S 0672 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY g^�7
CITY OF CUPERTINO -BUILDING-ELECTRICAL PF51TNO. O V 1 Z
BUILDING DIVISION APPLICATION/PERM[T PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDIN ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
QJ a/ �y,Z di"iv o7
OWNER' NA : �ctJ�J P `53 -7 ONTRA OR'S NAME � IC NO: / NIC CONTROLp
CHI ECTIENGINEP.R: I.CNO, A RES$:
CONTACT; PHONE: JC✓"2 rG/.f9 [w%r BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE jQg DESCRIPTION
I hereby effum that 1 am licensed under provision.of Chapter 9(commencing
G 1aZ with Section 7(NIO)n'Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL
ENTIAI:
p0 V// PERMIT ISSUANCE
in full force end elect. 7��3 ❑SFDWL ❑KITCHEN REMODEL
QUZU Licenu Cl Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE•PIPE
6
Data Cameroon ❑MULTI-UNIT ❑STRUCTURAL
FraARCHITECTS DECLARATION PANELS MODIFICATION
OZEv� 1 understand my plans shall be used as public records
E UP T0200 AMPS ❑IM'ERIOR ❑CHIMNEY REPAIR
1ul Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOIS
•�] Oat I am BUILDER DECLARATION Com oto OVER 111(X1 AMPS ATH REMODEUREPAIR ❑DEMOLITION
1 hereby affirm that 1 um exempt from the Cnmracm o License law for the
M U fallowing mason.(Section 7031.5,Business end Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
47 3 4, which requires a peunit to construe.,ohne,improve,demolish,or repair any Structure�yym prin, issmmce,also requires the applicant for such fermit to file a signed harmed SPECIALCIRCUITIMISC.
9999;W!�y that he is licensed pursuant o the previsions of die Conow,tor'x Licenu Law(Chapter 9 COMMERCIAL,
ad (commencing with Section 7")of Division 3 of the Business and Professions Cade)or TEMP.METER OR POLE INST.
d L n that he is exempttherefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
�t Section 7031,5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
ttFW.—ynot more than five hundred dollars($500). IMPROVEMENT
1,as owner of the rt,or employees with woes as their sole cmmnsmiun, SWIMMING POOL ELECTRIC
O ❑ prose Y Y p Y s le ❑OTHER
pp�a ill dothwitax and the siroctureisnmimendnse Law
ds sale,I,t(Ian owner
W � end Professions Cale:The Contractors License Lew does not upP1Y m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NIiW RESIDENTIAL EL
SQ FT.
wit.If.however the building or improvement is sold within one year ofcomplexiem,theFl.00 RF.A SISQ.FL
owner builder will have the burden of proving that he did not build or improve for pun-
pose of eels.). TOTAL:
I,as owner of the property,am exclusively contracting with licensed comonion to C �0
nswct the project(Sec.7044.Business and Professions Cale:)The Commemes Li
cense law does not apply m an owner of property who builds or improves thereon,and
QTY. PLUMBING PERMIT E aygy
who connotes,forsuch Impacts with a commands)licensed purstadto the Contractors
License law. PERMIT ISSUANCE
El I am exempt under Sec. ,B&P C for this reason QVA
ALTER-DRAIN&VENT-WATER(PA) VAL ON
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aRirm under Penalty of perjury one of the following declarations: VV C.fde/
❑I have and will maintain a Carifcate of Consent m self-insure for Workers Compcm DRAINS-FLOOR.ROOF,AREA.GOND.
STORIES TYPE CONSTRUCTED
cation,as provided for by Section 37M of the labor CWR,bertha performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will mention Workers Compensation Insurance,as required by Sean
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carie,rad Policy number are: GAS-EA.SYSTEMOVIiR4(EA)
Curler: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thiasection need nmheasmpkted iflapermit isfnr one hundred dollars(SIIA)) GREASETRAP
nr PLANCHECK FEE
lase.)
I certify that in the amNew o,a phis emit is issned,lxhu0 SEWER-SANITARY-STORM EA.200 FT.
act employ any fern man annera tinea 'act empem ENERGY FEE
44
Oz sedan Lwav,mC WATER HEATER W/VENTIELECTR GRADING FEE
AlP CE.
NOTICETO- PI. ANT.IL afar mnkin this Certificate of Exemption,you should WATER SVSTEM/E'RFATING SOUS FEF.
become subject to the Workers Compensation previsions of the labor Code,you must
�s
forthwith comply with such provisions onhix permit shall he deemed revoked. WATER SERVICE
n
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
"7 z Receipts
I hereby affirm that there is a construction lending agency for the perfomwnce of.
IU the work far which this perms is issued(Sec.3097,Civ.C.1 TOTAL:
O U Lenders Name TOTAL:
Linkers Adders.
fy� G BUILDINGI certify that 1 have read this application and state that the above information is
ity correct.l ugree to comply with all city and county ordinances and stain laws reining m QTY, MECHANICAL PERMIT FEE SEISMIC
V Z building cons.mmica,and hereby amhoricamprexemmivas of this city to enin-upon the
above-mentioned pmpcny for inspection purposes. PERMIT ISSUANCE ELECTRI E
(We)agree m save,indemnify and keep harmless the Ciry of Cupertino against10,
liabilitimpt gone . is ad expenses which may in any wit stsaid City AITERORADDTOMECH. PLUMBING
in couseque ofthegm mgoDhispermit.
APPLI TUNDE ANOSA PL WITH . NON-POINT AIR HANDLING UNIT(TO Ig1100CFM) MECHANICAL W:
SOU E EOU IONS
IR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TA
Signarm'bfNalicanncommon, ao EXHAUST HOOD OVIDUCT) HOUSING MITIGATIO ME
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicam or futurt building mcupant score or hanJle hezardova material HEATING UNIT(M 1011000 BTU)
n defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
HEATING UNIT(OVER 100.010 BTU)
Code.Section 2 532pq?
❑Yes El No _ VENTILATION FAN(SINGLE RESID) PAID
Date � Rcttipt p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR H10,00O BTU)
man hmardous in...h urinants as defined by the Bay Arte Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,000 RTU) _
❑Yes 7N
1 have read the asom us materiels requirements under Chapter 6.95 of the Cali, AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RE.SIDPIAL MECH. SQ.FT.
building does not currently have a toram.the it is my ce possibility to dairy the occupam
of the.ryeimmeats which must be met prior to issuance of Canificxm of Occupancy.
Owner or authorized agent Data TOTAL ISSUED BY,
OFFICE