S 1218 AMYLICASIT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO 1218
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECBANICAI'
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, Al'I'I.ICAI'ION SIIBMFI.1'AL DA'Z'E
O 3t, u� Z Cc Cf
OWNEnR'S NAME{{: \\ PI10//NF.0 DPI C TRACTON'S N. E: LI NO:
b NIC CDNTROI.«
•J ARCHITEC'17ENGINEER: LIC NO. SS:, ❑
CONTACT: PHONE: BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ >< ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herchy afiinn that[,,in licensed under provisions of"Chapter 9 on arms JOB DESCRIPTION
OCZ with Seetlon70(10)of Division3ofthe Businessand Ptnfessiom Code,andmylicenseix RESIDENTIAL
FW� full fartcund cfkc PERMITISSUANCE ❑SBUWI sTI K HEN REMODEL
Liccnse Cla. 4 `519' I ��
Q U APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE
P a a Date a,mmar,r
ARCII1TEC1'S DI!CI.ARATION ❑MULTI-UNIT ❑S UCI'URAI.
L O m PANELS MODIFICATION
Z p ti Z 1 understand my plans xnxll M1c used as public records
OZ�G UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1010AMPS IMPROVEMENT C]SWIMMING POOLS
6K 3 OWNER-BUILDER DECLARATION OVER Rich AMPS [I BATH BE MO EIIREPAIR 0DEMOLITIO
yyx C W 6 1 hereby affirm on 1 am exempt from the famine Co License law for the
W 06 U following rcusna.(Section](131.5,Business andmpr ve.drr oli Code:Any city or counlystructure SIGNS ELECI'RICAI. [I OTHER
3 LL which requites.a permit to construct,aalter,pplicant
improve,demolish,or repair any anctio c
prinrmincensed gaLwialto the the applisofthesuch Permr's o rile a LicnseLow(ned Cha mens SPECIALCIRCURIMISC.
that hmencienudpurtion70he of Dasionsaf the eBusinss License law(Chapter9
(commenring wird Section 7000)of Division3 ofthe Business azul Rofevsioas Cut r TEMP.MEI 17R OR POLE INST. COMMERCIAI:
YYWa 4 Oy that he is esempt therefrom and the basis for the alleged esemptton.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�nN Section 70315b licam torn is Beets the applicant m a civil II f POWER DEVICES by re 01)), i pp penalty ❑'TENANT ❑FOODSERVICIi
not mare then R fl hundred dollars(55(10}
HZ} IMPROVIiMFNT
6 �I,as owner of the pmpeny.mmy. emPlnyws with wages as their rompcnsmion, SWIMMING POOL,ELECTRIC
p=r0 will do dowok,and the structure is not intended or offered for side(Sec.704OT Business
El OTHER
W 3 and Professions Code:The Cortmnors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
L .. property who builds or improves thereon,and who does such work himself or through
Ids awn employees,provid.1 but such improvements are no intended or n0bred fnr NEW RESIOENTIA.ELECTR SQ FT.
