B 0279 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NOy�rq
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-
MECHANICAL 50001 j20279
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL UATI
$ u 0 s0 c
OWNER'S NAME: � 1 PHO G: COM'RACTO 'S NAME: 1.1 NO: NIC CONTROL#
ARCHITECT/ENGINEER: u t LIC NO: ADDRESS: IY� ❑
CONTACT: ?� ) PHONE: BUILDING PERMIT INFO
vrL+Co n�
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT. PLUMB MECH
L OU r'0 P ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELEC-rRICPERMiT FE JOB DESCRIPTION
I torch,afinn Thal I ort licenced under Is inions of Chapter 9 b ommen.ing
O d'Z with Section700soofoivision 3 ofthe Business and Professimur Code,and my licenu is RESIDENTIAL:
W O PERMIT ISSUANCE
FW� in full force and ef0ca. _ ❑SFDWL El KITCHEN REAIOUEf.
aUV Licenu Cl es Lie. 4 �� ��^� APPLIANCPS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Dam Contin
sn6y ❑MULTI-UNIT OSTRUCfURAI.
g-D Vs ARCHITECT'S DECLARATION PANELS
zon7; l understand my plans shall be used as public record. UPT02IXIAMPS MODIFICATION
c z -O ❑INTERIOR CHIMNEY REPAIR
Plie,,-qqu1 Licensed Professional ]Ob1000AMP5 IMPROVEMENTSWIMMING POOLS
�ky•J•t OWNER-BUILDER DECLARATION OVER I000AMPS O BATH REMODFIIREPAIR ODE bfD (TION
y __ /�C W Q 1 hereby on that I am exempt frothe Cracme,License lafor the
folloMwfi..
._^�
yxx OIaW,U wing..neafm outw on.(Section]071.5.Business rind Professions Conm
Cosi.:Any city county SIGNS ELECTRICAL OTHER
W 3 LL F' which requires a permit to concoct,alter,improve,demolish,or repair any structure r P A 1 r SG—"Ecl—t e
F,OI prion,its issuance,also requires the applicant for such lament to rile a signed statement SPECIAL CIRCUTUMISC. --J�
2�o that he is licensed pursuant to the provisionsoftheContractor's Licens,Law(Chapter 9 COMMERCIAL,
WSOO (commencing with Section7")of Division 3 ofthe Business and Professions Code)or TEMP.METERORPO -INS'C
L q C that he is exempt therefrom and the basis lot the alleged exemption.Any violation of O NEW BLDG/ADDITION O DEMOLITION
❑Xl trV/s.a
Section 7031.5 by my applicant for a pentyl subjects the applicant o civil penalty of POWERDIiVIC' 0TENANT ❑FOOD SERVICE
FZY not more than five hundred dollars H.500). IMPROVEMENT
ppQ O I,mmnnofthepmpeny.armyemploymswithwagesutheirsnlecompensution, SWIMMING OL ELECTRIC
OOAAGG iiGG``:: will Jo the work,and theswdure is not intended or offered for sale(Sec.]BW,Business OOTHER
W 3 and Professions Cade:The Contractor's License law does not apply to on owner of OUTLET SWITCHES-FIXTURES
propeny who builds or improves thereon,uad who does such work himself,.through
his own employees,provided that such improvements ate not intended.,offered Ior NE ESIDENTIAL ELECTS SO FT.
sale.If,however,the building or improvement is sold within one year ofeompletion.the Q.^:FLD AREA SISQ.FT.
