S 1773A
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONIPERMIT
BUILDING. ELECTRICAL
PLUMBING MECHANICAL
BUILDING PROJECT IDEViTFICNFION
Plill NO.
1 1% 17
3
ILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMI'fl'AL 1)ATI
NER'S NAME: I'IIONE:
S 973-
CON'1'RACfD12'S NAME: LIC NO'.
c tzmos
NIC
❑
CON 'fR01.#
ARCHITECT/ENGINEER: LIC O: I A1311RESS
siK ciN/R efRa�I�' f � �T
/ S
CONTACT: PHONE:
9,.✓�O
BUIIAING PIiRMIT INPO
BLDG ELECT PLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby offoo thus 1 am licensed under provisions of Chapter 9 (commencing
wish Rcaion]III10)of Divininn3of the Rosiness and Professions Coale, Wile nse is
Come in full ¢e un
C' _ e oC3�m# 60-0x3
Dae Concert 5ee�,� o U2M
ARCHITECT'S DECLARATION
I understood my plans shall M used as public records
QTY 1iLECTRIC PERMIT
PERMI"f ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200AMPS
FEE
JOB DESCRIPTION
RESIDENTIAL;
ObI'DWL El KITCHEN REMODEL
❑ADDITION ❑PLUMPING RE -PIPE
OMULTI-UNIT CSTRUC URAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
Licensed Rufessmnal 201-1000AMPS
OWNER -BUILDER DECLARATION
1 hmaso o(Ern onIll.[.[70 um exempt faro tire r Cootrn, Coo license Law for the
OJamel, sines and Pnrfeesin Any ay or county
reason ler.,(
OVER I(KKIAMPS
SIGNS ELECTRICAL
❑BATH RPMODc1/REPAIR ❑DEMOLITION
^
O OTHER
lmis o,
which requires n permit re corev the nlree Improve, dernh pentat t nr repair any avuaurc
which ,,
Met to issuance, nLm requires the applicant for such pcmdno flea signM amtemenl
i
that he is licensed pursuant o the provisions of the Contractors License Low (Chapmr s)
(commencing with Section 7000) of Division 3ofthe Busimessand Professions el Gaof
that he is exempt therefrom and the hasis for the alcgcJ exemption. Any violation of
SPECIAL CIRCUIT/MISC.
TEMP. MCIFR OR POLE INS'1'.
CL—
COMMERCIAL;
0 NEW BLDG/ADDITION 0 DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
Out ...,ban five hundred do)[. (S5(0).
O I. its Owner of the property, Or my employees with wages m4 heir sole compensation,
will Jo the wank, and the mmOure boat inmobscim offered for stole (Sec. 70F1. Business
and Professions Code: The ContmdOls License law does not apply a) an Owner of
IIOW17R DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FI ARES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
"
❑ OTHfiR
property who builds or improves thcreen, and who does such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sae.lf, howevee the huildingar improvement issold within one year of completion,the
NEW RESIDENTIA - R SQ F1'.
SQ. PL FLUOR AREA LSQ.tT.
owner -builder will have the burden of proving that he did not build or improve for par-
,are ofsale.).
0 L as owner of the property, am exclusively contracting with licensed comrvnom m
T(TI'AL'
p
p� A
r D
oatmct the prnjecl (Sec 7044, Business told Nofeslons CaIe:) The Contractors Li-
censeLawdoesnetapplymanownerofpmpeny who builds or improves thercon, and
ocamrunor(s) licensed pumuant to the Cno 's
who contractsfarmch projects with ntrenr
QTY, PLUMBING PERM
FEE
f+,� Q p11(1m
Juu 8 ANSI
License Law.
ec. ,B&PCfonhisason
0 lamcscmptunder Sre
PERMIT ISSUANCE.
ALTUS - DRAIN & VENT - WN! ER (EA)
,
Owner Dam
WORKER'S COM PENSATION OE Ce
BACK FLOW PR(TfECf. DEVICE.
folio ing
I hereby effect under Penalty of perjury one Of otic following dedmadons:
of for Worksls Ce
❑Ihave antwillforb
DRAINS - FLOOR. RIX)F, AREA OND.
