S 0164 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE MIT NO
NUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MF,CIIANICAL 01.64
IIUII,DING PROJECT'IDKN'I'IFICATION
BUILDING AIIDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ID of en CIVIC a51-7to91
ERS AME.: _l`PITO;E: ^I I CON TRACTOR'S NAME: LIC NO: ❑ 7
a071�• ^OCA (0 CNIC CONTROL#
CHITECT/IiNGINEE : LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
Lm that I DCONnsed TO R'Sunder
DECLARATION QTY'. { ELECTRIC PERMIT FEC
I bemby affirm that 1 am licensed under provisions of Chapter 9(commencing J08 DESCRIPTION
�cc thSection 7001hafDivision 3 of the Business and Professions Gde,anJmylicenmin RESIDENTIAL:
new p with PERMIT ISSUANCE
aU, tnfull cforce ClassnJ effete. ❑SISUWL [I KITCHEN REMODIiI.
11..czV ; 14cense Class Lic.p APPLIANCES-RESIDEN'T'IAL ❑ADDITION El PLUMBING RE-PITT?
+n6a Dae Commemr
g,Om ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z b n 7 I nureruand my plan.,shall be used ac public records MODIFICATION
Oz—, UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Vndecanted - 201-UHXIAMPS IMPROVEMENT SWIMMING P001,5
OWNER-BUILDER DECLARATION OVER UXXIAMPS O BATH RFMODEi1JREPAIR ❑DEMOLITION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
Lid$ 4 following mason.(Section 01131.5,Business and PromIgions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 W 1"' which require,n permit t.enn,Trud,nllc9 improves demolish.or repair arty slfncuua
mpriorwitsi,scarmeals.requits,theipplicam foiach permit to file unignedmaaneal SPECIAL CIRCUTOMISC.
Thal he is licensed pursuant to the provisions of the CommcTors License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Ctde)of '1EMP.METER OR POLE INST. COMMERCIAL:
4 e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDH ION ❑DEMOLITION
n Section 7031.5 by any..pliant foraperentotitFox the applicantm a civil penalty of POWER UHVICES
..y ❑'TIiNANT ❑FOOD SIiHVICE
not mom than live hundred dollars(E5 W).
OTHER FhIFNT'
Q ❑ Ichourver.f thepmpeny,ormyemplended withwoge,mlheirsole corn,B....inn, SWIMMING POOL ELECTRIC
will dmhcwon.,coin'he Contra pots Licenseed Lawc rd does of.,,Iynan Bu sine ss C1 OTHER
and Pmfessinns Cade:'Thc Contractors License Law Jces not apply to an net of OUTLETS-SWITCIIES-FIXTURES •
property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such inipsovements arc not intended or offered for I NEW RESIDENTIAL 6LECTR FI
sale.IL however.the building or improvement is sold within one year of completion,the O SQ.FT.FLOOR AREA ASQ.FT.
inner-builder will have the burden of Moving that he did not build or improve for par- PAID 1 D
pJ�ofsalc.). TOTAL: r N
N 1,ae owner of the property,am exdunivdy contracting with licensed contract:to
tract the project(See.7014,Business and Professions Code:)The Convaaor's Li- 'JUN
centhmm
se law does not apply to an owner of property who builds or improves etunit QTV .PLUMBING PERMIT FEL' RMI
who contracts far such proce s with a contmctof(s)licensed pursuant in the Commctors
License Law. PERMIT ISSUANCE. -
Ition exemptunder See ,BAPCfor do,reason CITY Uf
ALTER-DRAIN A,VENT-WATER(EA) VALUATION
er Dam �
WORKER'S COMP( SATION DECLARATION 1 BACK FLOW PROTECT'.DEVICE
n I hereby affirm under pe..try of perjury one of the following detlautiory
❑Those nnJ will maintain oCenifcau of Conserv t.self-insure for Worker's Compen- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
salim,as Provided for by Section 3700 of the Labor Cale,Farina performance of the
work for which This permit is ix,ued. .FIXTURES-PER THAI'
I have and will maintain Workers Compensation Insurance,as required by Section -
3700.f the Labor Cale,for the pard..noweofthe work for which this Permit is is,s¢d. GAS-EA.SYS"[TIO-I ING40UfLEI:S OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number ore:
Carm" Policy Na.: GAS-EA.SYSTEM-OVIiR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE ANDUSTRL WASTE INTIiRCIiI'lQR
(Thisseution need not be completed lithe pernit is for one hunlreddollar,s HXry .3{ '•o BUILDING DIVISION NCIiS
or less.) GREASE THAI' PLANCHECK FEE;.
