S 1130 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P�1T N0 113 0
BUILDING DIVISION APPLICATIONMERMIT PLUMBIrvc-MEcxpwcAl.
BUILDING PROJECT'IDENTIF'IC'ATION
BUILDING ADDRESS: - SANITARY NU. APPLICATIO
N SUBpM,ITTAI.DATE
;Z.r.Z � i .5 T 1 E v �
OWNER'S NAMfs: PHONE: CO ACfORSNAME: LIC NO:
}r`y`a— / ; \ .�( SIC CONTROL#
ARCHITECTMISGINEER: LICN ADDRESS: El
r(P+k ria St 44
CONTACT: AJ� ``-PHONE: al e� BU tDING PERMIT INFO
S},c.JLSLIG/�cr (4 �SC1486 ❑ ConsultantFeesPaidbyApplicant(Initial) BLDG ELEC PLUMB/ MECIy
rL-{ziY/ I(�J/ IfJ/ r
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
q1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencinge, is JOB DESCRIPTION
1—CZO with llSection](NNpaf Divisinn3 of the Business unJ Pndassions Code.anJ myliccnse is PERMIT ISSUANCE RESIDENTIAL
.ituQ infullfolaanJ effect 4 O ❑SFDWL ❑KITCHEN REMODEI.
aVV license Class Camara
"f APPLIANCEiS-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE'
N 6 6 Dale CoalmOar
ARCHITECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
F�t� PANELS
Z p!r1 Z I understand my plans dull M1e used as public records CHIMNMODIFEY
REPAIR JJ UPT0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
�] Licensed Professional 201-IgM AMPS IMPROVEMENT E]SWIMMING POOLS
�+y •�] OWNER-BUILDER DECLARATION OVER IfIBU AMPS ❑BATH REMODEUREPAIR El DEMOLITION
�j OC I hereby.utero that 1 1. exempt Tram the Cnntcare,C.License Law c.the
O p,U following mason.(Section]011.5,Business arW 11oPouions Cade:Any city or county SIGNS F.LECIRICAI. ❑OTHER
�a( Y
u131+
to which requires v permit o construct,alter,improve,demolish,or repair ony structure p
ysprior o its issuance,also requires the splicing for such Permit to file a signed statement SPECIAL CIRCUIT/MISC. _eG CC '
1!(p. then he is licensed pursuant to the provisions of the Contractor',License Law(Chapter 9 lZ
W.^p0 (commencing with Stttinn)IXXIIoI'Uivisinn3ofthe Bueiass and ProfesionsCafeTor TEMP,METER OR POLE INST. COMMERCIAL:
6 q that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section]031.5 by any applicant for a Permit subjects the applicant m a civil penalty of POWER DEVICES
ern ❑TENANT ❑FOOD SERVICE.
Z t mom than five thundredpro,or ,ordollamyemployees
/ IMPROVEMENT
6QI, camer propeny,orI ..Iimirdeswith wages astheir(Sol,compensation, SWIMMING POOL ELECTRIC
a W d Professions
ands: ew Cmutne oe,License usenoes not apply 'o an Business ❑OTHER
It. and Professions Cafor The Cthereon,
License law secs not apply s if owner of OUTLETS-SWITCHES-FlXTUR
.. properly who hails,or idedtimproves t such I and who docs such work himself or through
his own forswear,
the provided That such improvements arc not intended or offered I'ne NEW RESIDENTIAL ELECT SQ 'r.
owner-howeve.the building bur en of proem is at hewithindion oldyear of
or improve
the SQ.FT.FLUOR AREA EISQ.FT.
