S 1221 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEg IT NO
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL �J 1221
-BUILDING PROJECT IDENTIFICATION
o0eILDING ADDRLSS: - SANITARY NO, APPLICNI(ON SUBMITTAL DATE
a pis e,Llieff-R co�D CE46
LL\\
0 'S NAME: p PHONE. ONTR T 'S NAM LIC NO:
ARCHIT CTIENGINEER 6 IC NO: ADDRESS: O NIC CONTROL#
CONTACT: PHONE: BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) BLDGGEC PLUMB MECH
El El ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affrm mm 1 am licensed unJw prnvisinre of Chapter 9(commencing JOB DESCRIPTION
,cZ with Semion]gMJ7 of D1vlslon3oRbe Business and Pods Binns CnJc.antl my liwnse ix RESIDENTIAL'
F�� in full force and effect. PERMIT ISSUANCE. ❑SFDWL ❑KITCHEN REMODEL
I-UU Datc Comructtn
Class Lim#
CyLLl Deo APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
11 ARCHITECT'S DECLARATION
[]MULTI-UNIT []STRUCTURAL
F 7 N PANELS
ZOfO,7jIundersmd my plans shall be used as public records MODIFICATION
024q UP T02fM1AMP$
[I INTERIOR ❑CH[MNEYREPAIR
IO4I"'IVI Licereed Pmfessianal - 201-IOMAMPS, IMPROVEMENT E]SWIMMING POOLS
L4
y' .•]] OWNER-BUILDER DECLARATION OVER JINNI AMPS El BATH RE� V PAIR El DEMOLITION
I hereby affmt that 1 am exempt from the Co.,mamma License Law teethe
a O d O following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL. ❑OTHER
[.3 W y which requires a permit m Construct ala,improve,demolish, a repair any slrudere
prim to its issuance,also requiresthe applied.,toaster,permit.,file emgnedsmmte., SPECIAL CIRCUIT/MISC.
5� y that he is licensed pursuantto the provisions of the Contractor's License Law(Chapter 9
W.,00y (commenting with Session Map)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLL.INST. COMMERCIAL'
d c W that he iv exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m Section 7031.5 by any applicant for a permiteuhjects the applicant civil penalty of POWER DEVICES TENANT
FZ>+ not more than f ve hundred dollars($500). OIMPROV ❑FOODSERVICE
C�y 6n E] I,as owmerofphe Fiction,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
2F will do the work,and the structure is not intended wotfered for sale(See,7(N4,Business ❑OTHER
6 and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FI S
property who builds or improves Wereon,and who des such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECT FT.
sale.IL however,the building or improvement is sold within ane year ofcompletion.the SQ.FI'.P�(gH1R AREA $/SQ.FE
er-builder will have the burden of proving that he did not build or improve for par- I� A. D
pot 'sato.).
I,a own r cf the property,am exclusively remanding with licensed anmamms to AL'
o et the project(Sea 7044,Business and Ree essioms Code:)The Contractor's Li- PER 9
return
Luse does not apply to an owner mf n who builds or improves thereon,and
ppy trope yw t QTY. PLUMBING PERMIT. FEE •rr�111/
who tattoos for Boer,projects with a wnvuctogs)licensed toes.,.,m the Cantrnemr's
License Law. PERMIT ISSUANCE C11 (//" VV/_
I am exemun
pt der Sea ,B&P C ft"hisploark Lf7t
OwALTER—DRAIN&VENT—WATER OA) VALUATION
ner Date
WORKER'SCOMPF.NSATION[fikl,ARATION HACK FLOW PROTECT.DEVICE
I M1and w ll mai under penally of perjury ane of elf followingW Workers
Co:
❑ Ihave and will far by eCertificateio7 ofCouncent toLabor
sole,surefer Workers Cnmpen- DRAINS—PIAOR.ROOF,AREA,GDND, STORIES TYPE CONSTRUCTION
work,worm,I us provided for by Section 37 W of the Labra Cude,for the performance of the
work for which lilt antrum ix issued. FIXTURES—PER TRAP
❑ 1 have and will main min Worker's Ca performance
of the
work
for hi h his perm by Sefton
My orkar Labor Code,for Insurance cancer and Policy
for which this permit is issued. CAS—EA.SYSTEM-i INCA OUTLETS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number we:
Carrier: Policy GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRP.ASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES_
(This section need not be completed i f the permit is for one hundred dollars($IW) GREASETRAP
nr less.) PLANCHECK FEE
I certify that in the performance ofthe work forwhich this permit is issued,i shall SEWER—SANITARY—STORM EA.2W FE
tat employ any porton In any manner so as to become subject m the Workers'Compen- ENEROY FEE
Z cation Laws of Cali forma.Date WATER HEATER WIVENT/ELECIA
O7 O Applicant I GRADING FEE
G N NOTICE TO APPLICANT:If,after making this Cenifcme of Exemption,you should WATER SYSTEM/fREAT1NG
(~ become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS HE
fmnhwithetmpiy with such....kinds.this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.ET. PAID
UO ,.
1 hereby affirm that there is a consuumion lending agency for the Forbearance of onto#
LL t•+ the work for which this Nowitis issued(Sec.3097,Civ.C)
Lcus 'e Name _ TOTAV
L) Lender's Address TOTAL: -
D^ BUILDING FE
[r 1 curee ohm I ply read this application and sate that the above infnrmatinn k
fn cora[.Iagreemc a,and with ancity and eunty mAlnancwand timelaws mmdn the QTY. MECHANICAL PERMIT FEE
L.) �
building ronatrxc[ion.and hereby authorize represemmivw wild,oily.,enter open the SEISMIC
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE
(We)aFwmsmr,indemnify and keep harmless the City of Cupedino against ELE IC PEE
Iiabilities,juJgments,costs and expenses which may many way accme against said City ALTER ORADD TO SUCH.
in onsequenc,of the granting of this permit _ PL E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. - MECHANICAL
AIR HANDLING UNIT(OVER 10,000 CEM) CONS'FRICTION T
ign wre of App iwnl/Gmtmcmr om EXHAUST HOOD(W/DUC1) HOUSING MITIGATI PUB
HAZARDOUS MATERIAL DISCLOSURE
Wllltheappliwnl ce ram.,building ecupsat ame handle hazurdous mamrial HEATING UNIT(TO I I%1,IM0I BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Super, -
Code,Section 25532(x)? HEATING UNIT(OVER 100,030 RTU)
cy. ❑No. VENTILATION PAN(SINGLE RESID)' PAID F
Will thea applicant or future building eau nl use t or devices which Date R ipt#
pp g pa equipmcn HOILER—COMP CHP OR 106000 BTU)
emit haeardous air con tribute,ax defined by the Bay Amo Air Quality Management TOTAL
District? Yes El No - BOILER—COST(OVER Ifli BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Hutton&Safety Code,Sections 25545,25533 and 25534.1 underspend that if the NEW RESIDENTIAL SUCH. SQ.PT.
building dew sol currently have a tenant,that it is my respomitelity mercury the oecupam
of the requirements which..at be midpoint to issuance of a Ceaifwteof Crimpers,
Owner or authorized agent Dare TOTAL. ISSUED BY:
OFFICE