S 2477'APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
BUILDING - ELECTRICAL.
PLUMBING - MECHANICAL.
PERMIT NO.
q
6UIIDINC PROJF.LT IDENTIF'ICATroN
BUILDING ADDRESS:
��o l HON
S 77
J L (�
2
SANI'1'ANY NO. AV LICATION SUBMITTAL DATE
2 -_Z-9
OWNIiR'S ME: PHONE
CON" ACTT R'S NAME: LIC NO
LJ13) P
NIC CONTROL II
BUILDING PERMIT INFO�A?)795-rr9
ARCHIIELT/1' iR: I,IC NO
CONTACT: p PHONE:
D RESS:
�S F v c°
042
Consultant Fees Paid by Appcanl (initial)
BLDG ELLEEC[T PLUMB MECH
ED `K ° °
LICENSED CON'I'RAC'OORS DECLARATION
I hereby of vat the I am licenced under provislom of Chapler 9 (commencing
ZO withSmion]gq)nfDivisionJn(Ihe Business mJl40fessians GMP., and myliren+cis
Uin full lm re and ellen
Licen�+e Cyt 9�LieM_ �-�
W Dae * Commcmr
y
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL [I KITCHEN RE -PIPE.
❑ADDITION ❑PLUMBING RE -PIPE
❑MUhTI-UNIT ❑STRUCTURAL.
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
0 BATH REMO EURF-PAIR 0 DEh1OLITIQN���
CR
PERMIT ISSUANCE
O
APPLIANCP_S-RESIDENTIAL
ARCHITECTS DECLARATION
X. I undervtand my plans shall he used as public records
tai] LiceneeJ Pmfesvionai
-a{ OWNBR-BUILDER DECLARATION
1 hereby dBlm that I um exempt (..,he Ci mmear's License La "am
V which
Code: Any city necounty
following reason. (Section ](DIS, Business and improve de o demolish,
jqa which requires n permit m c 31.5, B sine, iand Pre demolish, a repair any swdnm
J prior to its issuance, -is- requires sheepplicaul hameh perming file- aligned amadual
thatheisliing withrof Law(Chopmr9
it pursnatl on 7M)) pnwlsivio oftheearavmr'end Profession,
sCodc)of
X (cat he
fine Businessandonn Any
xempt therefrom and th basis far
X the he is exempt tM1ercfrom and the basis for the alleged exemption. Any violation of
n Section 71131.5 by any applicant for a permit subjects the applicant b: a civil penalty of
H not more than live hundred dollar, S50B.
❑Las owner of the pmpeny, or my employees with wages ss their sole c0mpenwnion,
will of the work, and the,vuemre is not intended or 'offered fillsaid(Sec ](q Basin cvs
fession
and Pros Code: The Common., License Law does not apply to an nwner of
Property who builds or improves thereon, and who does such work himself m through
his into employee', provided that such improvements am not intended or offered far
sale. Ill however. the building or improvement is sold within one year ofeempletion. the
en -builder will have the burden of proving that he did not build or improve for pur-
Imse of sale.).
ANIiLS .'
P TO 200AMP5
20I-I000AMI'S
OVER I" AMPS
SIGNS ELECTRICAL
SPECIALCIRCUGYMISC.
O QenijZu)Q�
TEMP. METER OR POLE INS1
COMMPRCIAL:
[I NEW BLDG/ADDITION ❑DEMOLITION
[I TENANT C1 FOOD SERVICE
IMPROVEMENT
11 OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTUR&S
NEW RESIDENTIAL. ELECTR SQ IT.
SQ. FT. FLOOR AREA
LSQ. CO.
TOM
xFEE
0 I, as owner of the property, tun exclusively contracting with licensed contractors In
construct the Project (Sec. 7049, Business and Professions Code:? The C.mrucnofs Li -
c se Law does not apply to an owner of,ma my who builds or improves thereon, and
who conlear s for arch Projects with a contractors) licensed pursuant it, the Commeme,,
License law.
