B 0263 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI. SOOOI 'A0263
BUILDING PROJECT IDENTIFICATION
BUILDING ADURI?SS: SANITARY NO. APPLICATION SUBMITTAL DATE
Ioo52 F3 e�� /d vim• > eTl,jo ch-. gsoi4
OWNER'S ApQ+4p� PHONE: CONTRACTOR'S N6MIE LIC NO.
KKISi ✓iJLEe/G '¢ /Y1�S "EL£C r -7&90X1Nlc CONINo1.»
AR ITECT/ENGINEER: LIC NO: ADDR S: ❑
5 e
CONTACT: PHONE: BUILDING P iRMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELF. PLUMB MECH
❑ ❑ ❑
LICENSED that I a CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby often that 1 am licensed Bu under provisions of Chapter 9(commencing JOB DESCRIPTION
pZ with section 70Wlornivixion 3onnm Business and lRofexaimmx code.and my bceme is . r. RESIDENTIAL:
in full force and effect. PERMI'1'ISSUANCE 0 CV
oC�F ❑SFDWI, ❑KITCHEN REMODEL
<UU Licenu Class Lie.p APPLIANCES-RESIDENTIAL
�' R Date Compactor x ❑ADDITION ❑PLUMBING HE PIPE
ARCHITECI':S DECLARATION PANELS ❑MULTFUNIT ❑STRUCTURAL
Z p H Z 1 understand my plans shall Ire used as public records I MODIFICATION
OZ-0 UPT02MAMPS EI INTERIOR ❑CHIMNEY RI7PAIR
I, Licensed Professional 201-UH)JAMPS IMPROVEMENT
�..4l OWNER-BUILDER DECLARATION F]SWIMMING POOLS
6 1 hereby affirm that 1 am exempt from the Committers License Law for the OVER 1000 AMPS ❑BATH RFMODEUREPAIR ❑DEMOLITION
ixpyS.O ad U following mason(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 W ye which requires a pennit to construct,alter,Improve,demolish,or repair any structure /� ( Lr/
prior to its issuance,also inquires the applicant for such Permit file a signed statement SPECIAL CINCIT/MISC. AIQ /J_
F. } that he is licensed pursuantmthe pmvisinns of the Comrazoors Licrnulaw lChap¢r9
CO (eommoncin6 with 9cction 7fMx1)nf Division3 of the Business and Profoexions Cnlc7nr TEMP.METER OR POLI?INS'[ COMMERCIAL'
y thnt he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ao Section 7031.5 by any applicant for a permit subjaB she applicant to a civil penalty of POWER DEVICES
h []TENANT ❑FOOD SERVICE
1 more than five hundred dollars y amp.
� C wi Lo the work.one pmpeny,structure lines
emplended with wages uamci(role 044.8 sines. SWIMMING POOL ELECTRIC IMPROVEMENT
_ will dotheCone:add heConllsnotlnteneNoLawdoessfficipal rmic not
to an Business ❑OTHER
and Professions Rsle:imp eves maters License law does not apply us an owner of OlIT1.ET5-SWITCHES-FIXTURES
L 3 property,who builds or Empnrvw thereon,and who does such work himself or through
his own employeese provided that such improvements are not intended or offered for NEW RESIDENTIAL EL TR SQ F4.
sale.ILhowevegllhave the boder of proving
is at he did noneild or improve
foa,me SQ.FT.FLOOR AREA EISQ.FT.
neof s ilder will have the burden of proving that he did not build or improve far pur-
)xtse of sale]'
E]1,as owner of the property,a exclusively contracting with licensed contractors or T(* 00
construct me project(See.7004,Business and Pmfeasions CNet The Contractors Li- ,
cense Law does not apply to un owner of property who builds or improves thereon,and QTY. PL BING PE FEE
who contracts for such projects with a contraemgs)licensed pursuant tit the Contractors
License Law. PERMIT ISSUANCE
❑ I oro exempt under See. ,B&P C for this reastm
ALTER-DRAIN&VENT- AT ) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIEFtE
1 hereby aRmt under penalty of perjury one of the following declarations:
(] I have and will maintain aCcnifcen ofCovuno In self-insum for Worker's Compete DRAINS-FLOOR.ROOP,AREA,CON
.tion,as provided for by Section 31W of the Labor Civic,for the pedmmance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance ofthe work for which this permit is issued GAS-PA.SYSTEMA INC.40U'rLET5 OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy Nu: GAS-M.SYS'FEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(Tbis«cfirm need am be completed ifthe permit is for one hundred dollar(5100) BUIL LNG DIVISION ITEMS
or ices)I GREASETRAP PLANCHECK FEE a4
I certify that in performance ofthe wo kforwhich lhispcnnit iaisrved.IxM1nll SEWER-SANITARY-STORM M.2110 FT.
nm employ any Klan yt st �^uWeywtT GRI2 R:DINPP FEE 2
Z cation taws of Cantooro WATER HEATER WNENT/[LECTR
y�y � Appllcom s
f-1 VJ NOTICE TO APPI]117_�.If.ufmr mak g rots Certificate of Exemption,you should WATER SYSTEMIIREATING
abecome subject o the Workers Compensation provisions of the Labor CNe.you must SOILS FEE L,
O forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE rtrry
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID kV
L) l hereby affirm that there is a coommetion lending agency for the performance of Dam Receipt»
LL — the work for which Nis permit is issued(Sce.3097,Civ.CJ
0 Lender's,Name TOTAL:
WLenders Address TOTAL:
y I cent fy that 1 have read this applicm ion and acne that the above information is BUILDING FIT
y correct l agree to comply with all city and county ordinances and spite laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorise representatives of this city to enter uponthe SEISMIC FEE
sbrw,con mmed pmpeny for inspection purposes. PERMIT ISSUANCE.
(We)agree to verve,indemnify and keep harmless the City of Cupanlmo against ELECT RIC AEE O O
liabilities.judgments.costs and expenses which may in any way seems,against said City ALTER OR ADD TO ME.CH. PLUMBING PEE
in onscquence of the granting of this Noun.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signalaw of Applicant/Contmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stem or handle Encounter,material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532m)'I HEATING UNIT(OVER 100.000 B In -
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID -'
Will thea lienor or fumm baildin t twee l or devices which Dote Receipt
pp gby then aAirQn BOILER-COMP(3HP OR IW,000 BTU)
emit naaardous air contaminants to Defined by the Bey Area Air Quality Management
Distract? TOTAL:
E]In, ❑Nn BOILER-COMP(OVER Ifp,000 BTU)
I have read raWm
the haous aterials reyuiretmma under Chapter 6.95 M AIR CONDITIONER the Cali- l ISSUANCE DA
lomie Hwlth&Safmy CNe,Sections 55115,255JJ and 25530.1 understaN Nal if the NEW RESIDENTIAL MECIL ^
building does not comply haven tenant,that It Is my responsibility to notify the occupant
of the requirements which must be met prior to issuance ids Certificate of Occupancy. y^_�
Owner or authorized agent Date TOTAL: ISSUED BY: F/ V � �6 7—
OFFICE