S 1925 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE�ITNO. 1925
BUILDING DIVISION APPLICATION/PERMIT DING PRODBING CTIDENTIFIC
B1111.U1N(;PROJECT IDENTIFICATION
BUILDINGADORESS: SANI'I"ARY NO. APPLICATION SUBMITTAL DATE
OO-Z I C r-MD A c7 duf6R-T1 v CA 0'5014 g -2 d fi�l
OWNERS NAME: PHON•' CONTRACTOR'S NAME: LIC NO: NIC CONTROL
ttF_LLSt'1 S , N6UNM
ARCIII"fliCfIENGINIilili: LIC NO: ADDRESS: ❑ C� Q(
WJ JV O
CONT[AICE ro r�PHONE: 11/F BUILDING PERMIT INFO
SN-9LLF_y ro jo --, �T'�_ol q/2 ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLCT PLUMB MECII
£ 1 LT - ❑
LICENSED CONTRAC'TOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencinga� JOB DESCRIPTION
G Zwith Section 70010)nfDivision3ofhe Business and Professions Code,and my license is ( e�71 RESIDENTIAL:
W O '� CL
Fy-ty in full force and eRea PERMIT ISSUANCE.
❑SPUWL El KITCHEN REMODEL
¢uu UIaame Claw Lic.N AI'PLIANCIiS-RESIDEN'I'IAl. []ADDITION ❑PLUMBING RG-PIPE
QW Dare G,nfrnaor
Don ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z n Z I understand my plans shall bo used m'public re«trd, MODIFICATION
OZ-q UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional I 201-IMAMPS IMPROVEMENT L]SWIMMING POOLS
•�] OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
yI hereby offum that 1 min
exempt from the Contractor's License Low for the
(ax�S O d U following«amu.(Sediim 1031.5.Besides.,and Professions Cudc:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL N< which requires a permit to consttud,aper,improve,demolish,or repair any structure
~u-OJ
prior o its issuance.also requires the applicant for such Permit to a signed statement SPECIAL CHCUITMISC.
ythat he is licensed pamonand to the provisions ofrhe Cnmramnr's Licerue Ltw(Chapter9
Q� (comnmtming with Sedian]INMI)nf Uivisinn3nfthe Bnemnnand Pmfeselnn,Cwlc)or TEMP.ME'IiR OR POLE INS'1', COMMERCIAL:
L pp,,qo O that he Is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
Wy Sectian]B3L5 by any applicant for a permit suhjmts the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F.Z
not mart than five hundred dollars(SSW).Y IMPROVEMENT
C, ❑Lav oe wc,k,the properly,rmyemntendes with wages mthei(Sec. 014.Bmnon, SWIMMING POOL ELECTRIC
=o will do the work,and the structure is not intended or offered for sale(Sec.](154.Business ❑OTHER
W eo and projessionv Code:no Contractors License Low does not apply to an owner of OUTLETS-SWI'I'CHF.S-FIXTURES D
pro{erty who builds of improves thereon,and who does such work himself nr through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ IT.
sale�If,however the building or improvement is sold within one yemofcompletion.the SQ.FT.FLOOR AREA $/SQ.IT.
ownerbuilder will have the burden of proving that he did not build or improve for pur-
posL ie,o
Lie,owner of the pntpeny,ton exclusively convnctlng with licensed nmmantrts to AI
c siert the project(Sar.9144,Business and Pmfessimn,Cnde:)The Contractor's Li-
In'( ducs not apply to an ownernf,maNny who builds orimproves themon,and QTY. P B :RMIT FEE
who contracts for such projects with a commands)licensed pmsuanuo the Contractors
License Law. PERMIT ISSUAWE
tutu er Sec. ,B&PCRm thiv rear.
