B 0433 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT[NO _ BUILDIN0.ELECTRICAL PF;RMI'I'Nr,o r
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL LVSV�-Vy
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: SANITARY NO. APPLICATIDPN��TTAL DATE
q,501cl 1- 99
OWNER'S NAME: PHONE: I CONTRACTOR'S NAME: IJC N0:
UGG- - ` NAC CON I'ROI.#,
Ais I chor—malf)RCHITECT/ENGINEER: LIC NO: ADDRESS: '[,A 5 y ❑
CONTACT PHONE: BUILDING PERMIT INFO
Xo1 o;T ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ �[ ❑
LICENSED CONTRACTORS DECLARATION IQTY. 'ELECTRIC PF.RMiT• „FEE
I hmehy.Rin dul 1 an,heemad under pro.s ons of Chapter 9(commercial, . .' JOB DESCRIPTION
Woo with Section 9BBo)ofDivision 3 of the Business and Profesalona Code and toy licenses �� .
F1_ infallforce and affect F.F.ItMIT ISSUANCE FIIWI. ❑KITCHEN REMODEL
U U License C s Lie#
yQS Dale - Lee.# r APPLIANCES-RESIDENTIAL ❑ADDITION ❑PI,UMBINGRE-PIPE
ARCHITECT'S DECL ATION ❑MULTI-UNIT ❑STRUCTURAL '
z FOyZ Iundershooth plans shall be usedas public records PANELS MODIFICATION
O,Z4- IIP TO 200 AMPSEI INTERIOR ❑CHIMNEY REPAIR
Hs4 j Licensed Professional 201-IOMAMPS IMPROVEMENT E]SWIMMING POOLS
❑Iy,' OWNER-BUILDER DECLARATION OVER 1010 AMPS ❑BATH REMODFURumit ❑DEMOLITION
❑C WI hereby affirm that I ns er exempt from the Commutm' License Id w'for the kk��
aqS O d U holloware,mason.(Section 9031.5,Business and Pli,fassions Code:Any city or county SIGNS ELECTRICAL XOTHER _
1++3 W F which requires a permit m construct,ape,impmva demNish,or repair any s,mcmm Rp 'Q('p,[LYy}B[' r
prior to its issuance,also requlresthe applicant for such Permit m rile a signed statement SPECIAL CIRCUIUMISC
Yi t�Qfthat he is licensed pursuam to he pmvislomsrf he Cootmetter's License Law(Chapter 9
W p0 (commencing with Section 7000)ofDivisiun 3 ofthe Business and Professions Cede)or TEMP.METER OR POLE INST. COMMERCIAL•
d yM C
that be is exempt,harefrnm and the basis for the staged exemption.Any vhiloian of (_1 NEW BLDG/ADDITION El DEMOLITION,
W�� Section 90315 by any,applumufor.parmilaah)eets fied.,licamma civil mushy of POWER DEVICES ❑TENANT ❑FOOD SERVICE.
I.
not more than five hundred dollars X5000.
, SWIMMING POOL ELECTRIC IMPROVEMENT
,Buss
11 do the work,and the sh Cont 6 not intended or Law
does
ofor of apply it)an Business ❑OTHER
W and Professions Code The..ex there. License Lawdoesnmapplymlf owner of OUTLETS-SWITCHES-FIXTURES
�' .. popery who builds nr improves t seen improvements and who docs such work himself or through
bis own awvcveampla,ce,e provided that prov lw arc not intended m iWered for NEW RESIDENTIAL BLECTR SQ Pf.
sale.ILhowevewthchuilthe bur in or proving
he llbinone ymro improve fogthe - SQ.Rf.FLOOR AREA $ISQ.Irl'.
