S 1062 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO IIUILDING-ELECTRICAL PETIT NO.
BUILDING DIVISION APPLICATIONWERMIT PLUnWdG.MEC,HANICAL 1062
IIUILDING.PROJECT IDENTIFICATION
BUILDIW ADDRESS: (� SANITARY NO. APPLICATION SUBMITTAL DATE
>�e'Y, ' '
(ZNMS
S�NAME: /-a
' Itr+en ON h - _ CONT H'S NAME: iIC N l'
NIC CONTROLp
ARCHITECDF:NGINEER: LIC NO: AIDE
is sii�
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
0p I hereby affirm that 1 um liecmed undo Provisions of Chapter 9(commencing JOB D14SCRIMON
� with Sec0on 7tXX11 of Divnaon3 the Businexe and Pmfessimnw C'ule,nnJ mylicem'c is RESIDENTIAL
in full force an J,R PERMIT ISSUANCE
aF.UzU 4. nese Classes/ Lica ❑SFDWL CHEM REMODEL
N6L Dal Commcum APPLIANCES-RESIDENTIAL ❑ADDITION hUMHING RE-PIPE
Dm ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑S UCNRAI.
Z Z 1 understand my plus shall be used as public records PANF.IS
CZ— MODIFICATION
OO a UP T02(XIAMPS El INTERIOR ❑CFIIMN17Y REPAIR
Fs X.1'7W Licensed Professional 201-10XIAMPS IMPROVEMENT [I SWIMMING FOOLS
G0� mxe
OWNER-BUILDER DECLARATION OVER TWO AMPS
6 I h ❑BATII REMODEIIRiiPAIR ❑DEMOLITION
eachy affirn'hot I aexempt floor othe Convectors Liceno,law for the
d U i-lkwo ovicsnn.(Si 9(131 5,Business and Pmfmsians Cade:Any city or county SIGNS 1?LF.CfRICAL ❑OTHER
F p FyQ- which myuixes a Ex reed to construct,alcor,improve,demolish or repair ony,venue
rA..l prions its ixcmance,also requires'he applicant for such permit m file asignedscomem SP[CIAI.CIHCUIT/MISC.
i+ 'hal be is liuemed Pnrsamn m the 111111-ol I the Coomuemds Llemne Luw(Chapser9
ly_Co� (commencing with SIVian 7000)tf Division 3of'he Business and Professions Code)or TEMP.METER OR POLE INST. CQMMERCIA
a y M q that he is exempt duration and the basis for the alleged exemption.Any violation of E3 NEW BLDG/AUDITION ❑DEM01-(TION
LLXl Yy Section in.. byany rise
hundred
d.11 nmpermb soh,iec's tho appllcunuounvil penalty of POWER DEVICES ❑TENANT El FOO S_ LikVICE
F, y or mom th,n five hundred Jollmrs($500). IMPROVEMENT \\\
=Q ❑ has ownerofthe progeny.or my employees with rages as'M1eir sole compensation. SWIMMING POOL ELECTRIC
F. willdothewmk,McItheewemre is not intended oro0'ered dorsale(Sea VtHl,Business ❑OTHER
6'3$ and Pndiso.'.s Code The Comedos,License Law does nn'apply man owner of OU'11L'TS-SWITCHES-FIXTURES A
pmpeny who builds or improves thercom end who does such work himself or thmngh — 1"
his awn employees,provided that such impmvernI am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
late.l[hnwever.the brikhriEnr imptavement i,m1d within on,yearofcmnpeficat a, — FLoo Pyha $/SQ.17.