'
QTY, PLUMBING PERMIT
PERMITISSUANCE
❑ ImnowroplaultrSeo. ,B&PCfor this reason
Owner Date
ALTER-DRAIN&VENT-WATER )
VALUATION
' WORKER'S COMPENSATION DECLARATION
1 herehy offrm under penalty of perjury one of the following declared,,.,:
KA havicend will maintain a Cenifcateo(Consem msdf-here, for Workers Compere
scion, us pencilled for by Section 37W of the LabCale, far Ne performance of the
work I'or which this permit is issued.
❑ I have and will all for Worker's Compensationceofthw Insurance, h required By Section
3]00 ufthe LxMsrCMe,f:nhe performance of the work for which this permit is issued
My t it Ri)n�m mil Ins rricr sod VuNe n e7�i+�')
CarierQ 1 erU ce cn Policy No.: 79f!V If VO
CERTIFICATE OF EXEMITION FROM WORKERS'
BACK FLOW PROTECT. DEVICE,
DRAINS- FLOOR. ROOF AREA, COND.
STORIES
OCC. GROUP
TYPE. CONSTRUCTION
APN
FIXTURES - PER TRAP
GAS-IA.SYS -I TS
GAS - EA. SY. OVER
GREASPIIND 1 . WA.ST17 INTERCHM
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is Towne hundred dollars P; l00)
or less.)
GREASE TR
EB
III/1LDING DI VISION PIi1S
I'LANCHECK FEIi
I artily the in the perfomence of the work lir which thint is issued.l shall
permi
not employ ofCalhonin any manner so as to become subject mein Workers' Carrier.
scion laws of California. Use
SEW12R-S TARY -. STORM EA. 200
ENERGY ITS
WAT ER HF T /VENT/F.LECTR
Applicant
GRADING FEE
NOTICE TO APPLICANT: LL after making Nis Cenifcee of Exemption, you should
Because subject no the Worker's Compensation
pens provisions of the L.Mu CWP., you must
fimhwith comply with ash provisions or this pmmit shill be dcemel revoked.
WATER SYSTEM/TRP
SOILS FEE
WATER SERVICE '
CONSTRUCTION LENDING AGENCY
ffr
1 hereby un that them is a cm,,tiction lending agency for the performance of
the work for which this permit is issued (Sec. 309], Civ, CO
Lender's
PAID
Receipt k
NEW RESIDENTIAL PLM. SQ. FT.
Name
Lender', Add....
I certify thin 1 have reav tbis epplicaian and nae and the above information is
comet. l agree to comply withal) city and county ordinances and state laws miming to
building convnroctian,onl hereby nnthodee representatives efda, cityn, emenepm the
above-mentioned progeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
imuditivo, V dgntems, ren,, and expenses which may in any way accrue u,nom said City
I. consequence ofine gramin of this peon iL
APPI.ICA T'HNDERS FA DS AND WILL COMPLY WITH ALL NON -POINT
SOU f UdC.0 'ION
GIRL:
TOTAL:
BUILDING FEE '
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
as
PERMIT ISSUANCE
ELECTRIC FEE O
fyo
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT(TO 1(p(DOCFM)
MECHANICAL FEF.
AIR HANDLING UNIT (OVER 10,0011 CPM)
CONSTRUCTION TAX
Sreameaf Appllca Contract, Flute
HAZARD US :RIALS SCLOSURE
Willlheinniicamorf a uildingra smrenrhandlehazaedousmaterial
as defined byte Cupertinore pal Code, Chiller 9.12, and the Hcahh and Safety
Code,S 25532(0)1
es
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE -
HEATINGUMPOrOI(10,000BTU)
HEATING UNIT'(OVER I OBON) BTU)
VEU LATION PAN (SINGLE RESID)
Will the upplicunt noblare building occupant use equipment ar devices which
emit hazardous air "instructions se defined by the Bay Area Air Quality Management
District?
❑Yes a
PAID _
Date Receipt 1
l
O
BOILHR-COMP (3HP OR 100,011 BTU)
BOILER- COMP(OVBR I ad(M11 RTI])
AIR CONDITIONER
I have read the hazard,, nmenaln requircmcnts under Chapter 6.95 of the Cali-
II Sec'ons 2551;e )01.1 and 25531. 1 understand than if the
yd'thatitis my respomdbilily m notify ftevempann
forma QRiciys��-'
ae prinrne issuance oft, Coad.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FE'aI
em Danc
�^
BY:
TOTAL: I ISSUED
OFFICE