S 0683 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BDILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0683
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNSR'S-NNO
DM\v\• UNO= PHORE: CONTN`CIYI'R�',S 1�. ����LI�
(SLS r,A._`♦ • NIC CONTROL%
•ARCHITECTQ?NGINF.F.R: LIC NO: ADDRESS: ❑
CONTACT, PHONE: BU DING PERMIT INFO
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amu ^ 1 �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MOH
v p 0.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of chapter 9(commerelog JOB DESCRIPTION
GOO with Section 2Bn0ofDivision 3ohhe BminecsaW Prefe.esiuns Code.mid my license is - RESIDENTIAL,
O PERMIT ISSUANCE.
f�F Lfull force and eRect, I_�^ S ❑SFDWL ❑KITCHEN REMODEL
�UU License Cla Lic.M Y/ L APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RE-PIPE
HGL Dae Contmcmf
ARCHITECTS DECLARATION ❑MULTI-UNIT [-)STRUCTURAL
'Do,: PANELS
Z O n 7 1 undershoot my plans shall W used as public records MODIFICATION
oz_- UP TO 200 AMPS ERIOR ❑CHIMNEY RI?PAIR
Licensed Professional 201400)AMPS IMPROVEMENT E]SWIMMING POOLS
s❑ OWNER-BUILDER DECLARATION OVER 1(XIIIAMPS [I BATH REMODEUREPAIR El DEMOLITION
sc 1 hereby affimt that I am exempt from the Contm ons License law fm the
XO¢U following ream..(Section 7031.5,Btnittecs and Professions Cedi Any city or county SIGNS ELECTRICAL. ❑OTHER
yQ which requires a permit to.I.the,ohm,improve,demolish,or repair any nroiurt
F-LLson p0ormsxcevedpur orequires furomlicentfh,suchpwnse,Liced.le Law crul
SPECIAL CIRCUIT/MIS O
that he is licenced pursuwuathe puivisiom of the Comrecmrs License law(Chapter9
Wy'-Itp (eotmnevem,with Section2000)of Division 3ofthc Bmitworind Professions Crde)m TEMP.MELT?R F'O EINST COMMERCIAL:
a a cy that he is exempt therefrom and the maxis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W m W Section 7031.5 by any applicant for a permit subjects the applicant us a civil penalty of POWER DEVI
W—m ❑TENANT ❑FOOD SERVICE
F Z} not more than five hundred dollars y empl IMPROVEh1ENT
SQ OLo the week,the property,or myemntended with wages Bred their sole compensation. SWIMMING POOL ELELT C
EI„C will dothework.and the he Coe acme Livens Law does of a ply 90JJ,ownirof DOTTER
L�sI and Professions Cale:The Comracmrs License law does not apply m if owner of OUThIT$-SW HIS-IlX
6 3 progeny who build,,ns.or vided t s t such
and who improvements
such work hind o,ot though
his own employeese building that such improvements am nm itnended or odTered for NEW RL'SIIII?NTL :L R
owner
L bower will h ve building it at he did n one year r improve
the SQ.Ff.FLOOR AREA 5/SQ.FT.
nerbuilder will have the burden of proving Na he did not build or impmve for pur-
pose of sole.).
❑1.m owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.70W,Business and Professions Cedc:)The Contractors Li.
axe taw does not apply to an owner of property who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cuntmcmr(s)licensed pursuant to the Conwcmrs
License law. PERMIT ISSUANCE
1 am exempt ander Sec. ,B&P C for this rennin
Owner - - Date ALTER-DRAIN&VENT-WATER IFA) VALUATION -
WORKER'SCOMPENSATIONDECLARATION BACK FLO'k PROTEGE DEVICE
1 hereby affirm under penalty of perjury one of the following declarations: (f
❑I have and will maintain a Certificate of Consentto self-insure for Workers Compete DRAINS-FLOOR.ROOF.AREA.COND, ST((RIES TYPE CONSTRUCTION
sation,us provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have nod will maintain Workers Compe....am Insurance,as required by Section
370Uofihe Labm Code,forthe performanecofthework forwhich this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS - OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINUUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thlssecrirn need not be complied i0he permit is forma,hundred Jnllora($Il))) GIIHAS H TRAP
or less.)(This
FEE
I certify that In the perfmmamceofthe work for which this permit is issued,l shall SEWER-SANITARY-STURM EA.200 FT.
nm employ any person r y manner w as m heromc suhjccun @e Workerv'Cnmpen- - ENERGY FEEsation Lu fC I�rnot ma WAI'I7R I IEA'1'ER W/VENT/ELECfR
OQ Applicenj, GRADING FEE
zy NOTICE TO APPLICANT:IL afvrainking this Ccniliewc o1Excmpiifm,you shosdd WAI'Ell SYS1'IiM/1'RENI'ING
abecome subject to the Workers Compensation provisions of the Lmbor Gads,you m¢o _ SOILS FEE
ILIforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
UO k frwhichirmthauhereissued(See.30lending agency fnnhe performance of Data
r M
rw me work for which this permit is issued(See.3M],Civ.C.) -
124 F' fender's Neem � TOTAL:
,�s LUkI Lenders Address T
'I certify that 1 have read this application wd state that the above infonionoor is BUILDING FEE
i..i LI) correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT " FEE
V 71 building conswainn,and hereby autharim representatives of this city to enter upon the m Sji[SYIWE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities.judgments,casts and expenses which may in any way mcmc against said City' ALTERORADDTOMECH.
in consequence of Ne ming of this permit L B
GOT
APPLICANT UND R, fANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IERKCPM) .MECHANICAL FEE 0
URGE :GULA 1 S. `
W
O AIR HANDLING UNIT(OVER I0.000 CFM) !Y Ur tAGsEkGtilttidTAx
Signature of AVplRn/Cmadc l' Unit, EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicator future building excupam Boa or handle hazvNous material HEATING UNIT GO 100.011 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes CINo VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building nesu r use e t or devices which Date -Receipt p
pp g pan aAir Qu BOILER-COMP(3HPOR 100,000BTU)
emir Intonation air contaminants as defined by the Bay Area Air Quality Management
District? .J L:
❑Yes VN.
BORER 11%1,1100 BTU)
1 have read the huNou
ax mateials reyuimmentr under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
loon.Health&Sit y .Sations 25505,25533 end 25534.1 understand that if the NEW RESIDENTIAL SUCH. SQ.E r / / � '
Wilding does note havenanant that it is my asponsibiliry to notify the..put _
lI=
them "rements n hmustbemetpriorhsisxuencerfa •off ate of 4cupanay.
Q 1 A
Owner or au int age Data TOTAL ISSUEDBY: r� �-'� � • /
OFFICE