S 1246 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL J 1246
BUILDING PROJECTIUENTIFICA'1'ION
BUILDING ADDRESS: SANITARY NO. AAP—PLICKI ION SUBMITTALT
- DAE
, r�D� � r�
u (-- `PCU
OWNER'S NAME: PHONE CONTRACTOR'S h}gME: LIC NO:
Cliai L NIC CONTROL#
ARCHITEC'UHNGINEER: LIC NO: ADDRESS:
`l`` ❑
r\
'ONTACf: rHorvco_ - BUILDING PERMIT INFO
1hPl'ty SYIi``1)�O�N(o ��, 5�`T ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB BC
V ❑ ❑ ❑
LICENSEDCONTRACTOR'S
raviC...of CON QTY ELECTRIC PERMIT FEE
1 hereby rumored I am licensed order Povisiom of Chapter 9(cobmtmncing JOB DESCRIPTION
O00 with Section]IMIOpd DivisionJnf the Business and l'mfessiom CnJc,mJ my license In
OCO ,� RESIDENTIAL:
in Lull force and act. PERM]I'ISSUANCE.
�UZUW LiccnFeClas '�c.-3eP Lic.N,�l��� - ❑SFDWL ❑PLUjv iN REMODEL
PIPE
hQS Darla.3- dl Coal omt3t%14�, ( u APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMNING RE-PIPE
ARCHI'I ECIN DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F Z I undersand m l PANELS
Z O y plans shell be used an Public records
OZ-- UPTO 2GT AMPS MODIFICATION
f a W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
�Y .-.al OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENTSWIMMING POOLS
yy�q w g 6 I hereby atlina`hut 1 am exempt from the Contractor's License Law forme OVER 1000 AMPS C1 BATH REMODEUREPAIR ❑DEMOLITION
W 3 S FU+ following mmmt.(Section Tpl.5.Business and Prof erxlons Cose:Any city or county ❑OTHER _ aitili 0i
F=O ya which requires a Perini)to ronsmod,i ltec improve,demolish,m repair any machat, SIGNS Ii1.LC1 RICAL 1
wJ poor to its issuance,also requires the applicant for such pemtino files signed statement SPECIAL CIRCUIT/MISC.
}a that he is licensed Damson.the Provisions of the Corrector's License law,(Chapter 9
adMC) (commenctngwih Sction7")of Uivision3ofthe Baainexsand Pmfe,iuns CMd)or '1'ENIRMETERORPOLF:INST. COMMERCIAL:
a`y a y that he is exempt therefrom and the hunts fur the alleged exemption.Any violation of ❑NEW SLUG/ADDITION ❑DEMOLITION
iYfl 4y
Semen 7031,5 by anyappllemt for o Ranh subject.the applicmamu civil Pentdtyof POW17R DEVICES'
1F... not mor.than live 11 Imed dollars($500), ❑TENANT ❑FOOD SERVICE
C O ❑Las ownerofthc property,may employees with wages as theirsolecumlrensetion, SWIMMING POOL ELEC9'RIC IMPROVEMENT
2GC2', willdoe work.vndhe swearsbnm mandedoroRered hassle lSec.]BW,Buximco; ED h
L3 ro and Professions Codd:The Contracwr's License Law does not apply arm net mf OUTI.ITS-SWITCHES-FIXTURES
props ry who builds or improves thcrean,and who does such work bincef or though
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL F.LECTR
sale.If,however,he building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.
Iowner en builder will have the burdof proving that he did not huild or improve for Pur-
xeorxde.>.
❑1,as owner of the property,am exclusively contracting with licensed convacmrx t„ TOTAL:
nvtoct the pnbjct(Sec.70,14,Bmioees and Professions Co-e:)'ITe Contmnois Li
PA
come law does no,apply to an owner of popery who builds or improves hereon,and QTY. PLUMBING PERMIT /
who corrects forauch Projects with a conommo fs)licemc l punuabn m the Contmetor's
License law. PERMIT ISSUANCE d
❑ 1 am exempt under Sec .,H&P C for reason
Owner Date ALI'17R-GRAIN&VENT-WATER( Ut, VALUATION
RATION
ON
I hereby union under penalty of Perjury) h
one of following declamtionn: BACK FLOW PROTECT DEVICE `u~r`fl1/JVu
]I have and will maintim.CeniOcamof Consent m self-insure for Worker's Compete DRAINS-FLUOR.ROOF AREA.GOND.
