S 1459 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PHISIT NO. 1 4 5 9
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `\7
BUILDING PROJECT WENI'IF'ICATION
HUIIDINGADDRES'S: SANITARY NO. APPLICATION SUBMITTAL DATI
,Z16" ICIA9 e e 4e_ Cjt - o -4 s
OWNERS NAME: P )NE: CO CTOR'S NAME: LIC NO:(��f+�
i _TAAx_4 A Ai AA Nlc coNTRol.a
•ARCM" 'll?NGINEER: LIC I tq C< ADD ESS Elo0
681�r
'?23 5 Pill R{e
PHONBE ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB MECH
�/,�✓Aa� — -pL2S ❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FILE
1 mushy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Ssamion]WB.Havisian3 of Ne Ismans,rad Professions Csde,vndmy licenseis RF ID .NTIAL:
WOO PERMIT ISSUANCE
CWF- in full formind effect.-Z� �(,v ❑SFDWI. ❑KITCHIiN REMODEL
aUU Lsenu Class 'Conor _ APPLIANCES-RESIDENTIAL /gK Q ❑AUDITION El PLUMBING REPIPE
y6a Data Contractor _ ❑MULTI-UNIT ❑STRUCTURAL.
g.Oh ARCHITECTS a DECLARATION �ea,I PANELS
O p0 y Z` l undcmwund nny plans shall he useJ vs puM1lic records MODIFICATION
UP T021X)AMIS [I INTERIOR El CHIMNEY REPAIR
r4tW Licensed Prides siond 201-IIX0AMPS IMPROVEMENT []SWIMMING POOLS
.1.5a-? OWNER-BUILDER DECLARATION OVER IgX1AMY5 El BATH REMODEIBEI'AIR ❑DEMOLITION
S O W UaU 1 hereby affirm that I am exempt from the Caron is License Law for the ,El BAHER
x a following reasan.(Session 7113 1.5.Business and Professions Code:Any city ur county SIGNS ELECTRICAL
F O ya which requires v permit as construct,alter,improve,demolish,or repair any structure El
Aws" 01V
J poor m its issuance,also requires Ne applicant for such permino file a signedstatememn SPECIAL CIRCUITIMISC.
'j that he is licensed pursmantto the pring,mosof the Contractors License Cow(Chap¢r9 COMMERCIAL:
00 (commencing with Section lf00)of Division 3nOhe Business and Professions Code)or TEMP.MUTER OR POLE.INST.
d p,Q C thin he is exempt therefrom and the basis for the alleged eumption.Any vinlution of ❑NGW BLDC/ADDITION ❑DEMOLITION
LLXI ob Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER
RE
X71;NpNT ❑FOODSERVICE
�' of more Nun five hundred dollars What,
'�Q Las owner of Nc rt.nrm Io nes with wa es ns theirsole cont tion. SWIMMING POOL HLECTRIC IMPROVEMENT
SCO prose y YemP Y g ,ensu ❑OTHER
CCF will do the work.
n,Cmthe strhe Caron not intended ofoffereddoes r.,ippcc,to an ownerBusinif
a 3 and en,who
Qde:The Contnemr's License law docs nam apply bs if r Ih. It OUTLETS-SWITCIIES-FIXTURE.
progeny what builds of improves thereon,and who does such woo himself of thmugb
his own employers,provided that such improvements are not intended or of for NEW RF.SIDF.N'1'IAI,ELL(:R SQ
soJr.If,however,he building or improvement is sold within one yearofeompletion,the
SQ.F1'.IH.00R AREA $ISQ.IeI'.
owner-builder will have the burden of proving that he did not(wild or improve Lor pur-
pmrse of sale.).
