S 1129 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PF$ IT NO
BUILDING DIVISION APPLICATION/PERMIT w.uNlUmc-MECHANICAL- l`l
B
UILDING PROJECT IDENTIFICATION
BUIL`3D-h+�N}7G ADORE.S: - SANITARY NO. APPLICATION SUBMI'I'I'AL DATE
OER'S NAME: PHONE CONT DR'S NAME: I,�C NO'
rry_� `
rARC F.CIN'/ENTOINEER: LIC NO' ADDNF:SS: 7 O ❑
�ti c is -/ �P -
CONTACT: PHONE: BUILDING PERMIT INFO
-f� x ����// ^� ✓ ❑ Consultant Fees Paid by Applicant(Initial) RLDo 171 ECT
PLUMB MrprC�ly
�--( �/�� 731[ LrfJ•'/ LJ
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(enmmenemg JOB DESCRIPTION
G C4Z with Section 7007 fDlvi,fm 3i the Business and Professions Cale,imd arymberma, RESIDENTIAL,
infull force and effect. - PERMIT'ISSUANCE
W _ / ❑SFDWL ITCHEN REMOIIF.I.
�U$FU�il license Lis» —f-. gpPLIANCES-RESIDENTIAL ❑ADDITION - [I PLUMPING RF.-PIPE
hQF Dare Gmlmdur
F ARCHITELT'SDECL A'I N ❑MULTI-UNIT' ❑STRUCTURAh
-
OZ fG 7� 1 vndersland my plans xM1nll M1e useU as public rePANELS cords MODIFICATION
:J 00':0200 AMPS
[..N.,1" PAIR
Q Licensed Professional ❑INTERIOR ❑SWIMMIING POOL
2111-IOW AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDERm the Con ecto OVER 1000 AMPS ❑HALF REMODIi1JREPAIR ❑DEMOLITION
K W Q �- I hereby affirm that 1 am exempt frim the Connector's Co lianas Law far the
O L U which ire mason(Section 7(13L5,Business and improve,
d Professions Coda:Any city or county SIGNS ELECTRICAL El OTHER
which
also rc rmit In r'amxbucl.ulll cam for �hemolis ,,filen signny ed(�go
prior quires pp peri gne SPECIAL CIRCU IT/MISC.
�} that he is licensed pursuant to the provisionsofthe Contractor's license Law(Chapmr9
wX (commencing with Secs'Ion7pW).iDlvlslom3efdo,Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
d tY c that he is exempt therefrom and the basis for the alleged exemption,Any violation of• ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
1,es ownrrof the y p y g p
Q ❑ pr.prny,onn em to my with wa ccmtheir sole corn enxali.n, SWIMMING POOL ELECTRIC ❑OTHER
b will do the work,and the smumme,it rlinlendednrnffeted Basal,(see 9044,nosiness
13 m
and Professions Gale:The Conlovem'x i icense Law does not apply to an owner of -OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thereon,and who does such work himself or through
his own employees,providul that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Er.
sale If,howevegma building or improvement is sold within,,.,yed,of,dmpldion,the SQ.Ff.FLOOR AREA $/SQ.FT.
caner-builder will have the burden of proving that he did not build lir improve for par-
Toseofmle.). -
❑ 1,as owner of the property,ran exclusively contracting with licensed contractors Ira TOTAL.
