S 1109 APPLICANTTO FILL IN'INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
;CITYOFCUPF.RTINO - BUH.DiNr1-ELECTRICAL, FERMI No.
BUILDING DIVISION APPLICATION/PE"IT PING FROGCT,IDE MECHANICAL
S 1109
BUILDINUPROJEGTJDEN'CIFICATION . -
BUILDING ADDRESS
: SANITARY NO. APPLICATION Sl1BMITTAL DATE
`GlaqL I k Y) �s %01 , .z
O R'S NAME, HONE: T'RACTOR'S E: IC NQ: _
1 NIC CONTROLN
ARCHITE ENGINEER: - IC aMb ADDR �—r ❑Will
-
CONTACT: PHONE: �I BUILDING PERMIT INFO
�/ID��/1 ��' �' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB H
UI c ❑ ❑ ❑
LICENSE CONTRACTOR S DECLARATION z
QTY , ;.',ELECTRICPERMIT�: FEE
Q' 1 hereby aRmt that I am licensed under prnv; n. f chapter 9(comm , _ JOB DESCRIPTION
aZ with Sedion9fM0)ofDivisian 3nf@o Business antl Pro@seionsCWe,and mylieense is a BYSID T
!TEMP.
ISE
FwB in full forceand /'� '� SFDWI ❑KITCHEN REMODEL
�UcHj License Class f tee,+-�Lic.N NCESIDENTIAL ADDITION El PLUMBING RE-PIPE
P' W Data- Conlmdnr
m L ,. ❑MULTI-UNIT ❑S'I'RUCTURAh
ARCHITLCTS UE LARA N
F'r]Z Iunderitund my pl ARCHllbeuseJes - SMODIFICATION
OZ.`O+`� cit ` (NI El INTERIOR ❑CNIMNF,Y REPAIR
H.FW LicensedP fid cal- - OA - IMPROVEMENT - C]SWIMMING POOLS
OWNER BUILDER DECLARATION,.
OVER IKN ❑BATH R8 DH[ REPAIR �DEMOLITION
yWx Q I hmeby'eff that l ex pl immune Contractors License Law f tuc ���,,,sss111
WaOFtoll g (Sector 90315 ? 'rte dProfession,Cd An, ty nIYELEALOTHER.
u1 whichrequirespermit I c I I Ito P demolish. f pa y t mret� I AYI,w VU k,,x l _
prix t t I. y th ppl mf hpartial t fl g d t semen L CT/MIST
rthat be p pursuant thep fib C I Ir' L La (Chaprer9M
d� .(com g with9(IO)of Division J rNaB s dProfession,CnJe)nr MP. I'aLE INST.that hes exempttherefrom and Ilio basis for the alleged escnpl r e Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.56yanyappliwnl for a pcurna,ubjects the g,icantwiteivilpnnkyof D ❑TENANT ❑FOODSERVICE
of more than five hundred dollars($501).❑ Las owner of the property,or myemployees with wages as their sole compensation. INL EhIiCTRIC IMPROVEMf:NT
will do the work,and the sweture is not intended or offered for sale(Se,7044,Business [-]OTHER
a m
add Professions Code:The Cnnvamors License Law does not apply m a,,owner of OUTLETSCHES- 5
prmperty who hailds or improves thereon,and who does such work himself or tM1rongh
his own employees,provided that such improvements care not intended m coffered I'or NHW R116INTIAI.ELE 'R SQ ET.
sale.Towever the building or improvement is sold within one year of completion, SQ.FI'.FLOOR AREA $ISQ,PT.
L h
iter-builder will have the burden of proving That he did not build or improve for pan
poac f. ).
❑Ia: 1th p PexclusivelycontractingvithI' .ed act 1
construct lha product and rl � Tn
f ' rtCde) Contractor am L' - '
A
c L -d t app 04ply loan wneroaiff p pony who b improves thereon, a QTY'•' PLUMBING PERMIT .I EEE '„
who ova t
fit protests with acorn emr(n)l censod pursuant the C m Ina -
License Law. PERMIT ISSUANCE ift Q� I
I an exempt under Sec .B&PCBrthhmvw.m M
ALTER-GRAIN&VENT-WA'I'ER'EA) {� VALUATI
Owner - Date
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE tv
t l�
-• I hereby afinn under penally of perjury ane of[lie following dedumtione,.
❑I have and will maintain a Cenifcam arCnneenuo self-insure for Woder'.s Compen- DRAINS-FLOOR,ROOF,AREA COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance al'the
wok for which this permit is issued. r FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section 11
39(X1 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Wo at�C5o mI'ry�t{e ,at and Poli' nu
Cx`:O„yaaa�L .]�PoliaY No.� GAS-
EA.SYSTP,M-OVER4(EA)' -
CERTIFICA ,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -1 GREASE/INDUSTRL WASTE INTERCEPTOR a$ BUILUINGTIIVISION FEG r a"
(This section need mol bewmplemd if lhepermit is(Drone hundred Jnllars($TIN)) 5' -
or less.) GREASE TRAP - PLANCHECK HE
I certify that in the performanceofshe work far which lhispennit is iesuaL Tnhall SEWER-SANITARY-STORM EA.210 IT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY HE
,Z sation Laws of California.Date WATER HEATER WNENT/ELECTR
Applicant t GRADING FEE
H NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMG`REATING
fy become subject to the Worker's Compensation provisions of the Labor Cale,you must SOILS FEE
Lail forthwith comply with such pmvinirm or this permitshall be de,nodrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESNENT'IAI.PLMB. SQ.FT. PAID
Z' Iherehy affirm thanhaeiw conswetion lending agency fonhc performance of _
Data R'ceiplM
UO the work for which this permit is issued(See.3099,Civ.C.) `
Lenders Name TOTAL
LULenders Address TOTAL:
Iy 1 candy that I h d this applicationd state that thebinformations BUILDING F P.
-In wrrect I agree m comply with all city and county ordinances andate laws ardalaught QTY. MECHANICAL PERMIT FEE -
C,1 building construction,and hereby authorf,e representatives ofthiscity to nter upon the SEISMIC FEE
above-mentioned property fm inspection pargtses. PERMIT ISSUANCE
t I (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs end expenses which may in any way accme,against said City' ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of NPermit,
granting of this permi
APPLICANT UNDERSTANDS AND WILL COM WITH Li:NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE _
SOURCE IONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signatureplicamadontmc Data EXHAUST HOOD(W/DUCT) I DUSTED MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant(it duturebuilding occupant store or handle hacallous material T
HEATING UNIT(TO 100,000 RTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Sol cry
Code,Section 25532O? HEATING ONI'T(OVER 100,000 BTU)
❑Yea ❑No VENTILATION FAN(SINGLE RESID) PAID -
Date Receiptk
WiIT bednes applicant or future building by the Bay
Air Quality
Management
whichnt BOILER-COMP OHP OR 100,000 BTU) - -
40 emil hazuMoux air contaminants as defined by the Bay Area Air Qouliry Mamtgemeat .. - TO'T'AL:
District? u'so BOILER-COMP(OVER I(m,000 BTU)
E]Year ❑No
I halo road the hmnrdoqu
os materials reirements under Chapter fi.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forms Health&Safely Code.Sections 25505,25533 and 25534.I undemtond that If the NEW RESIDENTIAL MECH. SQ.FT.
building does narcotically haven tenant,that it is my msponsibiliry m notify the occupoul
mine requirements which must be met prior to issuance of a Cenificare of Occupancy.
i.
Owner or authorized agent - ( Date -TOTALISSUED BY:
OFFICE t