S 1808 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAI. IHSITNO, a� HOH
nUR.DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAU
v\ 1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SU BMITTAL DATE
ktl-185 k 11 CuP�2-n+� 7-/� 9�
OWN NAME: fIIONE: CONI RACI OR;S NAME: LIC NO'.
S. A NIC CON'TROI.p
RCHITECTIENGINEEIL ` LIC NO. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
'vvL. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT /PLU❑MH ME❑CH
❑ IL—t`1/
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 atm licensed kinder provisions kir Chapter 9(enn,mencing JOB DESCRIPTION
5
z wi(ItSmW ❑ivisi
(ion]Opdrn3arthe Businssand Professions and mmPERMIT ISSUANCE.
yliceeis RESIDENTIAI.
Yl :
0 p •$'7s
Fm— inion force and cµect. ❑SFDWL ❑KITCHEN REMODEL
<—U License Class LIC.M APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING R&PIPE
Nzw
Q 6 Dale Commercr
1„py ARCHIT[CTS DECLARATION PANELS Commerce-
0 MULTI-UNIT ❑STRUCTURAL
z p m` 1 understand my plans shall be used as public records MODIFICATION
UP TO 200 AMPS
Oz G Ll INTERIOR jEl�q,�CHIMNEY REPAIR
F'�., WWW ns
IaceeJ Profession+rl 2111-❑xXtAMI'S IMPROVEMENT Lyres my MING POLLS
OWNER-RUILDER DECLARATION OVI7R 10011AMPS ❑BATH REMODEIIRCPAIR El DEMOLITION
1 hereby,ar(ion don hI.,it exept mfrom the Cnntmdhr's License Llin aw the
El yx O y U fol Irwin,reon.(SemW
on 703 IS.Business and 1'ndcowns Ce:Any city ar county SIGNS HLECI'RICAL OTHER
as2 `'-
fzl�+0 W which requires a permit m Iledemolish.
c'nndract,a ,improve, or repair any structure ✓/J'S' /+�+7� Ty.�
prior to is issuance.also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
E pthat be is licensed pursuant re
o the provisions of the Contctars License Law(Chapter 9
aq1��}Zm (commencing with Section 7000)of Division Sof the Business and Professions Court or TEMP.METER OR POLE INST COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW RLDG/ADDITION ❑DEMOLITION
LLXl 4•
Section 7031.5 by any ii,inficind for.permit xuhhW,the applicant r a civil perah,of POWER DEVICES �/�{. y []TENANT ❑FOODSERVICE
I- 6Out more than five hundred dollars($500.
I,as owner of the OTHER F:MGNT
the
estrctre is emntendes oithwndcaox lalei(See7 ,14.Bsine's SWIMMING 1'001.1?LECTRIC
F.. will Jotnework,andthestrudurcisnotintended Law
wdoforot apply to
Business Fl OTHER
LL�1"� and Professions CWr'Da Comment's License Inw docs not apply to an owner of OUTLETS-SWITCHES-FlXTURES
pr.,dy who builds or improves Income,and who docs such work himself or through
his own employees•pmvidW tbal such improvements am not intended or offered for NEN'RESIDENTIAL ELECTR SQ FT.
sale.If,however.lhe building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of,owing that he did not build or improve for pur-
poxeofole).
