S0369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY O CCUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DI r SI N APPLICA 1 PLUMIDNG-MECHANICAL S 0369
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRE SANITARY NO. APPLICATION SUBMITTAL.DAP I;
�Il/ 1- 310 - 7/
OWNER'SNA N 'HONE CON"IRACTO 'SNAME: LIC NO'.
_ - O NIC CONTROL p���fff
IITE IENGI R: LIC NO: A RES%: ❑ 4 3�/'
CONTT { F - � 'FekSYSld P BUILDING PERMIT INFO
U..,
/nI� s/614/t/ hca IQ ) NLDG ELG I'LU At F.0
r/Y/
LICENSED ONTRACTORIDLCL PION - QTY. - F,LECTRICPERMIT
I hereby alTrn that l a enwd d p ns al Chapter 9(cmnnt tiny J09 ESCRIPT N
MZZ with Scci on 7aoo)orn Inc Bas d f•asm Cra rp.. Ic ki. D NTIAL
WOO } PERMIT'ISSUANCE
� in fell force amt Cttcm Qv Wh ❑KITCHEN REMODEL.
QUU Ise Cl s Lich APPLIANCES-RESIDENTIAL ADDITION
PLUMBING RE-PIPE
p.Z alt Conuacmr
'�' V, N ITECTSDECL PANELS MU171-UNIT ❑STRUCTURAL.
m Z 1 on rsland my plans hall be used as PUM1Iic nrnrJs MODIFICATION
rd, UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
62 hkcnxcd Pr ... ��3' ^�i�^Y�f�Jf//./ 201-1000AMPS IMPRO]IN]HR MODE [ISWIMMING
I[ON S
pay
log 22 x OW 2 +C ((f(� OVER I(NNIAMI'5 ❑ISATH k1iMODELIRY:1'Alk �DEMOLIPION
C Q I hereby oflimt that I am exempt from the Contractors License Law for she
X:a U following rector,(Section 7031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL []OTHER
hp
u: y which requires a permit to construct,alter,improve,demolish,or repair any%wcsurc - P .A 111
OQ prior tri,,issuance,ilm requires the applicant for such Permit o Ne aligned statement SPECIAL CIRCUIDMISC. -
y (hat he is licensed pursmm m the prmisions of the Cnmmemis License Law(Chapter 9
wao00 (commencing with Section 901)(gn1Divisim jailBminecsad Pmfecsi...Cover, TEMP.MEI'ER OR('OLE(NST. PI �,s�.
d ey shut he is exempt therefrom odd the basis fur the alleged cxemplim.Anv violation of ❑N. G� TlHlytA�DEMOLITION
W C Section 7031.5 byany applicant forapermit subject.,the app]i5m,no ncivil penally of POWERDEVICES }n+'rHNANT �a SRL{{// FOODSERVICE
`� not n Ib' f hunt 1 R :(%500) IMPRgVE SE NT
z,Z� ❑ 1 c fthCp p ny y pl yc: tit agc,. ,h' : cnmpm:1 m, SWIMMINGPOOLELIiGTRIC Vf-t_IYLINr)
F. will do the work,and the structure not'nte dd lieJf. (S 7044,Business ❑OTHER 6
Wim sad Professions Crile:The Contractor',License Law does not apply In an owner'ItOUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc nos intended or caTered for NEW RESIDENTIAL ELECTS SQ ET.
sale.If,however,the buildingor improvement is cold wilhin enc year ofcompletiun,the SQ.FT.FLUOR AREA StSQ.FT.