er Uae �%
ALTER-DRAIN&VL "F.R EA) VALUATION
UR KER'$ MPENSA'FION DECLARATION r BACK FLOW PROTECT.Dli O O
I hereby a n under penalty of perjury one of the following deribe icum:
❑ I have and will maintain a Certificate of Cement to self-in.vure for Worker's Cnmpen- DRAINS-FLOOR,ROOF.AREA,GOND, STORRIS "fYPECONSTRUCI'ION
ealion,as pmvided for by Section 3700of the Labor Cale,for the perrumance of the
work for which this permit Is issued FIXTURES-PER TRAP
E] 1 have and will maintain Workcr'x Compensation Insurance,as required by Section
39WCraft.of the lather Ce,for the perfommncc of the work for whichthis perp is issued. GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA.S YSTEM OVER 4 IEA)
CERTIFICATE,OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASMNDUSTRL WAS'1'li INTF.RCEPI'OR
(This section need not be completed ifthe permit is fin one hundred dollars 1$1 W) NUILDING DIVISION 1'13115_
I less) GREASE TRAP PLANCHECK FEE 'LD
1lenify the in the perfo.lifthe work mrwhieh this Permit is i,wast l shall SEWER-SANITARY-STORM P.A.2W FI'.
not employ any person in any manner sn as to become suhjeci w the Worker,'Cnmpen- ENERGY FEE
Z saber Lawsof Califtmiu.Dae WATER HEAT ER WNENUELECfR
�Oj O Applicant t GRADING FEE
q h NOTICE 10 APPLICANT:If,after making this Cenificae of Exemption,you should WATER SYS,EMITS FT NO
a ? became subject to the Workers Compensation provivions of the Labor Care.you must SOILS PEE
forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE
0
CONSTRU.const LENDING AG gerey NEW RESIDENTIAL PCMB. SQ.FT. PAID
U O Ihercby alTrm that 0crc isacnnmrudinn lending ngcnoy for the performance of Defa ewnfli
-
E-s the work for which this permit is issucd(Sec.3W],Civ.CJ
0 t, Lenders Name 3A
O Lenders Address TOTAL:
1 rectify that 1 have rend this appltedium and ,all than the above inform I no is B •E
ra/1 correct.I agree to comply with all city and county ordinances and date mw,relining to QTY. MECHANICAL.PERMIT F
V Z buildingcnnvtrucfimrnnd hereby authmi,ropresentrac,sol this chytoener uprnnhe SEISMIC FEE
aMwe-mentioned property for inspection purposes. ?
(We)agree 1.save,indemnify and keep harmless the City of CLperiino against PERMIT ISSUANCE
'16. ll
liabilities,judgments,costs and expenses which may in any way accuse against said City
in consequence of the granting of this permit. gLTER OR ADD TO MEGR. p0 PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N(IN-POINT AIR HANDLING UNIT LTO II,00K)CFM) B MECIIANICALFF.E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.001)CFM7 CO
Sucia.eof Appliemp/Cmanuor - Dec EXHAUST HOOD(W/DUCD k ,MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant nr future buildingoceupmmdere or handlehaaanlnm,evarrial HEATING UNI'P GO 103,000 BTU) '
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532109 HEATING UNIT(OVER 100,000 BTU)
❑Yc, 0 N VENTILATION PAN(SINGLE RESID) AID
Will thea applicant or future building t use equipment or devices which Date Receipt#
pp dby the
BOILER-COMP(3HP OR IW,000 BTU)
emit hu<nrdnus air conruniwnkv as inclined by the Bny Area Air Quality Management IA.
DPotrlcl9
E]Yes I-]No BOILER-COMP(OVER IllRODO BTU)
AIR CONDI'T'IONER
I have mad the hmnrdne,materials requirements antler Chapter 6.95 of the Cali- yr'� ISSUANCE DATE
forma Health&Safety Ciall Sections 25505.25533 and 25534.1 understand that if rhe NEW RESIDENTIAL MECH. SQ.FT. ,R Z� 8
building dues not currently have a saint,that it is my respnnsinllty to mthly thcocwpont
of the requirements which must be mer prior to issuance of u Certificate of Occupancy,
Owner or amhnduJ agentUac TAC: ISSUED BY (� 7rS-E4A T�g
OFFICE