cion,m provided far b Section 3700 of the labor Cole,for the STORIES T'YNIi CONSTRUCTION
Y performance of the
work far which his Permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Senior
3700of theLabor Gnic,for the r,f..nnnnce of he work for which this pernal is issued, GAS-BA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Wo Br's Compeneot ioq ins carr rand Policy pu��.( V
Cortise •hW\C \#k 1 1'Ix'i(Paliey Nu kik.x\ yr' \'" GAS-EA.SYSTEM-OVER 4(EA)
CHR ripacATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASE%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FliES
(This section need not be completed ifhe Permit is for one hundred dollars 1$100)
or loss.)(This
PLANCHECK FEE
1 middy than in the performance of the work for which this Permit is issued,I shall
•
lot employ any Pcnon in any manner so us mn
become subject to Wnrkec�Coo _ SEN'Ek-SANITARY-STONM PA.21M)FT.
natiuLaws Laws of Culifomia.Dam Asn ENERGY FF.F.
z O Applicant WATER HHATER WNENT/ELECTR
pP GRADING FEE
F+ ^ NOTICE
subject
APPLICANT:IL after making this Cisions of
)Labor io r you should WATER SYSTEM/1'RFATING
Behavi subject y it Worker's Compensation provisions of the deemed
Coded you must SOILS FEE
UJ fanhwih comply with such provisions or this permit shall be Deemed revoked. WATER SERVICE
� Z CONSTRUCGONLENDINGAGEiNCY NEW 8135 IDENTIAL PLMB, SQ.PI'. PAID
V O Iherehy ultimo that there inuamstndion lending agency lnr the performance ul Date 19101
ec pt
(L F the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name T AL:
F 4 C.) lenders Address TOTAL:
I certify that 1 have read this application and state that the above infomtation is BUILDING FEE
(A comet.l agree to comply with all city and county ordinances and state laws reining us QTY. MECHANICAL PERMIT FEE
UZ building conammion,and hereby cathartic represemmivesofthi.s city to enterupon he SEISMIC FEE
Ihn womationed propcoy for iaspeedan purposes.
(We)agree hs save,indemnify and keep harmless the City of Cupenin,against PERMIT ISSUANCE 35 5 EI-ECTRIC FEF.
liabilitie,n,judgment.v,cons and expenses which may in anyway acme against said City ALTER OR ADD TO MECH,ronscquence of the grunting of his Permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000CFM)
SOURCE REGULATIONS, MECHANICAL FEE
�N mmtantacAIR HANDLING UNIT(OVER I o.00b CFM) CONSTRUCr10N'1'AX
SS.' at%I eIIA pltor�Y\ J Date EXHAUSTHOOD(WMI1CI') HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicants or future building oecupmt store or handle haurdous material HEATING UNIT(TO 1011.00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532bd? HEATING UNIT(OVER 100,011)BTU)
L]Yes k-JKNn - TILATPAID
VENION PAN(SINGLE RES Date Receipt#
1
Will the it cintain orfurore building by the ntmeea i notAir
Devicesement C BOILER-COMP(3HPOR 100.00BTU)
mit hazardous air contaminates as JchncJ by the Bay Arca Air Quality Management 1
)istrict? � TOTAL:
E3 yet, 4
Q> . BOILER-COMP(OVER 100.00(i B'ru)
I have bead the hmallous materialsAIR CONDITIONER ISSUANCE DATE
requirements under Chapter 6.95 of the Cali
foods Health&Safety Cade,Sections 255115,25513 and 25534.1 understmJ that if the NEW RESIDEN'T'IAL MECH. SQ,FT.
building does not commonly have a tenant,hw h Is my responxihiliry rob notify thencabpum
of the nummuems which nwst be met priormissuance ofa Cenit'nI ofIh upan,.
OwneTnr authab nk 1 +FDate TOTAL:S ISSUED BY:
OFFICE