S 0219 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E.LEC`FRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL S0219
BUILDING PROJECT IDENTIFICATION
BUILDIN )/G$$;—Z/zo, I I-1ze, Aug dowir SANITARY NO.
(iAI ON APPLICATIONSUBMITTAL
D
ATE
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CONT 410MVr
SIC C NI'ROL#
ARCHITECI'IENGINEF.lu
LIC NO: ADYRES � ❑
CONTACT: o E'' BUILDING PERMIT INFO
� ��j� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELDCyfPW MECH
gu11aZ wn
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE EJI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DES IPTION
{yb WXCHITECFSDECLARA0F1O
B.slness and IS caai d ato license is RESIDENTIAL'
FSB infaS PERMIT ISSUANCE / RESIDENTIAL,
LiceI,ic.Y ❑SFDWI. ❑KITCHEN REMODEL
�W Date Comtvctor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR -PIPE
F.Dw PANELS ❑MULTI-UNIT El STRUCTURAL
Z O�Z I understand my plans shall be used m public.'ads
MODIFICATION
OZ - UPTO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
IA Licensed Profesnonal AMPS
�y OWNER-exempt RDE DECLARATION 201.1000AMPS IMPROVEMENT L]SWIMMING POOLS
oM El BATH REMODEIIREP IR I]DEMOLR
1 hereby affirm that 1 um exempt from the Contractor's License how for the OVER I
W 3 ti U following reason.(Seclam?031.&Business and Professions Cuo Any city or county SIGNS ELECTRICAL ❑OTHER
4l LLO which requires a permit to construct alter improve,demolish,or repair any,true,
u
N
prior to issuance.also requires the applicant for such permi
n nOleasigneAmm
[statement SPECIAL CIRCUIT/MISC.
Y
not he is license)pursuant to the provisi.nsofthe Contractors License Law(Chapter9 /
a1 00 (commencing with Section]n(I(1)of Division 3 ofthe Business and Professions Code)or TESIRMETERORI'OLEINST. COMMERCIAL•
14p,M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ElDEMOLI9'(ON
W4y Section 7031.5 by any applicant for a permit subjects the applicant m acivil Penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
F. not mothan rive hundred dollars(1511(1).
Z� D re I,as owner ofthe pmpeny,or my employees with wages as their sole compensation, SWIMMING POO1.ELECTRIC IMPROVEMENT
and
will do Ne work, the stryre cmis not Intended.roffeted tarsale Sex.71W.Business ❑OTHER
W end Professions Code:The Contrectofs License law diva not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'3 property who huilds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ R.
side.IL however.the building.,improvement is sold within ane yearofcon,hommhe SQ.FI'.FLOOR AREA USQ,FE
co-builder will have the burden of proving that he did not build or improve for put,
pose of sere.).
❑I,as owner of the pmpeny.am exclusively contracting with licensed cnnmacmm to TOTAL:
construct the project(Sea.]044,Business and Prnfesumv,Code:)The Coameor's L!0 S�E:
cenve Law does not apply to an owner of property who builds or improves lhere.n,and QTY, PLUMBING PERMIT FEE �/
who contracts far such pmjece,witah contractm(s)licensed pursuant m the Convacmrs
License Law. PERMIT ISSUANCE
❑Ivo exempt under Sec. ,B&PCfnr this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Data � / ATION
WORKER'S COMPENSATION DECLARATION
1 herchy union under Penalty of perjury,one ofthe following declarations: BACK FLOW PROTECT.DEVICE
l./
I have anJ will maintain aCenificam nfCnnunuo self-insure far Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND.
sation,as provided for by Section 37(N)of the Labor Cale,for the performance.f the STORIES TYPE CONSTRUCTION
solid!
for which this permit is issued. FIXTURP_S-PER TRAP
d have and will maintain Workers Compensmion Insurance,as required by Section
37M of Ne Labor Code,for the perf.rmance ofthe work for whichthis permil is issued, GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My W. C. as arier onJ Policy /��
CvdcrPolicy No `�7 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASEONDUSTRL WASTE INTERCEPTOR
(This section need not be cam lewd if the BUILDING DIVISION FEES
p permit is for.oe humdre4 dnllurs($IINry GREASETRAP or less.)
(certify that.the Performance ofthe becforwhichthis .it is issued.lshall ENERGY
FEE
not Law any person in any manner so us to Rasme subject t.the W.rkcrn''Com •n- SEWER-SANITARY-STORM EA.200 FT.
Z as Laws.f California.Dam ENERGY FF.Ii
z O A licant WATER HIEATER W/VENT/ELECTR
PP GRADING PEE.
o-ay
NOTICE TOAPo the Workers If,Cmrmoking tiaa provisionscate
of Exemption, should Wq'I'F.RSVSTEM/1'HEATINC
ma y' become suomply the Worker's Comp,or thin Permit
hal d the deemed
Code,you mu.a SOILS FEE
IJJ forthwith comply with such pmvisinns or this permit shall betleemed revoked. WATER SERVICE
G La
'Z CONSTRUCTION[,ENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O I hereby aRrm that hert isacwmtrvc.30 lending agency for the Performance of Dae ReceiryM
(L
thenworkder's or which this permit is issued(Sec.309'/,Civ.CJ
O V Lenders Neme TOTAL: '
W Lenders Address TOTAL:
(� I certify that I have rood this application and stain that the have infwmati.n is BUILDING FIFE
f/J cora[.l agree to comply with all city and county ordinances and state laws relating o QTY. MECHANICAL PERMIT FEE
L)Z building construction,andherebyaudmnre representatives ofthis city to enter upon the SEISMIC HE
o hovcmemiamed pmpeny for inspection purpnecs.
` (We)agree to once,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCEELECTRIC FEE r
liabilities,judgments,conso exWnses which may in anywayaccoeaguinstsuoi City ALTER OR ADD TO MECH.
in consequence ofthe gmnting.f this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIH HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ol'Applicam/Cormactor Dote EXHAUST HOOD(WMUCF') HDUSING'MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hanJlc hazardous mmenal HEATING UNIT(TO 100.000 BTU) /
as defined by the Cupertino Municipppyyy GNe.Chap¢,9.12,and the Health and Safety
Gde.Socnon 2S532(u)'t HEATING UNIT(OVER 100,1100 BTU)
❑Yes
VENTILATION FAN(SINGLE RESID) PAID A11144n. ,y ,is
Will the applicant or more building ureapam use equipment or devices which Tillim Receipt p
emit harsrdous air contaminants m,defined by the Bay Area Air Quality Monagemcnl B01LER-COMP(3HPOR Im),OIN111TU)
Diana? / BOILER-COMP(OVER 110,W0BTU) TOTAL:
❑Vex t N4
T have read the hvzvd.us materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma He &Safety Code,Sections 25505,25533 and 25534.1 understand nkat if the NIEW RESIDENTIAL MECH. SQ.FT. n
building snot conen0y have alrnanL the it is my reslamsibilitymnndfy the occupant /��✓'�
of ire mason hmusthemetpnonoixmanre.fe C ni ate f cup ry.
Do, r e TOTA Vz/ UED B
OFFICE