owner-builder sec .).will have the burden of proving that he did not mriltl or improve for pur-
pou of uwne
1,its owner of the property,oro exclusively contracting with licensed contractorscontractorso l'OTAL:
construct the project(Sec.7004,Business anal deuiu
Prtns CakThe
:)The Ctimmatds It-
nso Law does not apply roanowner ofpropertywho builds or improves thereon.and QTY PLUMBINGPjVAr FEE
who contracts forxuch projects with a commercials)licensed pursuant o the Common's
License U. PERMIT ISSUANCE 3 D
I amexempl under Sec. ,B&P C for Nis mason
Owner Date ALTER-DRAIN&VEIST-WATER(EA, VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROI'F,CI'.DEVICE. O
1 hereby affirm under penalty of perjury one of the following declarations:
10 Does,and will maximum a Certificate ofComenal to.elf-insum for Workers Compete DRAINS-FLOOR,to I, C'm
cation,os provided for by Section 3700 of the Lahr Code,for the Kowar sauce of the STORIES TYPE CONSTRUCTION
work for which this permit it;issued. FIXTURES-PER TRAP
I]1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of the labor Cade,for the performance of me work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUP - APN
My Worker Compcnsati Insurance` rand Policy nutrgqbc�ram: �F - +
Cartier.S' ���un fano Policy Sex:92 ^4 ` GAS-PA.SYSTEM-OVER 4(M)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR BUIL DIVISION FEES
(This section need not be completed if the Permit is formeleardned dollars(SIM) GRLASE TRAP
or less.) PLANCHECK FEE
I cenify Nat in the peRanmemo,ifthe work for which this permit is issued,Ishan SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as m becmnsubject,subjeco the Workers'Compc r- ENERGY FEF.
zZ xoom,Laws of California.Data WATER HEATER WNENT/ELECTR
Applicant I - GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Cc tificam of Exemption,you should WATER SYSTEMOREATING
P
' hecmme xuhjem m the Workers Compenmtion provisiore of the labor Code,you must SOILS F
IIJ forthwith comply with such provisions or this permit shall Ise dremed revoked. WATER SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELMS, SQ.ET, PAID pate Recei t#
.V O I hereby affirm that them is a construction lending agency for the performance of P
E' the weak far which this permit is issued(Sec.3097,Ci,C.)
0 U Lenders Name TOTAL:
{IJ Lender'sAddress TOTAL e
1 cenify that I have mad this application and.,tam that the above informmion is HUIL NG FEi
Ncancer.I agree m comply with all city and county ordinances arm stem laws relating to QTY. MECHANICAL PERMIT FEE
LJ 4, building construction,and hereby authorize represcmmives of this city to enter upon the I SF..MICPEE
shove-mer th ned property far inspection purpmus.
(We)agree in save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELE IC FEE
liabilities,judgments,costs and expenses which may in any way uame against said City ALTER OR ADD TU MECH. 7 /1
incoaeegoenceof Negrand.gofthupemrit PLUMBI IEE J s ,V
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(X111 CFM)
SO JRCF II,A� MECHASUCV FEE.
AIR HANDLING UNIT(OVER 0,00q CFM) CONSTRUCTION TAX
Signature of Appicam/Contmmor Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION PEE
HAZARDOUS MATERIMS DISCLOSURE
Will the...lie.,or boon bi ildlogrcce,ani steno,handle Waradeus matcdm HEATING UNIT(TO I(N.0n)BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cade.Section 25532000] HEATING UNIT(OVER IIX.0011 BTU)
❑Yen
VENTILATION FAN(SINGLE RE.SID) PAID Ume RecelprM Sd
Will the applicant or future building occupant use equipment or devices which
air bazvdou, it condemning,as declined by the any Arca Air Quality Management BOILER-COMP CHIP OR 100,"BTU) TOT
District?
❑Ys g,l..o BOILER-COME(OVER 100,000BTU)
I have read the hazmdaus tnatedals rcyuiremems under Chapter 6.95 of the Cgi- AIR CONDITIONER ISSUANCE DATE���FFJ
forma Heal@&SafetyCalc.Sections 255(15,25533 and 25534.1 unscntand that if the NEW RESIDENTIAL MECH. SQ.FT. �_ ^�
building doas rml currently have a moan.Net it is my responsibilityto notify theoccupant i
of the r, iremeI It It mus the metpriorlois.monceofa Cenificauof Ucupanc.
'dFIIEr��agenl 1 pn .,_ _ TOTAL: ISSUED BY: KA -
_ OFFICE ��