vm-builder will have the harden of proving thm he did tar build or improve for par-
pose of sale
❑I,as owner of the(Saopeny,.B exclusively conducting Cold licensed wmuters h, TOTAL: ,
construct the project(Sec.91W4,Business and Professions Code)The Covtraemr'e la- ,
cense Law does not apply corm owner of property who builds Or improves lhercon,and QTY. PLUMBING PERMIT FEE,
who contracts for steel,projects with a amwmm(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for thkodon
_
Owner DateALTER-DRAIN&VENT-WATER HA) VALUATION
WORKERS COMPENSATION DECLARATION" BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of,hm following d,da nduns: '
❑ Have and will maintains Certifienmef Consent msclLbrsurafnr Worker's G,mpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSIRUMON
sution,as provided for by Section 39IXI of the Labor Code,far the performance of the
work for which this permit is issued. - FIXTURES-PER TRAP
yy�f 1 have and will maintain Worker's Compensation Insurance,as required by Section
Toll of the Labor Cal,for the performance of 0e work for which this permit is issued. GAS-BA.SYS9'EM-I INC.4 OUTLETS EKG GROUP APF,
My Workers a this p rand Policynu C
Caries: ryTe1\Aa,_1C Policy No.: � �r •1[n 1 GAS-EA.SYSTEM-OVER 4(EA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE NDUSTRL WASTE INTERCEPTOR
(Th ction need not he completed irthe Permit s for one hundred dollars 1$IOtB lil)ILIJINC UI�I$bN PEES -
or le::) GREASE TRAP
PLANCNI CK FEE
Toy any latiperson in
anyperfiwrmaiia�
ine,, Bra work for which,hispumilisissuul,lshall SEWER-SANITARY-S'I'ORM EA.200 Ff.
not employ any person in any mrvnner s ➢s m epor��e�p��ecl,m the Workers'Compete- ENERGY PEE
z ,'� action Laws pf�ylifo Dm �"G�1��11 WATER LENDER W/VENT/ELECPR Z
_0 Applicata 7 11 Prl� - -I GRADING THE '
r/1 NOTICE TO APPLICANT IL after making this Cenificale of Exemption,you should WAPEE SYS'TEMOREATING
abecome subject to the Worker's Compensation pmvisirns of the LaFor Code,you mus, SOILS FEE
W forthwith comply with such previsions or this permit shallM deemed revoked. WATER SERVICE:
Q
� z CONSTRUCTIONLENDINGACENCY . NEW RESIDENTIALPLMB SQ Fr. PAID
V O 1herebyaffirrompt fore iso etrourmhorlendingagenoy teethe perfommnenot - Dom Reaript#
LL — the wnek for which this permit is ismeA Oce.3007,Co.C.) -
C F' Lender's Name TO'CAL:
LU17 Lender's Address TOTAL: yaso
1 n'fy thvtlhv ad lh application d'Wl that the aboveinformation is BUILDING FEE
h core t.I g t comply with II city .d county entrance,and amid lava rdaang to QTY MECHANICAL PERMIT t " FEE
U ]
building construction.and herebyimmense p r i esoftho city to emerupon the _ SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cuperino against PERMIT ISSUANCE ELECTRIC PPA
lishilities,judgments,ressandexperow,which may in anywayaemu,agalnstsaid City ALI'Ek OR ADD TO MECH. PLUMBING FEE
in asequence of the granting of Ons per at to
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGULATIONS. MECHANICAL FEB
�S n n^'�_ .Lir r- `-^(T AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Ei
sign of Applimr61/KCotrsctthr J Date EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe...he.,,,or future buildir,aee...at store or handle hazmdovemmerial HEATING UNIT(TO 100,000 BTU)
as def nsel by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
Code,Section25532(.)? HEATING UNIT(OVER 100,000 BTU) -
El Yes m
- VENTILATION PAN(SINGLE RESIU) —
Will the air Gran o or tumrc building occupant use equipment ur Mara which
Re t
blmLd�,.m
ardous air contaminants as defined by the Bay Area Air Quality Management BOILP.R-COMP(THE OR IfN1,OfNl BTU)
Ih,o BOILER-COMP(OVER 103,00OBTU) J~ O
ex
have read the humulous materials rc mems under Chapter 6.95.1'he Coli- AIR CONDITIONER quire p . ISSUANCE
lth&Safety Cade,Sections 25505,25533 and 25534.1 undemmrd that d the NEW RESIDF.NTIAI.MECH. SQ,PI'.
s not emren0y bavmalenan,lhrvt it is my msponsihilily to notify the mcupmn ir , isswwhich mind be mel prior to Lssmance ofu Certificate of Occupancy.Blhonm Date TOTAL: Is
OFFICE