79,901,as owner rf the popany,am exclusively contracting with licensed contractors in TOIA1.1
umswct the project(Sec 7044.Business and Protexsin is Code)The Contractor,LI-
st,Law does not apply to ant owner of properly who builds or improve.thereon,and QTY. PLUMBING PERMIT FEE
who contracts far such projects with a convaciand limned Pursuant m the Commenn i
License Law. PERMIT ISSUANCE
❑ l am exemp under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATz E VALUATION
owner Data U Ci
WORKER
under Penalty
DECLARATION BACK FLOW 1'R(TfECf.DEVICE ��� —�
1 hereby affiant under penalty to perjury enc of the following declarations:
Ihave and will mninmina Certificate kir Cnnsenun self-insure for Worker's Crntpem DRAINS-I'LOOR,RODE AREA,GOND' TORIIiS TYPE CONSTRUCTION
cairn,ax provided for by Section 3](X1 rf the Luton Calc,for the performance of me -
work for which this permit isissued. FIXTURES-PER'I'RAP / S/`�aa..L
1 have and will maintain Workers Compensation Insurance,as required by Section
37M rfthe Labor Code,for performance of the work for which this pnnit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number ate:
Carrier. Policy No.: GAS-EA.SYSTF:MOVER4(HA)
11
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDl15TRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FLEES
(Thissection acedrm becompleted ifthe permitNfrrnne handreddollan(SI(g) GREASE TRAP
or less.) PLANCITECK FEE
I,an,(pe,o thcpcollormsersamarnance ,1.work l'rrwhich
ncoopernitrker,'Crater.. SEWER-SANITARY-STORM EA.2(X1 FT.
nI employ any panne in any manner so os m hentms>uhjm((o the Workers'Compcn. ENERGY FEE
O Zsatiun Laws of Califmmia,Date WATER HEATER W/VE.NT(ELECI'R GRADING FEE
Z 2 Applicant `
h NfTIICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IRFATING
become subject to the Wader's Compensaina provisions of the IsM,Code,you must SOItS FEE
{aTa forthwith comply with such provisions or this permit shall he deemM revoked. WATER SERVICE
Q
Uz CON59is ac ONLENDI NGAGIieGY NEW RESIDENTIAL PLMH. SQ.FI. LAID Date ReceiptIf
I hereby affiant levantthere is sued(Sec.30 I7,Civ.agency for the perlitnumce of
C..1 O the work for welch this permit is issued(sec.3007,Civ.C)
u' LJ IsnJcrs NameTOTAL'
lender's Address TOTAL: -
�' 1 1 certify that I have mad this application and stale that the above infonnurion is BUILDING FEE
to cored l agree to comply with all any and county ordini and suite laws mlanngtu QTY. MECHANICAL PERMIT FEE
U building construction,and hereby amhorizempreunconitsofthis coymenteru,un the SEISMIC FEE
r above-mentioned property for inspection purposes. PERMIT ISSUANCE �79� No
(We)agree to save,indemnify and keep h rmilc.ss the City of Cupertino against ELECTRIC FF.F. I
liabilities,judgments,costs and expenses which may in any way accomauind said City ALTER OR ADD TO MSCI I.
in ome,trec.cilia grnming ol'(Itis permit PLUMBING PCI:
APPLICANT UNDERSTANDS )WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1R00()CFM)
SOURCE 'ULA'1'1 5 MECHANICAL I?
7 � AIR HANDLING UNIT(OVER III,(018CFM) CONSTRUCT
N N TAX
mm D 5ApplicnUilntmcior am EXHAUST HOOD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS M// ERI DISCLOSURE
Will thea,plicafum
mrrre bail cuparI store kir handle hazardous ntatedal HEATING UNIT ITO I rafforXI BTU)
as defined by the CaKrunr Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Section 25532(a)7 HEATI NO UNI f(OV ER IMT00 BI GO
❑Yes [_1 No VENTILATION PAN(SINGLE RUSID) PAIDAsk Da¢ RaeiplM
Will the applicant or future building occupant use equipment or devices which BOILER-GDMP DHP OR Ig1,IXX1 BTU)
mit hazmdous au contaminants as defined by the Bay Area Air Quality Management TOTAL:
District] BOILER-COMP(OVER 100,000 IGU)
E3 Yes Li No
I have read the hazardous Orchards requiremun
ent, der Chapter 6.95,adn Cali- AIR CONDITIONER ISSUANCE DATE
Tem it Health&Safety Cal venoms 255(15,255)5 and 25534.I ondentatd that if that NEW RFSIDEN'I'IAL MECH. SQ.PI'.
hnidm notcurrea(enamthat itisnryresgm.ibilitytonmilythunmrry
tnt
1`1 im I ) imancy.c
wIagent Data
TOTAL ISSUED BY:o
OFFICE