S 1042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE$ ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. ` 0 /�
BUILDING PROJECT IDENTIFICATION V LF
BUILDING ADDRESS: SANITARY NO. APPLICA'I"]ON SUBMITTALIATE
AO 8 COZ&
OWNER'S NA ,O
n PHONE: CO 'HACIR)R'$NAME: LIC NO:
f�� � N/C CONTROL M
• ARCHITECTMNGINEBR: LIC NO: ADDRESS nO ^ ❑
' CONTACT: PHONE:
C p� BUILUINC PGRMIT INFO
t �e I n9 _Q/� ❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(p ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC P17RMIT FEE
1 hereby affirm that I am licenced under provisions of Chapter 9(commencing
with th Smnc00)ofilivisinn7of the Rosiness and Professinnn Cade,and myliecnse is JOB DESCRIPTION
I,,,WO mull farceeanmid eRm, PERMIT ISSUANCE RIAL
aUZ License Class Lic.# WL ❑KITCHEN REMODEL
yQ Date Comm,hm APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE.PLPE
ARCHITECPS DECLARATION PANELS ❑MULTh UNIT ❑STRUCIURAI.
Ox[/12 1 understand my plans shall be used as public records MODIFICATION
J UP TO NIRAMPS C1 INTERIOR ❑CHIMNEY REPAIR
�i�W Laensed Professional 201.100IAMPS IMPROVEMENT []SWIMMING POOLS
0L,U Oat I ma exempt
from
m he CoATION OVER 1000 AMPS ❑BATH REMODEVREPAIR ❑D17MOLI PION
3d'W< I hereby off rte Nal 1 em a pl Tann the Cnsimis C's License Law efarm the
0 which requires
Parma
ato construct,alter
w,detol Code:Any cityorcmunly SIGNS ELECTRICAL ❑OTHER
W o wmen regaires a permit to ennntna,rarer,improve,dentmian,or repair any Nwaare
ESN primo itslssuance,also requires the applicant far such permit File a signedsmmmem SPEC IAL CIRC'HDMISC.
>. Nm he is licensed Inrsuannn the provisions of the Contractors License Law(Chapter 9 J
W�C0O (commencingwilh Section 70f)ofDmision7 ofthe Business and ssio
Profens Curator TEMP.METER OR PILE INS'1'. OMM R CIA
a X n pf that he is exempt therefrom and the basis for The alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W,_,m Section 7071.5 byanyapplicanl fora permit subjects the applicant ma civil pararkyof POWER DEVICES
�a} notmore(him live hundred dollars(SSW). ❑T17NAW ❑FOOD SERVICE
Sp ❑ I,as owner ofthe property.Or my employees with wages as their sole compensation, SWIMMING POOL ELE IMPROVEMENT
will Jo the work,and ot the structure is nmanced!Oronered for sale(Sec.7044.Business ❑OT ER
Ice and Professinnn Coca The Corom ma,License Law does not apply To an owner of OUTLMS-SWITCHES- URES
property who builds or impmvea thereon,and who dove such work himself or through
his Own employees,Provided that such improvements are oat intended or offered for NEW RESIDENTIAL ELECIR%(LA) )X4
sale.If,however,Ne buildingor improvement is sold within ane year ofcomplaiom.the SQ.PC FLOORARBA $ISQ.Ff.
er-builder will have the burden of proving that he did not build Or improve for put.poseOfsale.). 14❑ h as owner of the ProPny,um exclusively contracting with licemcd contractors to tense La the es not (sec.n an wner of and Professions d'or impro)The Correctors Li- �����censelawdrennmapplymon owner Ofprotons who buildsnrimt Loth thereon,and QTY PLUMBINGPEFE
who seLaw,fur such projeea withacantnctor(s)licensed pucxmanl mthe GsmnemsLiwna law.I am exempt under Sm. ,B&P C for this reason PERMIT ISSUANCE
OCT
A 1997
Owner Dmc ALTER-DRAIN&VENT-W1 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIhereby afOrm under penalty ofperjury one Of the following deulimmons:❑1 haveand will maiiat CcnificateofCnnammself-imm for Workers Corpcn- DRAINS-FLOOR,ROOF,RHSTORIES TYPE CONSTRUCTION
Nation,as pnwided far by Section 37M of the labor Code,future performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation brunnce,m required by Section
3700 of the Labor Cale,for the performance of the work far which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker i, nsel�n lns7ariePlcy leo.: nhc_y� _'I�D^Z- GAS-EA.SYSTEM OVER 4(EA)
COATIFICAT6 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not becompletctl ifrhe .it is forme hundred dollars($100) BUILDING DIVISION FEF_S
or less.) GREASETRAP
PLANCHECK FEE
I cenify that in the performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.210 FT.
.or employ any person in any manner so as to become subject m the Workers'Compete ENERGY FEE
O ,� action Laws of California.Data
Z O Applicant 1 WATER HEATER WNENT?:LECTR GRADING HE
rr h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTI?M/TREATING
becomesubjentothe Worker's Compensation pmviaiomoflhe Later Codayot mull SOILS FEE
LSI fimhwith comply with such provisions Or Ws permit shall IN,deemed revoked. WATER SERVICE
Q n
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
L) 0 l her which
Nanhete isacamwc.30 len ding agency for the perfomonre of Date Recciptp
W the work for wM1ieh thin pernil Is issued(Sec.JT0],Civ.C.)
U Leader's Name Arora
� � Lendar'.e AJJresa TDITAU
1 cenify that I have read this application and stale that the shave mfomrlion is BUILDING FEE
to come[.l agree to comply with all city and county ordinances and stem laws robing to QTY. MECHANICAL PERMIT FF.E
U� building construction and hereby authori,representatives Of this city to mar urym the SEISMIC FEE
chose mentioned pr.,my for inspection purposes. PERMIT'ISSUANCE
(We)agree to.save,indemnify and keep harmless the City of Cupertino againn ELECTRIC FEE
liabilities,judgments,cents and expenses which may in any wayaccmengainslsabI lily ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQWII CFM)
ION
SOURCE REGULATIONS. MECHANICAL FEE '
AIR HANDLING UNI'IyOVER 100X)CFM) CONSTRUCTION TAX
Signature of ApplicantlCoutmcmr Data EXHAUST HOOD(W/DUCD HOUSING MI"fIGAT10N HE
MATERIALS DISCLOSURE �s
Willtheapplmmam future building cam.pant xmreor handle hazardous material HEATING UNIT(TO 101,000 BTU) Z `�
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and safely
Code.Section 25572(a)t HEATING ONIT(OVER 1000M)BTU)
❑Yes ON.
VENTILATION FAN(SINGLE RFSID) PAID
Will thea 1h ant or future building p equip rcol or devices which Use Raelpt#
pp gaecu occupant
emit us air contaminants as defined by the Bay Area Air Qualify ManagementBOILER-COMP LHP OR 100.000 BTU
District?
] TOTAL:
❑Yes ❑No HOILER-COMP(OVER 100,000 B'I'O) _
I have mad the harurcous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
famia NwITh& comerolely Cade,Sections 25505,2.55]3 and 25574.1 understand a that if the NEW RESIDENTIAL MECH. SQ.FT. /O ^/ `?y
building dues nor is which
y have a met p dot n is my c eol a C mfito ramify,Ne parry. /
of the rgairements which meq be mel prior in issuance nl a Cartilicam of Occupancy.
Owner or amhonzed egant pate L' V �•'"` A ^�O
ISSUED BY,
OFFICE