STORIES
"fYPL'CONSTRUCf101
Code, far of he
smion, r provided for by Section J]W of he Labor Crane, Tonle perfornunce of the
Section 3700 he Labor
work for which this permit is ianuN,
FIXTURES -PEN TRAP
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
37Wofthc Labor Csae,far the perfonnarecnfthe work for which this permit is issued.
GAS - EA. SYS TEM -1 INC. 4 OUTLETS
[ICC. GROUP
AI'N
orJfy''sCs,y�e t�nlawner{ esycr an Nw: twmhu or 03�
Carie ( G TD'[ t nor 'A licyo icy i /10
OAS - EA. SYSTIiMAVER4(EA)
CERTIVICATE OF EXE "I FROM WORKERS'
COMPENSATION INSURANCE
GR17ASFit] NDUS'I RL WASTE I NTERCEPfOR
BUILDING DIVISION RiE_S
(This section need not he completed iffie permit is forme, hundred dollars(11001
Or less)
GREASETRAP
PhANCHECK IEE
I cenify lhill in the perfanane.ofthe work for which this permit is icmed,l shall
not employ any permmn in any manner so as to become subject m the Workers' Comple
SEWER -SANITARY -STORM EA, 20I FT.
ENIiRGY FEE
GRADING FEE
>' satiun Wwsof California. Date WATER HEATER WNE1,1M/ELECTR
Applicant
] NOTICE TO APPLICANT. If, after raking Nis Cle ificme of Exemption, you should
' became subject to the Weikel., Complueelon rowi,iod, of the Latin Code, you must
WATER SYSTEMaREATING
SOILS Fl3E
fanhwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
CONS'TRUMON LENDING AGENCY
I hereby oBthat irm thahem is a emostmction lending agency teethe performance of
w the walk In, which this Penn, is issued (Sce. 31397, civ. C)
a Lundeh Name
NEW RESIDEND IAL PI.MB, SQ. Fr.
PAID
Ume Huceiptp
UT
Lenders Address
TOTAL.
BUILDING FEE
1 certify that 1 have read this application and ,all Nal the above information is
0 enact l agree mcamply with all city and county ordinances and state laws relating to
building co isNsminn, and hereby ourboris mile senmtives of this city to enter upon the
QTY, MECHANICAL PERMIT
FEE
SEISMIC FEE
ELECTRIC FEE
above-mentioned property for inspection proposes.
(We) agree to save. indelibly and keep Imnmless the City of Cupertino against
PERMIT ISSUANCE
PLUMBING FEE
liabilities. judgments, cons and expenses which may in any way scans against said City ALTERORADUTOMECH.
in emeco,n nee Of the grunting of this pennil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT(TO 10,(MCFM)
MECHANICAL FEE
SUURCF. 11LAl'ION
AIR HANDLING UNIT (OVER 111,000 CPM)
CONSTRUCTION TAX
Signatum ofApplicam/Commctor Dole
- HAZARDOUS MATERIALS DISCL(ISIIRE
tile applicant or future lail,ing occupant store ormal, mocadoos material
Will dh
as defined by the Capiamer Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)]
EXI MUST HOOD(W/DUCT)
HEATING UNIT (TO 100,00( BTIB
' HEATING UNIT (OVER 100,00D BTU)
HOUSING MITIGATION 'E
❑yes 0 N
VI:NfILATION PAN (SINGLE RESID)
PAID
Date Rcceiptg
'Will the uncal m future building nel.pal use equipment or devices which
emit hmardoas air contaminate us defined by the Bay Arca Air Quality Management
BOILER- COMP UMPOR 1041KX1 BTU)
'
'TOTAL:
DisWcl?
BOILER -COMP (OVER 100,M) BTU)
❑Yes ONO
ISSUANCE TE
ous moments mems under Chapter 6,95 of Nc Calm AIR CONDITIONER
I have read Ne hamNquire
torn Health & Safety Cale. Sectinns 155(15,2553] and 2.55311 nndemmod that if the
NEW RESIDENTIAL MECH, SQ. Ff.
buildingdoes nm currently have a moat Nat it is day responsibility m notify the occupant
of the re immmeras which must be met prior to issuance of a Cenif<me of Oceupmey.
ISSUED BY:
Ownersus thmiud agent Date TOTAL
OFFICE