Ssb
onatmet the pars,(Sec.9044,Baxter,,and Pmfe,xions C,,dep The Conhacmra Li- -
crow Low does not apply to an owner of property who builds or improves thereon,and QTY;. PLUMBING PERMIT -FEE'
who contracts for such Projects with a c.mrachand licensed pursuant to the Contractors . •
License Law. PERMIT ISSUANCE _
El I am exempt under Sea B.@ P C for this rraami
Owner Uule ALTER-DRAIN cit VENT-WATHECOND
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI'EC'I'.DEVICE
I hereby affirm under formally o[pmjury ane of the following declaanionex b. O o
• O'Ihvvovnd will mainmina Cenificamef Conaennoaelf-i...rcfor Worker's Camper- DRAINS-PLOOR,ROOF,AREA, STORI TYPE CONSTRUCTION
salion,as provided for by Section 3704 of the LaborCode,fur the performance of thework for whichthis permite,issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Grmpensmion inwmnce,as required by Section 3700,,file Labor GWe,for the performance ofmd work for which this peunil is issued. GAS-EA.SYSTEM-I INC.4 OUfOCC.GROUP APN
My Walker,Compensation homncre carrier and Polley numM1m'are: _
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR hyi..NO'IVIrSION FEES
0 his section need not be completed iftepenot is Intend hundred dollars(5100) ° a
or less.) GREASE TRAP PLANCHECK FEE
I cenify that in lheperformenceoftheworifor hie htldxprrtmtic....ed.l shall SEWER-SANITARY-STORM P.A.200 PP -
nntemplmyanypersp in aoy mamnrr v.list t ^uh" i m Be,Workers'Comfort- ENERGY PER
,tZ, cation Lawe of G]) rod D�tc//�,,,,,000gq {f.
Applicunt�']C/BIM. ' Yw /tt t WATER HEATER WIVGNT/Ii1,liCTR GRADING FEE
z r~Ni NOTICE}�)A�PLIC'p�y.�If,Glor'noliftyThis Ccnifcalc of Exmnptirn•you.should WATER SYSTEM/TREATING
rI"vt became.abject It,me NGder.,Compensation provisions of the Labor Cede,yen most SOILS FEE
^f forthwith comply with such provision,.,this pc.ill shall to deemed revoked WXI ER SERVICE
W Q
CONSTRUCTION LENDING AGENCYNEW RESIDENTIAL PLMR. SQ,FT,
PAID
V Q thereby affirm thavlmm is.construction lendingageney fon he performance of jPFR
Date Ree{Ica C.t the work for which this permit is issued(Svc:3097,Civ.C.)
OLenders Name 'TOTAL>" LUkI Leners Address - - TOTAL:
04 1 cenify that I have read this application and state that the above information ix - RUILDING FEE
o-i0 correct.l agree m comply withal]city and county oNinanms and slate laws relatingm QTy- MECHANICAT FEE.
IJ Z building construction,and hereby authorize representatives of this city to enter upon the r SEISMIC FEE
above-mentioned property far inspection purposes.
(We)agree In,save,indemnify and keep harmless the City of Cupertino agninsl 'PERMIT ISSUANCE ELECTRIC FEE S to
liabilities,judgments,costs and expenses which may in any way accred against said City' ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UND tTANDS AND WILL MPLY WITH ALL NON-POINT AIR HANDLING ON[F(TO 10,000 CFM7
SOURCE REG ONS. i MECHANICAL PEE 3t�
- AIR HANDLING UNIT(GVHR 10,10410 CFM) CONS'T'RUCTION TAX '
Si ppm oly Dae EX HA UST HOOD(W/DUCT)
H ARDOUN MATERIALS DISCLOSU r HOUSING MITICAt'ION FEE
Will
lhd applic mar future building occupant-xmrc orbmdlc hazardous matarinl HEATING UNIT(TO 100,000 RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Coda Section 25532(a)'! HEATING UNI'I'(OVER 100,000 BTU)
[-I You, -
VENTILATION FAN(SINGLE RES IIp PAID Dam Receipt#
WIII the applount or nes a building by the B all A ea Air
or Matas whichement BOILER-COMP(JHP OR I(NL000 BTU)
.icazardeus air c.atandnamx as defined by the Ray Area Air Quality Management TOTAL'
o victR
Yes BOILER-COMP(OVER 100.000111 U)
❑ �Nrt��
Ihavereadl hamM,,as alleau,re emenls undo Chapter 6.95 of he Cali- AIR CONDITIONER quit fo ISSUANCE DATE
fomia He3hh ty Cale,Sections 25505 255)3 td 25534,I undersvmd that if the NEW RESIDENTIAL MECH. SQ.PR n
builJing does ntly have tenant,tl I'.vm' spensibilitymnatify the m'cupahl
ofthe wt bleb ran. t. td orbs eofa Cenifiema,,'Oe illi /�� �qsa
O er ur cuthoriz eat me IOTA ISSUED BY I Vr'
OFFICE