S 1616 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �p
CI TY OF CUPERTINO BUD DING-ELECTRICAL PEJ° 1616
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ^^ll ,f � SANITARY NO. APPLICATION SUBMITTAL DATE
O BR'S NAMED ` V P{+(lN' �4/ N �,�TRACTOR'ti NA & LIC NO: - 51y
34l T� 4A V AO oNr 3 ty
NIC CONTROL It
ARCHITECfIENGINCER'. LIC NO: ApDRESS OSP P C+ ❑
CONTACT: PHONE e-l)CC BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) �BLU�G EJECT PLUMB MUCH
Po K) /l/� i -1 �' ❑ ❑ ❑
LICENSED CONTRAC OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed oder provisions of Chapter 9(commencing _ JOB DESCRIPTION
WCZO with Section 701spof Division 3mfine 0seinessand Profession,Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
F W F in fall force and effW 2� 6 Z 3 3 t!! ❑SFDWI. ❑KITCHEN REMODEL
�UE Licens lass IJeM '� APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
FZ W Dare - �- OG Convnc.rt L POAt Mu<�lor.. t
FDti �� ARCHITECTS DECLARATION �— PANELS
❑MULTI-UNIT El STRUCTURAL
Z p m Z 1 understand my plans shall be used as public records MO CATION
UPTO 200 AMPS LJ INTERIOR IMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
...]]] OWNER-BUILDER DECLARATION OVER IOfI(IAMPS [_1BATH REMODEUREPAIR Ll DEMOLITION
{ I hereby affirm that 1 am exempt from the Cartoon.,',License Law for rhe
{iillS5 O y U following roes...(Section 7131.5,Business and Profesaion.v Code,Any city or county SIGNS ELECTRICAL ❑OTHER
u+ WO y which regwms it panel,a codumcq alar,improve,demolish,or repair any structure
qtyafprim , t I q thef suchpe a fl signed Lament SPECIAL C[RCUFUMISC.
pi ,hath licensed o r, her0 fth C t' 1r' I L' (Chapter 9
C� (commencing with r 70f10) fD i fm N : dProfessions Code)or TBMP.MI dER OR POLE INST. _ COMMERCIAL:
d Qo C that he s exempt therefrom xe
m and the basic for the alleged empton.Any rotation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^of Section 9031.5 by any applicant for a permit subjects the upplimntm a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
F`Z is IMPROVEMENT
M D 1,as owner ofthe progeny,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
O will dome work,and the summon,is not intended or offered batch,(Sea 9044,Business COLDER
Iii]rte" and Professions Code;The Connector,License Lew does not apply t.as owner of OUTLETS-SWITCHES-PIX'I'URES
C• property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered Far NEW RESIDENTIAL.ELECTR SQjFT
sale.If.however the building or improvement is sold within mmyemofcompleuion,the SQ.FT FLOOR AREA $ISQ.Fr
mer-builder will have the burden of proving that be did not build or improve for pur-
pose occult.)
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to OTAL:
onstmer he p Jee(Sec 7044.Business and PmEad.ns Cade)The Gmbunmr's Li-
room Law does notapplyro an owner of property who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE
who contracts for such projects with u commands)licensed pursnam to the Contractors
License Law, PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C fon us reason
ALTER-DRAIN&VENT-WATER EA) VALUATION
Owner Data
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ Ihave and will maintuinaCertificare of Cnnsenun sdl'-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND, STOR1 S 11 TYPE CONSTRUCTION
union,as provided for by Sierra,3703 of the Imhnr Code,far the graonoame of the
work far which thin permh is issued. FIXTURES-PER['RAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
370(lolmd Labor Code,Ends,perPormemeofthe work for whichlas cannot is issued. GAS-EA.SYSTEM-I INC.40U'1'LETS OCC.GROUP APN
MY Worku p�ryp a�nlpsu �tganieP ld.YNay nT1rr:1)4;f GAS-EA.SYSTEM-OVER4(EA)
Carrier: 1' 4 Ipt C .3 O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IN'I'PECHTER
BUILDING DIVISIq FEES
(Thisseari.n aced not Ind completed ifthe permit is forms,hundred dollars(SIM) GREASETRAP
or less,) PLANCHECK HE
I certify the,in the pmf.rman,c.Rhewmrk for which this pefnnir is issued,[shall SEWER-SAN]'T'ARY-STORM EA.20017.
not employ any person in any manner sat us,m become subjeat to the Wodrers Compen- ENERGY FEE
O z sation Laws of California.Date WATER HEATER WNENTIELECfR GRADING FEE
Z Applicant
ti pj NOTICE TO APPLICAN'C If,after making this Ce ti roc of Bxempard,you should WATER SYSTEM?REATING SOILS PEE
f"1 become subject a,he Workerde,s Compensation provisions of the Labor Coyou must
Wr..0 forthwith comply with such provisions or this permit shall bedeemed rcooked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB, SQ,CE PAID
U p I hereby afford hat there is a construction lending agency far the performance of m Rotuma It
N
the work far which his permit is issued(Sem.3097,Clv.C.)
0 F' Lender's Name TOTAL:
U
Lenders Address TOTAL: BU
FEG
I em-a y,hnt 1 have and this applicatio „
n and statba,theabove information is
C, ret earrem.I agree m comply with all city and county ardlnanma and a,.a Incas relating to QTY. MECHANICAL PERMIT FEE hh���q
UZ building construction,and herehy authorize repnesenatives of city a erre,up.nme EpsnF'
alsed mentioned pmpeny for inspection purposes. PERMIT ISSUANCE -
(Wel agreca save,indemnify and keep hamJess meCry of Cupertino against ELECTRIC F r
IiabiWies.j.dgmentx,users and expenses whicbmay in any way sccmurgabnt,aid City ALTER OR ADD TO MSCI{, MAY
consequence of the granting of this permit. f$1M �I®0
in PPLICANTUNDEKS'IANDSA WILL UNITY WITH ALL NON-POINT AIR HANDLING UNIT TO IO,Ofq CFM) MECHANICAL FEESCI '�ULAIIONS. VII I
�4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSYSUCTION TAX
Signature of ApplicatContmmmr Dao EXHAUST FOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupentsoremr handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
O Yes 7N VENTILATION FAN(SINGLE RESID) PAID
Will then applicant or future building an,useequipment ordevices which Una Recoils M
pp gbyamBOILER-COMP(3HP OR 100,030 IF[Of
emit hazardous air,omeminanls as Aclined by rhe Bay Area Air Quality Management TOTAi,
District? BOILER-COMP(OVER Istood BTU)
❑Yes ❑No
1
I have read the hazardous materialsrequiremAIR CONDITIONERemx under Chapter fi 95 of Om Cali- ISSUANCE DATE
forms Henle&Safety Code,Sections 25505,25533 and 25534.[understand rho if the NEW RESIDENTIAL MECH, SQ.FT, l
building does nor currently have a tenant.that it is my responsibility to notify the occupant t
i
of the requirements which must be met prior to issuance of a CerliOCaa cf0 mupancy. D Ft /+
Owner.raumorized agent Data TOTAL ISSUED B '' D
OFFICE