sale.If.however.the hadding or improvement is sold within one year of completion,he SQ.14.FLOOR AREA sISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- FEB
pnsc of ynlcJ. Nn
E]1,as owner of the progeny am exclusively contracting with licensed contractors to TOTAL: r R1V
construct the project(Sec.70,l Business and Professions 0—)The Conwcmr's Li- C/f�a
stLawdoesman
napplymtownerofpmpeny who buildsarimm
pvestheran
eomd QTY, PLUMBING PACT/
FETE I Vr VUrCry IIDIV
who matrons forsuch projects with a contranot(s)licensed pursuanOn the Cmnracmrs
License Law. PERMIT ISSUANCE
❑ I.m exempt and,see. .Ea&P c for this reason
Owner Date ALTER-DRAIN&VENT- RIE ) VALUATION
( WORKERS COMPENSATION DECIARA'1'ION BACK FLOW PROTECT.DEVICE/
I hereby aRren under Penalty of perjury one of the following deelamtions:
❑ Ihnveand will muimein aCeniOmm ofConsennn self-insure for War kers Campen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPF.CONSTRUCI'ION
sa0nn,as provided for by Section J]W of the Labor Code,for the perfnrmvnce of the
work far which Nis pemtit is issued. FIXTURES-PER TRAP
1 have and will nmintain Worker's Compensation Inxumnec,us required by Seniors
000 afthe Labor Code,for he performance of the work for which this lrrmit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Wmky'spCom, pep\. plpvurence Cartier and Polio'phr ars
Carrier: ( ♦ MY Policy WfiylA L(-rr�a'��— GAS-IiA.SYSTEM-OVER J(F.A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE:INTERCEPTO
BUILDING DIVISION FF.13S
(Thak,ection need not he completed if the pennd is intent,hondrcd doll.,1$1 But GREASETRAP
or less.) PLANCHECK PEE
(certify that in the performance of the work forwhicMhispetmit inissueJ,(shall SEW17R-SANITARY-STORM F.A.200 Fl
not employ any person in any manner s i as to become.subject m the Wnrkeri Compen- ENERGY FEE
zz sation laws of California.Date WATER HEATER WNENTIRLECTR
0 Applicant GRADING FEE
to NOTICE TO APPLICANT:If,after making this Cenilieme of IisemPtion,you should WATER SYSTEMiTREATING
(-" become subject in the Workers Compensation Provisions of the labor Code,you must SOILS FEE
11al � forthwith comply with such provisions or this permit shall be deemed revoked. WArER SERVICE
a �
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Da, Receipt
V p Iht,mhy affirm that there is v wnstmeuon lending agency for Om performance of
f~' the work fur which this permit is issued(Sec.3097,Ci,CJ
Lenders Name TOTAL:
0 U Lendcr'x Address rFEF'�" G1 certify that 1 have read Nis application and stare Nhe aGwe informvtion is BUIfA1NG F E
correct.l agree to comply with all city and county ordinances and nate lawsruLting m QTY. MECHANICAL PERMITbuilding usmauctlon,and hemhy authorice representatives of thiseity to enter upon the SEISMIC FI ?aMvcmemianed preen for inspection purposes. PERMIT ISSUANCE(We)agree ms save,indemnify and keep harmless the City of Cupertino againstELLCfRIC PIiE
liabilities,judgment,coos and expunses which may In anyway neuron against said City ALTER OR ADD TO MF.CH.in consequence of the granting of this Permit. PWMBING FEE
APPLIC NI' 1NDIiRS'FANDS ANU WILT.COMPLY WITH ALI.NON-POINT AIR HANDLING UNI'T(TO 111,00E CFM) MSCI IANICAL FEE:
5)URE i iULA'I'ION ♦� �_ q
��(g-o AIR HANDLING UNIT(OVER 10.000 CFM) CONSI'RUCPION TAX
Signature of Appla"Im tmcmr Uatc EXHAUST HOOD OVIDUCT) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fntort building occupant save or handle hazardous material HEATING ON]T PTO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codc,Section 25532(x17 1 HEATING UNIT(OVER 100,(100 BTU)
❑Yes I VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building t use equipment or devices which Date Receipt N
pp d by the B quip ROILER-COMP(3111)OR 100,000 BTU)
emit hamdnuv air cnnlxminut>�JcfineJ by the Nay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
Dyes
AIR CONDITIONER
� 1 have re 1 the haurdms materials teyuirtmenu uttler Chapter 6.95 riche Cali- ISSUANCE DATE
fomia llealth&S ety Cc k,Seetioms 25505.25533 and 25534.1 undemmmd Hatt if Ne NEW RESIDENTIAL MECH. SQ.FC
building snot treadyin vI t.that it in my respmsihility to notify Ne oecupam
the uirt /,w�his, be met prior my mance of a Cri igen. focoanry.
Ow cro t mrg7,edigpm, ban, TOTAL:TOTAL: ISSUED BY:
0FFICE