S 1184 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 1184
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /J ��' 1 e' � � �� SANITARY NO. APPPLLICATIOON(SUBMITTAL DATE
F/C�. ,IJP,� J ( I L9-�I
OWNER'S NAME: - ys Pr��: 0 31/ CONTRACTORSNAME: LIC NO
N/C CONTROL is
4RCHITE NCINER: LIC NO: ADDRESS: - ❑ �� A--�
GK U
CONTACT, / t PHONE: BUILDING PERMIT INFO
I� #U 5-2141f —d 9 2( ❑ consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
I IV `a 7 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby offiren that I am licensed under provisions of chapter 9 b:ontmeaclns _ JOB DESCRIPTION-
DaZ with Section 7000)of Division 3 of the Business and Professions code,and my license is
OO PERMIT ISSUANCE. ElRESIDENTIAL,
CUF Licene Cls and effect. ❑SPDWL [I KITCHEN REMODEL
aUpp License Class L .N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PI.UMBING RE-PIPE
y a Dme contractorDELL
ARCHITECT'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
Z pvJ,4 1 understand my plans shall be used as public records PANELS MODIFICATION
0z _ UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
�4F`W Licensed Professional 20I-1000AMPS IMPROVEMENT WIMMING POOLS
.l OWNER-BUILDER DECLARATION OVER IBM AMPS ❑BATH REMODEUREPAIR MUTATION
Q I hereby affirm that I am exempt from the Cumo cu is License Law fur the
3 Id following reason.(Section 7031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL .[-]OTHER
_
F O which requires a permit to eonswcp alter,improve,demolish,or repair any smtmure
prionoia issuance,also requires the applicam fur suchpermomfileasignedmawnrem SPECIAL CIRCUIT/MISC.
p. [bathe,,licensed pursuant to the provisions of the Contmetors License Law(Chapterr,GAO (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
d c C [hal he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y( WWSemmn 7031. yy
5 banappppp
licam fora Permit subjects the applicant m a civil penalty of POWER DEVICES
u1 ro V, ❑TENANT 11 FOOD SERVICE
not more than five hundred dollars($500) OTHER IMPROVEMENT
do the
work.the pmpeustar isemplees sale(Sec.
compen.iness SWIMMING POOL LLEC'TRIC
AZ.O will do the wons and the he Con a not intended Livens or offered fin of apply of an Business �DTHER
W and property
who
Code:The Connector's License Law does not apply s if owner of OU'TLF.'1'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself f Nmugh
his own employees,provided that such mentis sold within
are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
'le lLhowever,the hbuil helamen afementissolhedidin ,buildnfrnmple Inn.
[he - - SQ.FT.FLOOR AREA SISQ.FT.
own µder will have IM1e burden of proving Into M1n did not build or improve fm pur-
p a).
r of Na properly,am exclusively contracting with lieenseC mminute, to SAL'
tine La the es jecl(Sec.o an Bulinus antl property
wh i bad Gdep The es theme,
Li- p
who
wdtsfors apply man with
aoffroperly whosedporimpmvee thereon,and QTY PLUMBING PERMIT FEE PAID
D
who contracts for such projects with a Conttaeeor(s)licensed pursuant to the Commemrs t p�
License Law. PERMIT ISSUANCE /y�
I am exzt under Sec ,B PCfrW rc 4
Owner Dme ALTER-DRAIN&VENT-WA'[ER(EA) yt ION
O 6R'S COMPENSATION DECLARATION BACKFLOW PROTECT.DEVICE III U/'
Ihereb (firm under Penalty of perjury one of the following declarotlons: - LVrC/
•� I haveand will moinmina Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation.as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section `-
37M of the Lehr Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I.INC.4 OUTLETS DEC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy Ism, GAS'-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
' (TTis section need not be complemd ifthe pertnit is Forane hundred dollars($1110), GRP.A56 TRAP
or less.) PLANCHECK FEE
I cerci fy that in the perfermeare of the work for whichthis parcel[;,issued,Is hall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subject In the Worked Compeer' ENERGY FEE
,z whom Laws of California.Date WATER HEATER WNENT/ELECTR
Q Applicant t GRADING FRE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
a ',�^ become subject to the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
W K, forthwith comply with such provisions or his pemtit shall be deemed revoked. WATER SERVICE
F A
� z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT PAID ReceiptM
Ihorwhich un th emit isisued(S .30d.lending agency I,,,the performanceof
W the work for which Nla permit is issued(Sea.3119],Co.CJ
I--t Leader's Name TOTAL
U 4 Lcnder' Address TOTAL:
I certify That 1 have mad this application and smut that the above information is BUILD( EE 2
V7) correct.l agree to comply with all city and county ordinances and state laws relating In QTY, MECHANICAL PERMIT FEE
V.G building convection,and hereby authorize representatives of this city m enter upon the SEISM FEE
uMwe-mentioned property for inspection purposes.
(Wed agree to save,indemnify and keep harmless the City of Cupertinsi against PERMIT ISSUANCE ELECTRFEE
liabilities,judgmetns,costs and expenses which Way in anyway accrue against said City ALTER OR AUD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WHd OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
OURCER rULATIONS. MECHANICAL FEE
S
w' AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Sig tore pplicandCommcmr - -r t EXHAUST HOOD(WMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant core or handle hazardous material HEATING UNIT TO 100,000 BTU)
e nod by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING,UNIT(OVER 101"BTU)
E-]Ye. ❑No VENTILATION FAN(SINGLE RESID) PAID "-
Date Receiman
COMP COOR IW,IMYJ BTU)
Will the sufficient or future building occupant use equipment or devices whits
;mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-
District?
❑Yes ❑No BOILER-COMP(OVER 100.000 BTU)
- - t
I have revel the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Trade Health&Safety Cale,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT
building does not currently have u extant,that it in my responsibility to notify the acupam
of the requirements which must he met poor to issuance of a Certificate of Occupancy. �I
Ownercrautlammedagem Date TOTAL: ISSUEDBY"t��' ^ v
OFFICE