B0643 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL RQ PERMIT NO.
BUILDING DIV
APPI,ICATION/PF,RMIT PLUMBING-MECHANICM, SOOOI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SAN]EARY NO. APPLICATION SUBMITTAL DA
2114a S11ANNOA) COVIr S '2 ( 7
OWN"SNA G `e PI{O 's3-9'73 CONT 'S NAMIy /puC� 1 �-7 NIC CONTROL#
ARCHITECDENGINEER: G LIC NO', ADDRESS: H I ❑
CONTACT: PHONE: BUILDING PERMIT INFO
�V / A �^ -���� ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECII
C 7� ❑ ❑I� ❑ Lill,
LICENSED CONTRACTOR'S CLARATION QTY FLECIRIC PERMIT FEE
M9zI hereby M.that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
F�coo, ssbh Sectio 9slf0)ofDi,i,[ou 3ofthe Business and Profession Gd ityBcenwi. RES117ENTIAI;
� full farce and t. PERMITISSUANCG
C utl 'n ZA? amp / ❑SIV WI. ❑KITCHEN kIiMOD81
.LUU 1.tcane: I-ss Lien AI'I'LIANCES-RESIDENTIAL I1�ADD1'1lDN [I PLUMBING RIiPIPE
y Wim Dam crnwn.r
ARCHITECTS DECLARATION ❑MUTA[-UNIT ❑S"IROC1'URAL
F+O H PANELS
O Zh Z I m tudcrsland my plushall he used m puhlic ,,.,d, MODIFICATION
�Q— UP TO 200 AMPS
[. F'WW Licensed Pmfeeo.c.) El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT DSWIMMING POOLS
�yE, OWNER-BUILDERexemm Ce Contractors
ON OVER HKOAMPS ❑BATA REMODELTEPA{R ❑DEMOLITION
C C Q I hereby affect that 1 am exempt from the Comranor s License Law for the
�3 tLU following reason.(Section 7031.5.Business and Professions Code Any city(it county SIGNS ELECTRICAL ❑OTHER
u p
y which requires a permit to cnnzuucl.alter,improve,demoBN,or repair any insurers,
5 prior to its issuance.also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT(M ISC.
that he is licensed pursuant to the provisions of the Com eroh License Law(Chapter 9
� 0 (cmm�mncing wish Section 700(odDivldrn 3oDhe Bu,ine,,.ed P fieWoux Core)rr TEMP.MI3'1*17R OR POLEINST.
O.MR EAI-:
Erin he is exempt therefrom and the hnsis for the alleged exemption.Any violatiEl of NEW BLDG/ADDITION ❑DEMOLITION
Scetin1]1131,5 by any opiffcuot lin a pernN xuhjmd NDEVICES applicant lea civil penalty of POWER DEVIC
IA"m ❑TENANT ❑FOOD SERVICE
=G tet more than five hundred dollar,($51X).❑ I,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
E
will do the work,and the simeme,is not intended or offered forsele(Sec.](004.Business ❑0THER
u�] m and Professions Code:The Commutator,License law does not apply bs if owner of OUT'LfiTS-SWITCHES-FIXTURES
6 3^ his opmaco,who builds or imded that
trsuch i and who does mph work himwed or or through
his own owever the
provided trim such improvements are not intmded or offered for NEW RESIDENTIAL ELECTR Sp FT.
ownee however will h ve the burdding or en
m of mason:that hewithinon old or i completion.the SU.FT.FLOOR AREA S/SG.II'.
(pew it uilJer will have the burden of proving trim he did not build or improve for pur-
ryeseaefsale).
