S 1321 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1 CITY OF CUPERTINO BUILDING-ELECTRICAL PF; ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1321
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. - SANITARY NO. APPLICATION SUBMITTAL HATH
O AM L PHONE: CONTRACTORS AME./N
t Zl -�y�� NIC CONTROL If
. Ak HITECT/ENOINEER: LIC NO: ADU t rIr/// ❑
CONTACT: PHONE: BUILDING PERMIT INFO
CCfi (�e /� O� /7�� O�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
nL4 �f Q ❑ OK El
LICENSED C NTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE [[ �`
I hereby affirm that I am icensed under previsions of Chapter 9(commencing JOB DESCRIPTION
Oaz wild Sectimm7001 Divisioa wane actions,and Professions Cwa,rainy heenxei. RESIDENTIAL:
O O PERMIT ISSUANCE.
In full force and effect.
IY W F ElSFDWL [I KITCHEN REMODEL
QUU ole ansa Lie.#
yQa DDale Contractor ❑ ❑
APPLIANCES-RESIDENTIAL ADDITION PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS
L'7 r/+ Ll MULTI-UNIT ❑STRUCTURAL
O Z Z l understand my plans shall be used as pantie records MODIFICATION
OZ-Q UP T02W AMPS C1 INTERIOR [_1 CHIMNEY REPAIR
a��; Lmensed Ptafessionul 201-BOO AMPS - IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(XI(IAMPS BATH REMODEIIREPAIR DEMOLITION
a W Q 1 hereby affirm that 1 am exempt from the Conlmetors License Law for the
31L U miner,moeom(Section 7031.5,Business and Professions Cade:Airy city ar wunty SIGNS ELECTRICAL ❑OTHER
which requires u permit to construct,alter,Improve,demolish,or repair any structmre
liewkt;. it
HoI
mmrm it,issuance.also requires the opplicam forsucb mth to fil—,radsmtemem SPECIAL CIRCUIT/MISC.
that be is[mariW purvuanl m the....kmnsofthe Gmtractors License Law(Chapter9
O (commencing with Section 7oo0)afDivision 3ofthe Bramosisnnd Preevsions Code).. TEMP.METER OR POLE INST, COMMERCIAL:
PE C thin he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
go Section 903 IS by any applicant tar a permit subjects the applicant to acivil penalty of POWER DEVICES
y not more than fee hundred didirom($500). ❑TENANT ❑FOOD SERVICE
' d0 ❑1,as owner ofthe pre norm employees with woes as emir sole cam IMPROVEMENT
Pe Y Y P Y g ,B.simon, SWIMMING I'(30L ELECTRIC
will do work,and the he ctureCoot is not intended icensesmothered
Laos
dls red apply 1.an
❑OTI{ER
w pro erly who b Cada:The C es thereon,
License Lows such
ern apply,,xn owner of Ol1TLb-I:S-SWITCHES-FIXTURES
progeny who hands or Impedes thereon,and who docs such work ded o r or through
his own employvthe provided that such improvements sold w are not intended or offered for NEW BESIDES UAL ELECTR SQ FE.
wle.If,haweseq the building hu anpmvemenl is he ilhinone,build dolga etinnlhe SQ.FT FLOOR AREA 3/SQ.Ff.
ner-builder will have the burden of proving that he did nm build or improve rnr Fur-
polo ofsalcJ.
❑ 1,as owner of the progeny,am exclusively contracting with licensed contractors to T
construct the pmjent(See.7LU,Basiaesx nad Professions Cade.)The Cantmemds Lo-
retain Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PF-RMI F E A
ID
who contracts for such projects with n con owl.,L)licensed pursuant m the Co imuc,a, /���p
E]enselam Law. PERMIT ISSUANCE WAR 3 ANS-0❑ Iam�Law.exempt under5 c. ,B&PCfor this reason �ryY�/�ijjR /�
�- _ ,•. ALTER-DRAIN&VENT-WATER(EA) /1 VALUATION
Owner : ORKER'S DMPENSATIONOECLARATION�I�F� BACK FLOW PROTECr.DEVICE CITY UF VUrC111iIVV
Iherebya rmunder pet ally of peOurY one of the following tleclurminns:
❑ I interim will maintain accorfineof Cnrvsenten self-incomfor Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code,for the gerfannanca of the
work if,which this pem+il is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance aide weak for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN
My Warkcrs Compensation Insurance cooter and Policy number ma:
Cartier: Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GRFASF/INDUSTRL WASTE INTERCEPTOR BUILDING DI VISION FF.F.S _
(Thissectioa nmednal he complemd i f the permit is for one hundred dollars($100) GRCASETRAP
PLANCHF.CK FEE
Ioyary cancer in perfoanyanance nerofts to
for subjectch to the Wreat rkersoed.Iehaller. SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner w its m become subject to the Workers'Compen- ENERGY FEE
x Applicant
Laws o[Celifarnia.Data
�O A licam t WATER HEATER WNENT/ELECTR
PP GRADING FEE
NOTICE TO APPLICANT.If,atter making this provisions
sof of Exemption,you should WATER$YSTGM?BEATING
abecome ser...r,to the Worker's Compensation provisions of the Labor Code,you mull SOILS FEE
W fnnhwilh comply with such provisions fir this pantie,shall be deemed invoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
Q work
thi that there lsamn(Sectian lending agency for the performance of Date Receiptp
Fthe work for which this pcnnd is issued(Sea.3097,Civ.C.)
O Lenders Nanta TOTAL'.
LUkI I<ndes' gddrcFx TOTALI certify that 1 have read(hip applicminn and state that the above information is BUILDING PEE
vat cmtrcct l agree to comply with of city and county ordinance,,and state laws relmfngm QTY. MECHANICAL PERMIT FEE
V Zig alm,ingeonstieddogorl hereby auction pmrp representatives of this city to enter upon the SEISMIC FEE
aMrve-mentioned propene for inspection purposes. PERMIT ISSUANCE
IWe)agree to cave,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
iabillties,judgments,costsand expenses which may many way aeartmaimma said City ALTER OR ADD TO MECH. PLUMBING FEE
consequence of the granting of this permit.
APPLICAN ;RSTANDS AND WILL COMPLY WITH ALL NON'-POINT AIR HANDLING UNIT(TO 61,01X1 CFM)
SOUR EGUI rIONS. .-- sf MECHANICAL FEE
C J
Z AIR HANDLING UNIT(OVER 10.000 CFMJ CONSTRUCTION TAX
Signatu A IicanUContrector Date
EXHAUST HOLD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSU E
I the applicant or Pomm building occupant stare or handle hazardous material lHCNING UNIT(TO IOROW BTU)
as defined by the Cupertino Municipal Code,Coupon,9.12,and the Health and Safety
Code,Section 25532(m) HEATING UNIT(OVER 100,001 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID -
Will oapplicant or future building use equipment or devices which Dare Receipt to
emit hnvM
zons us air contaminants as defined by by the the Bay Area Air Quality Manvgcment BOIhER-COMP(3HP OR 100,000 BTU)
DixaicTl TOTA6 41
E]yea 7N BOILER-COME(OVER IIXI,fI(NI RTU)
I have most the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDITIONER An
ISSUANCE DATE
from,.Health&Safe,)Cade,Sections 25505,25533 and 25534.1 understand,hoot if the NEW RESIDENTIAL MECH. SQ.FC
building does not umntly have tenant,Ihm it is my responsibility to notify the accupnnl
.rhe requirements which mml be mel prior m issaanre of a CenificamofOccu may.
Owner or authorized agent Data TOTAL ISSUED BY.
OFFICE