I cenify that in the Nafarmance of the work forwhich this permit is issued,i shall SEWER-SANITARY-S OHM FA.21X1 FT.
not employ any person in any manner so as m become subject In the Workers'Groper- ENERGY FEE
ZZ satlon Laws of California Dote WR'I'ER 1112AI ER WN HN'I IELEC'IR
Q Applicant I GRADING I:I7I7.
r. NOTICE TO APPLICANT:If,nose making this Cmificae of F,xrona on.you should WATER SYSTEMn RL'ATING
n
h become suhject to the Workers Compensation provisions of the Lobar Cade,you mural SOILS FEF.
fimhwith comply with such provisions or this permitxhall be deemed revokW. WATER S17RVICE -
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Da¢ Receipt
U 0 I hereby aifimt that hem is a comwction lending agency for the performance of
the work for which this pemal is issued(Sec.3097,Civ.C.)
0 (~ Lender',Nanta TOTAL:
0 Lender's Address 'Ifyl'AL:
W 1 certify that 1 have mind this application and sate that the aNice information is BUILDING FEE
CLI
rp correct.I ague to comply with all city and county ordinances and sure laws relating to QTY. MECHANICAL PERMIT - FEF,
V building comwction,and hereby authorise representatives of lhiscity a enter upon the I SEISMIC FEE
uhovo-mentioned property for Impaction purposes. PERMIT'ISSUANCE
(We)agree no nasi,,indmn
enify:md keep hailcss the City of Cupertino agaimt ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way'aceme against said City ALTER OR ADD TO MITCH.
in mmequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALV,NON-POINT AIR HANDLING UNIT('1010,000 CFM)
SOURCE REGULATIONS. MECHANICAL Ill:
ila..,"Y1 AIR HANDLING UNIT(OVER I(L(XH)CFM) CONST RUCTION TAX
Signature of AplicanUContmdor I Date EXHA UST HOLD ONMUCT) NOUS ING MITIGATION ITE -
- HAZARDOUS M ATHRIALS DISCLOSURE -
WllltheapplicantorRombuildingaccupuntXmrc or handle haccolor ,innaial HEATING UNIT(TO IIX),000 B'I'U)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cwle.Section 25532(a)7 HEATING UNIT(OVER 100.000 BTU)
Yea •$N. VENTILATION FAN(SINGLE RESIDE PAID
Ilwc Rcccipt#
Will the applicant or future Wilding occupant use equlpnmm or devices which BOILER-COMP(3HP OR 100,000 B'TU)
emau
it hrdio s air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District? �4!' BOILER-COMP(OVER 100,000 BTU)
El Yea
I have read be havN..,materials nealremems under Chapter 6.95.E the CutI- AIR CON DI I ION ER ISSUANCE DATE
hands Health&Safety Code.Sections 25505.25533 and 25534.I under,tand that if the NEW RESIDENTIAL MFCH. SQ.PL
building does not currently have a Tenant,that it is my renpmobility Io notify the rveopanl
tamemaaioaT�SµywA Amax,he _-I nitro a issuance of n Criifiutm-10cenouncY.
KV hu
Owner or amisDateTOIp1^ ISSUED BY:
OFFICE