❑Lox owner of the property,.E exclusively professions with f Treed mover'"to TO Ah:
un,c Lo J e,jest(Sec.]BW,Baine¢and Professions ds i The Cnnlmclor.and
ccmlatwdocs nm apply wan uwncrofpropeny who
.od imir:..I(ods,Come .a.d QTY. PLUMBING PERMIT PEE
when#Lawa for snch prulats wIN u conrucwHs)liecnecd Purvuanl In the Conlmclnr,
License haw. PERMIT ISSUANCE
Cj I am exempt under Sec. ,B G P C for this reason
ALTER-DRAIN&VENT-WATER(GA(>(jO
Owner Dole (� V
WORKER'S COMPENSATION DECLARATION HACK FLOW PROffiCT.DEVICE
1 hereby affirm under perry oe Perjury one of Ne fnllowing Worker:ono
❑Ihave and will by Section
of the Laito r Code,
for Woormace of the
DRAINS-19,OOR.ROOF AREA.GOND. STORIES TYPECONSTRU If
,moon,m provided for by Section 3]1X1 of the Labor CWe,for the Performance of the
work for which Nis .it is issued. FIXTURES-PER TRAP
DO I Lave trod will maintain Worker's Compenw em Insurance,as required by Seetia Y
1700 of the Labor Code,for the perfornntnee of the work for which this pemeil is issued. GAS-EA.SYS'rEsv-1 INC.40UTLETS CROUP AI'N
My Wnrkcr's Crmnx
peation ImmH
nnpe' ier and Policy numb#:uc:
Carrier: Policy No.: I GAS-EA.SYSI'FM"OVER 4(EA)
CERTIFICATE:OIt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI.WASTE INTERCEPTOR
(This section need nm be completed Hum permit is for one hundred dollars($100) BUILDING DIVISION FENS
or less) GREASE.TRAY
PGNCH[CK ITE
[certify mad in Ne anymannecof Ne work for which this pew itis iss ed. hill
not employ anWER-SANITARY-STORM EA.200 FT.
p y y Person in any manner so as m become subject rte the Workers'Co.,.-ComPen- ENERGY FTai
O Z ,alio.laws of California.Date WATER HEATER WNENDELECTR
z O Applicant GRADING II717
ti
NO[CH TO APPLICANT:If,after neakin, his C,"ifiesm of Exemption,you should WATER SYS'(IoMfrRP-ATING
become,.hjcef m the Worker',C.nuwn,uern provio—of thel.aleor Code You snow SOILS FRIT
OI'nnhwiN comply with such Pmvirionn or this spoon,hall he de%teed rcvskc:L WATER S17RVICIT
az CONSTRUCTION[.ENDING AGENCY NEVIRHSIUENEALPLMB. SQ.17. PAID
U O (hereby affirm Nut there is a crmuuction lending agency for the Eeronomwe of )m Receipt#
IL F. the work for which Nis pecouth issued Ser.30N1,Civ.C.)
O U Lemice,Name TOTAL:
uj Tender's Add.,, TOTAL:
Fr^ y I certify,that I have mad this application and state that the above information is BUILDINGP iE
VI correct.I agree to comply with all city and county ordinances and.state law%relating to QTY. MECHANICAL PERMIT FEE
U building con.stmetion,and hereby authorize representatives ofthis city Inciter upon the SEISMIC ITE
a roe-mentioned Property for inspection puegoxc PERMIT ISSUANCE
(We)ugive m suss,indemnify unit keep harmless thr Cory of Cupertino against ELF,C'1'RIC ITT
Iiubililics,judgmers.co,I anA cxppns'c:which may in anyway acermagaino said City ACTER ORADDTOMF.CH.
nscquencc of Ns granting of thispc nit. PLUMBING]it:[:.
AI'PLICAN'I"UNDEI !DS AND LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(1,1X10 CPM)
SOU T I I1 10 MECHANICAL PEE
I O e'er O i AIR HANDLING UNIT(OVER 1I.000 CPM) CONSTRUCTION TAX
Signature ofA s J �'fJ Date EXHAUST 11001)(WMUC17 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future Building(versant store or handle hazardous mamrld IIGTING UNIT(TO I Of"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Gdc,Section 25532(.)^ HEATING UNIT(OVER 100.000 BTU)
❑Vee ❑No
VENTI[At ION EA N(SINGLE RE SID) PAID
WIII the PHenor urcbnlldin•na eont mequipI
or devices which h '
Dino Beer,n
ruvdrua arcrnwminan,udulind byhe Bay ArcAirQuality Management BOIHR-COMI'13H'OR IOU.0)0BT1)
Ui"rict^
'T01 L:
❑Yes 7 N BOILER-COMP(OVER 10100OBTU)
T
I M1me read Ne ha. findsMaterials requirements under Chapmr6.95nf Ne ifthe AIR CONDITIONER ISSUANC.DATE
4smin Health A Safety Wc, tions 25505.3533 and 25531.I aedenlaml Net if the NEW RESIDENTIAL MECH. SQ.PT. /t
Wildi 1 ecu fy bete ,Na it
yyy onsibiIity,.notif bcoc t q 7
ofd quirem h n Eris I muu�lnre If
res yp.�y /
ISSUED BY:
OFFICE