S 0322 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGPROJECT
IDENTIFIC S 0322
BUILDING PROJECT IDESFIPICATION
tlU1LDIN0 ADOBF,SS: SANITARY NO. APPLICATION SUBMITTAL UATF.
o Q S e-P -6k.kXE bR F
N 'S NAME' •a kin F P 852 1 CONTjtACfOR'S NAME: LIC NO.
_ C W NIC CONTROL,Of
s�ARCHTPEC fP GENE ER: LIC NO: ADDRESS: 1 ❑
- CONTACT: - PHONE: fE.3
UILDING PERMIT INFO
❑ Consultant Fees Paid by Appllrant(initial) ELECT PLUMB MIiCH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT ]OB DESCRIPTION
1 hereby norm that I un IicenseJ under provisions of Chapter 9(commencing
aZ with Section 7000)ofDwision3afthe Business and Professions Csde,and mylice..is RESIDENTIAL;
PERMIT ISSUANCE CHBN REMODEL
1n full force end effete.
aUl License Class N APPLIANCES-RESIDENTIAL PLUMBING RE-PIPE
Z`4�f Date Convector
Iis6y T ❑STRUCTURAL
ARCHITECTS DECLARATION PANELS��y x 1understand my plana shall be usedaspublic records MODIFICATION
C4C UPT02MAMPS ❑CHIMNEYREPAIR
rg0t-Ly LicensWProfea.ional 2111-I Wn AMPg IMPROVEMENT []SWIMMING POOLS
W OWNER-BUILDER DECLARATION OVER 1000 AMPS- ❑BATH REMODEUREPAIR [I DEMOLITION
1 hereby.(Sent onnt 11. exempt fmin the Comms Cod License city
o for the
. OyU (allowingreason(Smiiot 7031.5,Business and Pmfessions Code:Any can ormncre SIGNS ELECTRICAL F1 OTHER
3 tL which rcyuims u permit m eonxwc0 nlmc improve,demolish,or repair any amewre
E-� -1 pdorm itsisstunce.also acquires the applicant for such Permit o file a signed statement ItSPECIAL CIRCUMMISC.
ythud he is licensed pursuant unhe provisions of the Cnnwemr's License L.uw(Chapmr5 COMMERCIAL'
00 (commencing with Section 7f100)of Division 3 of the Business end Proficum.,Code)or TEMP.M2fER OR POLE INST.
d y=pC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iLLl12 Y• Section 70315 by any applicant fora Fee,itabjectsthe upplicum to a civil penalty of POWER DBVICFS ❑TENANT [IFOOD SERVICE
try nm ore than live hundred dollar, 55000 IMPROVEMENT
Las awnerofthe property.nr my employeev with wagesm Neir sole compensation. SWIMMING POOL ELECT RIC
F will do the work,and the stractarc is not intended or offered pursue(Sm.7044.Business [I OTHER
and Professions Cade:The Contittor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
prolan y who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT.
aide If,hswain.the huildingor improvement is sold withinone yearofemopletion,the SQ.Pf.FI, R R@tk $ISQ.IT.
n r-builder will leave the burden of proving that he did not build or imve profor For,
V
poseofsale,. CIf �1
L,as owner of the property,um exclusively contracting with licensed contractors to
mnntaa the project(Sec.7014.Business and Professions Code:)The Canowns's Li- C/ry
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEF. Q/ `
who connotes for such projects with a conemnedsl licensed pursuant o the Contactors
Limn.I.me IWA� H
ISSUANCE
❑lamexem der O. B&PCfo hisr o V
-DRAIN @VENT-WATER(EA) VALUATION
WORKER'SCOM INSATIONDECIARATION LOW PROTECT DEVICE
rcM1yaffirm under penally M perjury one of the following dislocation.vI have and will maintain a Cmificam ofConseovo self-insure farWorkers Compen- S-FLOOR,ROOF.AREA,COND. STORIES TYPG CONSTRUCTIONsution,as provided for by Sealed 37(X1 of the labor Code,far the performance of the ;fitwork for which Nis permit is issued. ES-PER TRAP :13❑I have and will maintain Worker's Compensation Insurance,as required by SectionI3700 of the Labor Code,for the performance of the work for which this permit is issued. IM.SYSTEM I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance tamer and Policy number arc:
Carrier. Policy No.: 1iA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOR KERS' - IHINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thlssection need rout be completed if the permit is for ono hundred dollars($LOVEE TRAPar less) PLANCHECK FF.IiI certify Nat in the performance oflhe work rorwhich this pencil is issued,l shall -SANITARY-STORM EA.200 FT'.nm employ any parvo in any manner so as m becmnesubject 1r Ne Workers Cow,aO- ENERGY FEE
union Litws.fCalifomia.Dam HEATER WNENT/ELECIR
Applicant I GRADING FEE
NOTICE TO APPLICANT.If,after making this Cenifmcate of Exemption,you should WATER SYSTEMITREATING
s'^ become mbjmuo the Workers Compensation provisions of the Lobomust
Calc,you muSOILS FEE
forthwith comply with such pmvisiom nr this permit shall beJcemcd revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
LEOIherehy affirm that there iso construction lending agency for the performance of Dam Receipt
the work for which this Permit is issued(Sec.3097,Civ.C.)
OU Lender's Name TOTAL:
{17 Lenders Address TOTAL
I certify that 1 have read this application and nam ohm the oMwe infammeion is BUILDING FEE
it y coma.l agree to comply with all city and county ordinances and swat laws relating to QTY. MECHANICAL PERMIT FEE
V �. .building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above.mentimned property,for inspection puryosea PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against 13LECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accrue against aid City ALTER OR ADD TO MECH. PLUMBING FEE
In consequence.(the granting of this permit.
APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL N N-PO 5AIR HANDLING UNIT(TO 111.1100 CFM)
MECHANICAL FI:E
SOUR C.REGULATIONS. .
• u AIR HANDLING UNIT(OVER ILNX)CFM) CONSTRUCTION TAX
g 413"
S muaemAppicansCanruaor I D EXHAUST HOOD OW/DUCT) IIpUSING MITIGN'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will eheapplicant or future building Iscipa knave or handle haeatdous namoviol HEATING UNIT(TO I W,"BTU)
re defined by the Caliendo.Municipal Calc,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'0 HEATING UNIT(OVER FOR."BTU)
El Yea ❑N. VENTILATION FAN(SINGLE BESIDE PAID -
Date Receipt 4
Will the upplicant or future Wilding oecupit u.sc cquipmem or devices which BOILER-COMP(3HP OR If ,"BTU)
unit luxuriousair contaminants os defined by the Bay Area Air Quality Management TOTAL:
District? - BOILER-COMP(04.1t 100,000 BTU)
]Yes FIN.
I have real the facardnus materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade.Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building dives not cmrenely have a mount,that it is my responsibility to notify the ocapam
of the mryiremems which man be men prior to issuance of a Ceni leate of'Occupwai
Ownero..diffident agent Date TOTAL: ISSUED BY: �
OFFICE