCPS DECLARATION ❑MULTI-UNIT L1 STRUCTURAL
PAN EIS
Z O w Z I understand my plans shall be used as public occorde MODIIICATiON
OZ4GUPT02MAMN ❑INTERIOR ❑CHIMNFY REPAIR
-+4Ly) Licensed Profcnxionul 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS E3 BATH REMODELREPAIR El DEMOLITION
3 d
y C tY Q 1 hereby affirm that 1 am exempt from the Coutimar's License Law for the
X following emon.(Section 7031.5.Rosiness and Pmdessi uo Code:Any city Or wanly SIGNS ELECTRICAL ❑OTHER
YJ u.V, which requires a permit m construct.alms,improve,demolish,or repair any sometum
OQ Pri,,,.as issuance,also requires the applicant fmsuch pertnitto file a signed statement SPECIAL CIRCUITIMISC.
� het he islienwelpurxuunno the pruv:aomul he Cnmrunm's License Law(Charter Y
"Mc (commencing with Section 7000)of Dlvision3 of Ne Huslnessand Pmm,sionsCodOor TEMP METER OR POLE INST COMMERCIAL:
a It o y that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEN'BLDG/ADIII'FION ❑DEMOLITION
Xmlr, Section 7031.5 by any applicant for u fiction subjects then applicant m u civil Penalty of POWER DEVICES
00). J pV ❑'IMPROV ❑FOOD SERVICE
not more than Trus hundred dollars,(SSW).
F Z Y IMPROVEMENT
=6 0Lothe work,
the pmdarear myemntendes or orcmlot ode rxele 044.lotion. SWIMMING POOL ELECTRIC
atE.O will do the wok,and uhesumnnrc is not intended or offered for role(Scu.]Ugq.l)minesx ❑OTHER
Wim and Foifir"am Code:The Commences License Lew does not apply to an Owner of OUTLETS-SWITCIIIS-Il%TURIS D
property who huilds Or improves thereon,and who docs suchwork himself ar through
his own employees,Provided the,such impmsemend are nut imendcd or otl'c:ed Inr NEW RESIDENTIAI-ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completionthe SQ IT FLOOR AREA $/SQ.FT.
owner will have the burden of proving that he did nm M1add or improve for pur-
o(xele.),
r Tn
of the property.am exeludest,contracting with licensed comraao x to TOTAL.
construct the project(Sec.70yLq Business and Pofession,Cod,)no Commerce,Li-
verve Law does nor apply It,anowner of property wM1a bulldsmlmproves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commewr(b)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for Ihis reason
Owner
ALTER-DRAIN&VENT-WATER(EA) V 10'
Dam
5�RF2R
under
DECLARATION BACK ROW PROTECT.DEVICE
1 hand is affirm urim a penalty of perjury one of the followinsom or o Worker's
io o
❑ Ihave andwill for
Section 3Wficric of the sent to Lbor Code.for are WodeLace of th- DRAINS-FLOOR,ROOF,AREA,COND. S"IDRIES TYPE C(1NS"rHl1C'1'1(
smirk,r providedhhe for mi Section 3]W of the Labor Code,for the performance of the
work far welch Ihis permit is issued. FIXTURES-PER TRAP
1 have and will maintain Wmonfo COaccoft con rkfohearr hi as his Perm by Scmian
My Of the o Cole,
nsationhepedormanierand otic forwhichthis Permit is icsaW. GAS-EA.SYSTF.M-I INOa0UT1,Ef5 OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy nwnber arc:
Curtiue Policy No.: GAS-EA.SYSTEM-OVER 0(EA)
CERTIFICATE OF E%EMPIION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRI.WASTE INTERCEPTOR
Crhlaxnom aced nal be eonipl avel it the permit ix far ane hundred doll rs(511X1) BUILDING DIVISION FEES
GREASE"TRAP
or It's.) PLANCHECK FET-:
It,any porrom in pertercirrawf thewmk for wbichthto the it Worker,'
oLshdl SEWER-SANITARY-STORM EA 2W Eel'.
not employ any person in any manner so m m bemrme subject nr the WnrkacJ Cnmlrcm ENERGY IIiF,
O Z cation Laws of Califomio.Date WATER HG, TER W/VENVELECTR
z Applicant l GRADING FEE
h NOTICE TO APPLICAN'P If,after making this Conifien(e Of Exnnpruien,you should WATER SYSTEMO REATING
a ? become.subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
09 formoteh comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
DCONSTRUCTION L12NDING AGENCY NEW RESIDENTIAL.PLMH. SQ.FT. PAID
I hereby affirm that there ina censtuction lending agency for the Performance of Date Receiptp
CG F the work far which this permit it issued(See,3197,Cts.C.)
DU Lehi Name TOTAL
r P4Lmdcrs Address TOTAL:
CL 1 certify that I h ve read Ihis aPPlicrtion J cram lhm the aMwe inb mesion is BUILDING I tE
Ern carted.I agree no comply with all city and county Ordinances and sure laws relatingto QTY MECHANICAL PERMIT FEE
U z building construction.and hereby authorize representatives m day city(center uponthe SEISMIC
dawe-menlianed property fia nope tion putposcs. PERMIT ISSUANCE.
(We)agree m save,indemnify and kcep harmless the City Of Cupertino against ELT: I'I rE
limbilities.judgmenvs,costs andexpenses which may in any way acemcagainx(said City pLl'[R OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,003 CFM)
SO CE ItEGU LATIONS. MECHANIC,LFT],
A;� AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRU NTAX
Signature0�� PlicanJConvacmr hate EXHAUST HOOD(WMUCI) HOUSING MITI TIDY FEE MATERIALS DISCLOSURE
Will the applicant or future building oeeup:mt store or handle hazardous material HEATING UNIT(TO 100,000 BTI)
as defined by the CuPenino Municipal Code,Chapter 9.12.and the Heald(and Safety
Code.Station 25532(x)? �/ HEATING UNIT(OVER 100.0010 BTU)
❑ H
Yes N" PAID
VIiN'1'[LAI'ION FAN SINGLE RESIU) Dole Receipt
Will the ape omar or fume building occupant use equipment or Micas which
emit hannlous kir conmminame:'y defined by the Bay Area Air Quality Management BOILER-COMP OIIP OR IIp.OIX)BTU)
District I l 'I'U'I'
❑Yes C]No BOILER-COMP(OVER](*."BTU) w
have read the havudors mmerialseqmocamots under Chapter 6.95 ofthe Cali- AIRCONDI'HONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 and 25530.1 understand that Kite NEW RESIDENTIAL MECH.
haildingdmes not emren0y have amwnt,mal it ismyeespomsibility turbots the occupant SQ.FT. S_
o he nb--which n be msec poor m issuance of a Cmfjc le of t cupexv. J /
Owneturauthorreorl agent Dam TOTAL: ISSUED BY: 74-7->
OFFICE