t ner-builder will have the harden ofmi ing sem he did not buildorimpmvCfrrpur- /� ���� t
"eofmle.). Y -
M 1,as ownerof the propery,am excl,iivelyrontracting with licensed contracture to /
r
cont act lit pJclBss dPf Thon t I'
r i L does nail apply,oar n e fproperty who hudds,numproo,i,the n 1 QTY. PLUMBING PERMIT FEE
,xifincontractsfor such projects with a coronations)licensed fousund omcCon ou" w
IJ,cm,o f . PERMIT ISSUANCE 2�
❑lamexempt underSw B&P C for this reason s�
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dale
WORKER morder S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
a 3
1 hereby Rrm under penally� of me of the following declaration,:Inave and will maintain CertiOemeofQmsenudsclf insurcf rWnrkersComlicn- DRAINS-Fl.00R.kOOI;AREA,GOND. S'TORIIiS 'TYPP.CONSTRUCTION
sullen,as provided for by Section 370)of the Laity Cale,for she permormanee of the
wnrI lid which this dermal is isomer. FlXTURLS-I'lilt'TItN'
❑ have and will mainmin Worker's Connote nsdo,w rk to,cc,as requiruJ by Section
JAN,dl the Labor CaiJe,bd lite peditmtan of the work ler which this ucJ. GPS-EA.SYS'TIiM-I INC.G OUTLHI'S OCC.GROG q AI'N
My Wer -C in In, Ince fa Eof to c GAS-EA.SYS rRAFOVER 4(EA)
Carncr {•/ !!Y/
CERHFICAW.OF MPI'( FRO WORKERSGREASFIINDUS'IRL WASTE INTERCEPTOR
COMETS.AT10N INSURANCE 1 NG DIVISION FEF
(Thk section need not he completed iflhe pcimitis(none hundred delta,(SIBH GREASETRAP
or less 7 I'LANCl{177
I certify that in the peffornumccofthe work lid which lhispermil is issued.I shall SEWER-SANITARY-STORM PA.200 F]'.
no,employ any Person in any Insurer so as to become%able,,, Com",the Woe",ComIiNIiI1CY TEE 3if A-V
Z .ration Lao, fCalifdrm..Date WATER IIEAT17R WIVENr IELECTR GRADING ' E
C) C) Applicant
lZl NOTICE TO APPLICANT:If,after making this Cer ilicate df Exemption,you should WATER SYSTElvVTREA'f1NG
F-' ? SOILS P
become mbjem to the Worker's Compensation pmvisinna of Inc Irbor Code.Ina most
forthwith,omply wish zu,M1 Provision or this permit shall be deemed m'oked. WATER SERVICE
0 Q logo][
� z CONSTRUCTION LENDING AGENCY NEW RF_SIDEIVI'IALPLMR. SQ.IR. Date oor,atN
I ncrcby off on that Inca is a crnvwclirn Lending agency Gtr nhcpc,to im......l
W - ,be work to,which(his permit is Lamed LSCC.Il97,Civ.C.) 'T['
I
ULender,Name
Lender,Address
}. 1 nify nitro 1 have mad this application and stent that aboveinformation is _ If1111,DIN H FEE
re
F-' y
correct.I agree to comply with all city and county ordin:nce%and s me laws minting to QTY. MECHANICAL PERMIT FEE SEISMIC FF
V Z building construction,and hereby amhonw,representatives ofneis city to enter upon the
above mentioned tses.
ioned property for inspection purpPERMIT ISSUANCE ELIiCr l
(We)agree to save,indemnify and keep harmles she City of Cupertino against
liabilities,judgments,cods and expenses which may in any way accrue again,said City ALTER OR ADD'11)MECH. EL .1 I GFE
n 'eyminer of hegordso df this permit.
Al'1' ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR f]ANDLING UNUf JO Eyfm0CFM) Mli NICA FEE
SOI; LATION��
- AIR HANDLING UNfr(QUER IO.INNI CI'M) CONS'I'kUCTI NTAX
Sig u Applica txzonsmmor Dme EXHAUST HOOD(WIDUC) HOUSING MIT ATION PF:E
HAZa,li MATERIALS D%CLOSURE
Will the applicant or future hui]ding creation store or handle hazardous materia] HEATING UNIT(TO I by"BHV)
as def ndl by the CaKayino Municipal Calc,Chapter 9.12.and me Health and Safety
Code,Section M5320C HEATING UNIT(OVER I W."BTU)
Yes Fl No VENTILATION PAN(SINGLE RESID) LAID
Dalt Rcceip,p
Will the applicant at trmm building rcapant use 5luiPnmiti or dcvi,u which - BOILER-COM[1(3HP OR 1X,000111U)
r hmardnus air conmminants as defined by the Bay Arca Air Quality Monagcntein
TOTAL
t)isnictl BOILER-COMP(OVER 100,000 BTU)
[D Yes ❑No
AIR CON DmONER ISSUANCE DATE
1 have read the h ode Se maleii 55 refinements an under Coapier 6.95 of theed Coli-
Bimii Hwnh&Scurry try have
Salines 35505.255)3 esp 29574.I uMctify th tom if the NEW RESIDENTIAL MECH. Sp.FT
of thong does m currently have a tenant that n is my responsibility tote notify the pancyam
dl the Rquvemenls wnich Inu4 he mel torr Ir issuance at 0 Certificate of Occupancy to
Owne,m ouln"i'al agent Dale .I. ISSUED BY:
OFFICE �J