S 0424 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAI. Pf;$NIT NO. O �,
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL `V
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA'DON SUBMITTAL DATH
>< ans3 �� 'a
OW R'S NA E: ' HONE.: CUM ACTOR'R A LIC NO:
'/C✓ NIC CONTROL.
HIT It INFER: CNO'. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG "LE eIMPROVEMENT
PLUMB MECH
LICENSED CONTRACTORS DECLARATION Qty ELECTRIC PERMIT FEE
I hereby affirm that l an licensed tinder provisions of Chapter (commencing JOB DESCRIPTION
Pe Z wi
th Sectinn]1)OB)nf Division Jofthe Businessand Prof<xsinns Cade.and mylicense is RESIDENTIAL,
O PERMITISSUANCE
k-�O❑ in full tome oboe L A ❑KITCHEN REMODEL
aUf' Umm Cl ss C Lia# APPLIANCES-RESIDENTIAL []ADDITION0PLUMBING RE-PIPE
FZQ fx� Dae Contractor
FDn ARCHITECTS DECLARATION PANELS �STRHCfURAL
Z O ZN I understand my plans shall Ie used as puhit.recoMs MODIFICATION
OZ-O UP TO 2110 AMPS ❑CHIMNEY REPAIR
rot Licensed Professional 201-I000AMPS ENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 100(IAMPS [:]BATH RI? Dli REP
RiAIR ❑DEMOLITION
st I hereby intimation am exempt I aexempt from the Contractor's License Law for the
kO a V fallowing reason.(Section 7031.5,Business and Pmfes ions Code:any city Or county SIGNS ELECTRICAL []OTHERIvl a ry. which nations a permit to construct.alcor,improve,demolish,or repair any s menum
�0se
prior m its issuance,also requires the applicant for such permit as flea signed statement SPECIAL CIRCUIT/MISC. -
thin he is licensed pursuant to the Provisions of te hContractors License Law(Chapter Y
III IZC (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL;
d dx Oe C that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDGIADDITION ❑DEMOLITION
LQ^m
Section 7031.5 by any applicant for a permit subjects the applicant o a civil pamalry of POWER DEVICES ❑TENANT ❑FOOD SERVICE
� 6 not more than five hundred dollars(8500). IMPROVEMENT
Las owner of theProperty,orm loea$with woes es theirsate cora tion, SWIMMING POOL ELECTRIC
❑ tshYennp Y 6 .ensu ❑OTHER
Sat willdothewons and the structure is notis¢icense offerval Law
dofnrsale(Sen 11.im Bu sine ss
W
and Professions Code:The Contractor's License Irw docs nm apply m on Owner of OUTLETS
-SWITCIfES-FIXTURES
property who builds or improves thereon,and who docs arch work himself Or through
his own employees,provided that such improvements ve nm intended tar offered for NEW RESIDENTIAL.ELECfR SQ PI'.
sale.IL however,the huildingor imve
proment issold within one year ofcompletion,the SQ.PT.FLOOR AREA E/SQ.ET.
tier-builder will have the burden of proving that he did not build or improve for par.
pose Of sale.).
i 1 I,as ner Of the Import,am exclusively o mracting with licensed contractors 1. TOTAL:
sto
conduct the project(Sec.](WA,Business and Professions Code:)The Comracmr's Li-
m Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMB IT FEE PAID'
who contracts for such projects with o emonactods)licensed. to the Cnnwetor's PP9
License Low. PERMIT ISSUANCC
❑lamexemptander .Sec. ,B&PCfonhi,.om
ALTER-DRAIN&VENT-WATER lFA SEP CV
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROJfF.CT.DE CB /x
I hereby uBirm under Penalty or perjury one of the toll........dedurariovs
❑ I have and will maintain aCcnificatcof Conwmtosel6insurefor Workers Compen- DRAINS-FLOOR,ROOF,AR:A.G .TORIES ITE CUNSTHUCf10N
•mine,as provided for by Section 37W of the WMr Code,for the pedotmance of the
work for which this permit is issued. FIXTURES-PER TRAP
XI have and will maintain Workers Compensation Insurance,as required by Section
W of the Labor Code,for Ne performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.O OUTLETS OCC.GROUP APN
My Workers Com ensvuoGJn�sur�-a(n�tcGe ca—crier vnd Policy num eram; _ - .� GAS-EA.SYSTEM-OVER 3(Ea)
Cartier. OC Policy No.: /LJT�'
CERTIFICATI3 N FRO WORKERS' GRF.ASCIINUUSTRL WASTE.INTERCEPTOR
COMPENSATION
INSURANCE BUILDING DIVISION
(This section need not W completed ifthe hundred is for one hunddollars(SIg) GREASETRAP
m lens) PLANCH[CK FF.F.
Icenify but in theperformanconfthewmk forwhich thispenniOnismeJ.(shall SEWER-SANITARY-STORM EA.200 FT.
not employ any penton in any manner so as to become subject m the Worker: re CompeENERGY FEC
z has Laws of Catlif.roa.Dam WATER HEATER WNENT/ELECTR
O Applicant I GRADING FEE
'Zr NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTEMO REATING
N SOILS FEE
(~ become subject to the Worker's Compensation provisionsa ,al of the Labor Code,you must
forthwith comply with such provisions or this permit shullMdecmed mmked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NF.W RESIDENTIAL PLMB. SQ.FT. PAID Ilam Receipt#
V 0 I hereby affirm that there iso conman
construction lending agency for rhe perforce of
lL r. the work for which this pcmnit is issued(Sec.3(19'/,Civ.C.)
TOTAL:
O U Limiters Name
end
TOTAL:
Lander',Address
4 I reality that E have read this application and state that the above information is BUILDING FEE
C4 correct.)agree r)comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE S17ISMIC FEE
L) 4 building construction,and hereby awhoHze reprewmadvex ofthi,city menter upon the
alrovememimad proporty for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way seems against said City ALTER OR ADD TO MECH. FLUME'
NG FEE
in consequence of the granting of this permit.
10,000APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO, O CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,010 CFM) CONSTRUCTION TAX
SigWImo of ApplicanUCammnor Doc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamor(uture building uccupam atom or handle hazardous..roo l HEATING UNIT(TO 100,001 BTU)
as defined by the Cmamsoo Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
OYea ON, VENTILATION PAN(SINGLE RESID) PAID
Date Racipn#
Wall the applicna or future building occupant use equipment or devices whichBOILER-COMP(7HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Madagemcm TOTAL:
Dnsmm? BOILER-COMP(OVER 110,(.0 BTU) _
❑Yee ❑Nn
I have mad the hasmorms materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505,25533 wd 255M.1 to derxturat that if the NEW RLSIDENTIAL MECH. SQ.Fr
Wilding does not currently have a tones.that i0 is my resP sora iry m notify the occupant
of,4
fthyme qui.7ts whic•A h most W met pri 1.Potence of.Cahrx?vm .
UDRI
Haow or authom , , ✓- 'of�OccuynJ yDam TOTAL ISSUED BY:
sed
OFFICE