C]1,as owner of the pmpeny,am exclusively contracting with licensed Contractors m AL
construct the project(Sec.70,14,Business and Professions Code:)The Lorimcmrs Li-
moveLaw does not apply toanownet ofprogany who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comracmr(s)licensed pursuant m
o the Contnors
License law. PERMITISSUANCE
❑ I vat attempt under Sec. ,B&P C for this reason
ALTER-DRAIN At VF,NI'-WATER(EA) VALUATION
Owner Dole
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE �SY/
I hereby of eff under penalty of perjury one of the fallowing declarations: J& 10
�Ihxve and will mainuiine Cenilicmeof Cnnxnt mm calf-Insure lin W..ker'a Cunneen- DRAINS-FLOOR.ROOF,AREA,COND' STORIES TY PE CONS'TRUCIOI
scion,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is Issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,sa required by Section
37Mofthe labor Code,for the performance of the work far which his permit is issued. GAS-EA.SYSTEM.I INCA OUTLETS OCC.GROUP APN
My Workers QamN tioa Insurance Carrier and Policy nu�r,i.�9PL,/eD GAS-fiA.SYSTEM-OVER4(EA)
Cartier: KK Iw+Pi9S Policy No
44
CHITIFICATE OF EXEMPTION EOM WORKERS' GREASEnNOUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION
(This section need trot be completed ifthe petit is furonelmndead dollars(HCB) GREASHTRAP
PLANCHECK FEE
of less)
I Certify that in the performance of the work for which this permit is issued,l shall SrWER-SANITARY-STORM EA.200 FT.
not employ any person in any mama,so us to became std ea Int the Workers'Compete- ENERGY FEE
Zz settee laws of Cadifomia.Date WATER HEATER W/VENTIELECTR GRADING FEE
O Almhe rat
y NOTICE TO APPLICANT.If,after making this Cenlficatn of Exemption,yon should WATER SYS'IEMGD EA'UNG SOILS FEE
a ; hecome subject to the Worker's Cmnp,nautlon provisions mf the Labor Coda,you must
forthwith comply with such provisions or this permit shall be deemed invoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
Date Receipt If
V I hereby affirm that there is m con.stmnlnn lending agency for the performance ofaffirm
LIs r the work for which this permit is issued(Sec.3097.Civ,CJ
ULender's Nome TOTAL:
W Lenders Address TOTAL:
y 1 cenlfy that 1 have rend this application and suite that the above information is BUILDING FEE
.F.,tn cored l agreem comply with all city and county eminences and state lawsrelotingm QTY, MECHANICAL PERMIT FEE SEISMIC FEI?
(J Zi building constmction,and herebyuut brine representatives ofthis city to anter upon the ^
above-mentioned pmpcAy far inspection purposes. PERMIT ISSUANCE V
(We)agrsave,indemnify and keep harmless the City of Cupertino against ELECENIC FI?E
eem
liabilities,judgments,costs and expenses which may in any way mems against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('TO 10,000 CFM) MECHANI Loi: O V
SOURCE REGULA3'IONS. 13,
f AIR I IANULINGUNINOVER 10.000C17M) CONS UCTIONTAX
Signatumof ApplicanVContrucmr Dam EXHAUST HOOD(W/DUCT) HOUSIN 1 O G
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle transitions material I WA'I'ING UNIT(10 1(",000 BT U)
as defined by the Cupcniom Municipal Calc,Chapter 9.12,and the Health and Safety
Cade,Section 25592(x)? I IHATING UNIT(OVER 1X1.100 BTU) ccIV Vs w
❑Yes �s'o VENT]IATION PANS INGLE RESIDE PAW` Dat, Receipt,
Will the applicant or future building tecupant use equipment or devices which BOIL ER-COMP(3HP OR. I W,(XX)BTU)emit",do.,air contaminated.,as defined by the Bay Area Air Quality Management TOTAL:
District? ���,,,/// HOILER-COMP(OVER 10,0011BTU)
(]Yes 1�:'�0 I'
I ham he ham
aaous materiarels micrcods under Chapter 6.95 of the Cali- AIR CONDITIONER n A L ISSUANCE DATE
fomis Hyy-''h& fey Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. _ /O V
builditt/Joes cu tl tenant,thatitismymspmsihilhyunnmilythe mcupant / VV
oft rc ui a s i v be mm peon to Certificate of(Xcupmay.
authorized ager Uv¢ TUT s ISSUED BY: s a se� — �
OFFICE