owner-builder will have the burden of proving that he did not build or improve for pur- Q/1)1
�
poseefsaleJ. /`Y a�a�
❑ 1,as owner of the property,man exclusively contracting with limned contractors to TOTAL:
onswcl the project(Sec.7614,Business and Professions Calc:)The Contractor's Li- �� IJJ(y$-
came lawdoesnot apply'o an owner ofpropeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE `GF'` wCj4D
who cotmm�s for such pro)ccts with a earmactorts)licensed pursuant to the Contractors l"js. ,F'
License Law. PERMIT ISSUANCE yet
Iumexemp'under Scc. ,B&PCfor'his reason
ALTER-DRAIN&VENT-WATER EA)
Owner Oute VALUATION
Wan der'SCOMPENSATION DECLARATION BACK(TOW PROTECT.DEVICE
14
1 herebyaffirm under Penalty of perjury one o the insure or declarations:
❑Lhave and will maintain nCenilicumM Consent ho lion Worker's Con,Rn- DRAINS-FLOOR,ROOF,ARBA,COND. 'S '1'YP"ONSTRUCTION
,mhos,as provided for by Section 37(X1 of the labor Code,for the perfommucc of the
work for which this permit is issued FIXTURES-PCR TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
or
370(1 nllhe Labra-Code,forthe perbannaracOthe work l'nrwhich this permit is issued. GAS-EA.SYS'I'EM.I INC 40U'1'LETS OCC.GHOUL APN
My Workers Compensation Insurance carrier and Policy smoher are:
Cancec Policy Nn: GAS-EA.SYSTEM-OVER 4(EA)
CL'RTIPICATE OF CXP.MFI ION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINUUSTRL WASTE INTIiRCF.FI'OR
(This ration need ood od completed tithe permit is foram hundred dollars($100) BUILDING DIVISION PEES
or Iex,.) GREASETRAP PLANCIIECK FEE
(certify thmern In performance of the work for which this permute isucdlstrll SEWER-SANITARY-STORM LA.20014.
no'employ any person in any manners n become subjce'to the Workers'Courtier-
lion Lows of Calif IiNF.RGY FEE
pplicom WATIiR HF.A'1'IiR WNIiN'I'/HLI!CfR
GRADING FGIi
i X017 O A 1.� r I. 'his
Cenificme of Exemption,you should WATER SYSTEMnRGTING
M c s tPi Workcra Compensation provisions odds,lemur Calc,you must SO I S ITE
fonhwithcomply wif.such provisions m'hi.vperini'shallltdecined revoked. Wg11iR SERVICE
d
oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FINE SQ. PAID
UO Ib,robynrfirmthw dbooisnamstmctinn lendingagcncY fnnhepedarmonwof Date Recap]0
LL F the work for which this permit is issued(See.300,Civ.C.)
O U Lenders Name .1.0.1.
W Lender's Address TOTAL:
12• I certify that 1 have read this application and stat,that the alwve intonations Is BUILDING FEE
Ei
Ln correct.)agree to comply wahaR city and county ordinancesuad satelaxxmlmingo QTY, MECHANICAL PERMIT FEE
U Z buildingeomwaion,andhereby authmimreprsemmivesnfthisci'y'oenterupon'he SEISMIC Ffi�
move-mentioned properly for insPrchon purposes.
(we)as.1.save,indemnify and keep harmless the CityorCapenino against PERMIT ISSUANCE ELECTRI( FE
babilincw,judgmems,cos',and expenses which may in any way accmc against said City of;TER OR AUDIT)MIiCH. O
in consequence of the proton, rdaklran,i'. Tli
PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 1'17110.000 CFM)
SOURCE REGU MECHANICAL P.E
P� AIR HANDLING UNIT(OVER IIkWOCFM)
CONS'IRUCI' NTAX
Si a n, cor Dae EXHAUST HOOD(W/DUC17 HOUSING TIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will theupplicamlir future huilding mcupan'mom lir handle hommms mmenood IILA'I'ING UNI T(TO 100,010 H9'U)
as defined by the Cupertino Municipal Code,Chase,9.12,and the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER I W."BTU)
[:1 Ya, [_1 No
VENT ELATION CAN ISINGLL RIiSID) PAID
Will the applicant nn future building by the B use equipment m devices which
Doc RaeiPtp
emit District? us air contaaninums as defined by the Bay Arca Air Quality Management BOILER-GDFTP(JHI'OR I(IB,(ND BTU)
Dislri,l'! L:
(]Yes ❑Nn ROIhER-COMP(OVER I00,000 BTU)
I have re:ul the haarNous ntmedals requiremmb under Chapmr 6.95 of the Cali- AIR CONDITIONER ISSUA C ATE
fords,Health&Safety Code.Sections 25505.M533 and]5531.1 understand that R the NEW RESIDENTIAL MECH. SQ.FT.
building draw not currently have a tenant.that it is my responsibility to an'ify the occupant
of the m,rimmem,which ams'be coal prim m Issaanm of a C,mEradc cr Ocenponcy.
Owner lir aumorixcd agent Date TOTAL:
ISSUED Y.
OFFICE