tombobuilder will have the burden of proving that he did na,build or improve for par-
pnse.fsme.'. JUL 0 8 ANS'D
❑I,as owner of the property,am exclusively contracting with licensed c.mamc.#s n, TOTAL:
.auris the prgect(Sec.]DW,Business and Professions Code)The Cmdowme.Li-
seLaw does meapply toanowner ofpr,perry who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such istroo xwimucontmcoms)Iicensedpursuannothe Contractor's `IIY Ur wr an IiNU
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(G) VALUATION
Owner Dam p
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I p 75' 00
I hereby affirm under penalty of perjury tons of the following dmlumtions: 1
❑leave end will maintain aCenifcate of Consent mulf-insure for Woher's Compcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES
TYPE.CONSTRUC'flOt
stator,as provided for by Section 37(X1 of the Lm.n Cone,for the purfibramnce of the
work for which this Pemba is issued. FIXTURES-PER TRAP
�'1 have and will maintain Worker's Compensation Insurance,as required by Section
31011ofthe laMa Cale.forte perlb..ref the work for which this peme,is issued. GAS-EA.SYS'1'EM-IINC.JOUTl S pCC.—GROUP APN
My Worse k, 1.pearmion{p�umncefam rand Policy nyq a{�
Cartier: l 'Le- '/L-tea( a Policy No.:h.. rCI UL.IeIL GAS-F.A.SYSTEM-OVERJ( )
CERTIFICATE OF EXEMPTION FROM WO$$KERS'a 7NYF GREASFIINDUSTRL WAS .INTERCF.PfOk
COMPENSATION INSURANCE bIgP. I/J 1 q� BUILDING DIV] FEES
Oris section need not becompleted ifNepemait is for onehundreddollars(SIOG) GREASETRAI'
or lues) PLANCHECK FEE
I certify that in the performance ofthe work for which this Penni,is issued,l shall SEWER-SANITA -STORM HA.200 FT.
no,employ any person in any manner so as,o become subject to the Workers Cooper- ENERGY HE
Z stalks.laws of Crlifomia.Date WATER HFAI'� W/VENT/ELECTS
Z Q Applicant I GRADING FEE
NOTICE TO APPLICANT:If,after musing,his Cer illcate of Exemption,you should WATERS EMffREATING
ti SOILS FEE
(•' become subject;.the Worker's Comms or this previsions shall h the rancor Code,you man
forthwith comply with such pr�visi�nsmthis swrmil sbullRJeemed revoked.
WqT SERVICE
CONSTRUCTION LENDING AGENCY RESIDENTIAL PLMB. SQ.FT. PAID
zI hereby afflrm that them is a construction lending agency for performance of Date ROceip,X
4, 0 the work for which this permit is issued(Sea 3097,Civ,CJ
O U Lender's TOTAL:
Name 'TOTAL:
W Lender',Address
1 certify that 1 have mad this application and state that the above information is BUILDING FEE
ice. Vl correct l agree to comply with all city andommaymilintacea and state laws belning to QTY, MECHANICAL PERMIT FEE SEISMIC IZE
U z building construction and hereby amhmiac repoewrta,ives(if this city to enter"Pon the
aMrve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hamfess the City of Cupertir.against
liabiliues,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in ennsegnencc of the Granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLI NO UNIT TO 1000 CFM) MF,CHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,OfN)CP CONSTRUCTION TAX
Signature of AliplicinifC.rtmche Date EXHAUST HOOD(W/DUCr) HOUSING MITIGATION PER.
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store o,handle hardous material WNGUNT OY)IWP00 )
i s defined by the Cupertino Municipal Cone,Chapter 9.12,and the Health end Safely
Cade.Swoon 25532(x17 IT(OVER .000 BTU)
OYes B,TN. FA INGLE RESID) PAIDDate Rweiga
Will a he applicantor fluuture building occupant use equipment or devices which (3HP ORI T(M BTU)emit hmaNrus air contaminants as defiled by the Bay Area Air Quality Management TOTALDinrin:' MP(OVER 100,S)l BTI)❑Yes VNoI have read the hawdeas materials raluiremcnts under CTupter 6.95 of the Cali- ONER ISSUANCE DATE
forme Health&Satily Cone,Sections 25505,25533 and 2553J.I understand flat ifthe NTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibigty to notify the occupant
of the o,tim uc s hich mos,N met prig s issuance of a Cenifcam f Oce panty.
Owner or aut.du age am TOTAL: ISSUED BY:
OFFICE