S 1625 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 1625
BUILDING PROJECT IDENTIFICATION
❑UILDING ADDRESS /I /� l SANT"fARY NO, A T U(1MITTAL�DATE
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OWNER:SNAME: �PIfP�YL /� ONT q F: n�C l]'P:
SVGA✓Ft0�1- LVL {��✓h NIC CONTROLM
. ARCHfI'ECUENGI EER LIC NO: ADDRP 5i q . ❑
CONTACT: PHONE: L✓-r (/�/Yl///a,.c0� BUILllING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG F,LeCT ry.UpIR c
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ I'/IS\\k1JJtt 1 IAO�FJ
I nereny arum mar I nm Ihm,ed ower nraxiaion,orenapmr 9(mmmwomg JOB DESCRIPTION
Oe62 witliSection]WO)of Division3ol"the Business.ndPof a. Code,and ylicen.eia' RESIDENTIAL:
W W— y PERMIT ISSUANCE,
y;VrjF ly.. in toll force ndI force e'er/ �C✓! rZ s ❑SFDWL El KITCHEN REMODEL
Licens Lick APPLIANCES-RESIDIiN'1'IAL ❑ADDITION [I PLUMBING RE-PIPE
Z G W Dam s Convacmr
p.7m ARCHITECT'S DECLARA O PANELS .O MULTI-UNIT ❑STRUCTURAL
Z0,ZZ I understood my plansshall In used as public records ' (� MODIFICATION
OZ�o UP TO 2W AMPS El INTERIOR [I CHIMNEY REPAIR
FBF'; Licensed Professional 201-I0010AMPS IMPROVEMENT F]SWIMMING POOLS
OWNER-BUILDER DECLARATION
d 1 hereby affinn that 1 am exempt from the Contractor's Licence Law for the OVER I"AMPS C1 BATH REMODEV AIR DEMOLITION
3 W H following reason.(Section 9031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. OTHER
m which require,a permit to construct,aper,improve,demolish,or repair any structure
jprior o itsissuarm,"so requires the applicanl far Inch peril In file aligned statementSPECIAL CIRCU IT/M ISC. ,5�
that he is licensed pursuant to deprovisiorsofthe Conitucmrs License Law(Chapter9
W 00 (mmmmcingwith lection 7000)af Dlvi,ma3oftha Badnessand Profession,Cedelm TEMP.METER OR POLE INST. COMMERCI
d y m W that he is exempt dereform and the basis for the alleged exemption.Any violalion of ❑NEW BLDG/ADDITION ❑DEMOLITION
y^m Section 7031.5 by any applicant bra pennitsubjecle the applicanua a civil penally of POWER DEVICES ❑TENANT ❑FWD SERVICE
F. y ant more than five hundred dollars($500) - IMPROVEMENT
p 1-IG p1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
CAL FSO will do the work,and the structure is not intended confirmed for sale(Sec.9044,Badness ❑OTHER
am and Professions Code:The Contmm0rs License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTU 5
property who huilds or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements ore not intended or named far NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building nr improvement is sold within one year ofmmplelion,the SQ.FT.FLOOR AREA $/SQ.FT
mancer-hailder will have the burden of proving that he did not build or improve far pur-
Posc of sola.).
1,as Owner at the property,am exclusively contracting with licensed contractors to TOTAL'
mrelmcl the protect(See 7044,Business and Professions Corley The Contractors Li-
evice Low does not apply to an owner of property who bonds or iinpmves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a emnrect0gs)licensed pursuant 0 the Contractors
License Law, PERMIT ISSUANCE
❑ I am exempt under Site ,B&P C for Nis reason
ALTER-DRAIN&VENT-WATER(EA) L 2VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE r/✓�6
L] I hereby affirm under Penalty of perjury ane of the mllnre wias declarations: D v
I have and will maintain a Cenificateaf Consenuo self-insuforworker's Counter- DRAINS-FLOOR,ROOF,ARE ,GOND, STORIES 'TYPE CONSTRUCTION
mtmq ov
codod far by Section 3700I of the Labor Cade,for he performance of the
hich this peon;,II i...ed. FIXTURES-PER TRAP
o I hove o I will maintain Workers Com ons I Insurance,as required by Section
3VWoflhe Labor Code,farl rfmma of the work far which Ibis permit is lssnw, GAS-EA.SYSTEM-1 INC.4OUTLETS OCC GROUP AIN
My Warkc's 'on whom u e er and Policy ttyy��d.rLtsI�rk
Carrier POIIoyslic- V�Ld GAS-EA.S'fSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASEIINDUSTRLWASTE INTERCEPTOR
BUILDING_DIVISION_FEES
This section need not hewmplcted if theM it is fnnsnehundred tlollary($lIX) GREASEI'RAP
or less.) - PLANCHECK FEE
Terrify lhatin the Panamanian ofmc work for which this permit is issued,Tshall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workeri'Comport ENERGY FEF.
z serum laws of Califomio.Dom WATER HEATER WNENT/ELEC'FR
�j��j Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after mNsing this Cenificare of Exemption,you should WATER SYSTEMlI'RGTING
rHv 5 become subject to the Worker's Compensation provisions of the Lobar Cale,you must SOILS FTSE
n r� Intlhwith comply with such provisions or this permit shall be dcemeJ revoked WAHER SERVICE 1
P
�z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ:FT. PAID [ le eqa#
1 hetehy off un that therein.construction lending agency for the performance ofrk
V Q 'hework for which this permit Is issued(Seo.309''.Civ.C.)
U -(•"t Lender's Name TOTAL:
V Lower's Address TOTAL:
W I certify that 1 have reoJ this applicadHn Ind slate thm the shave informminn is BUILDING
hcorrect,l agree to comply with all city and manly ordinances and stale laws Mining to QTY. MECHANICAL PERMIT FEE
U ,Z building construction,and hereby authorize representatives of this city to enter uponthe SEISMIC E P
above-mentioned property fm naltax ion purposes. PERMIT ISSUANCED
(We)agree to cove,indemnify and keep harmless the City of Cupertino against ELECTRPCG
liabilities.judgments.costs and expenses which mayor any way accme against said City ALTER OR ADD TO MECH. UL
in asequence of the granting of this peit. PLUMBING E
rmL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR I IANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONis
Signature of Applicant/Cantnemr Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant=or future building occupant store or handle hazardous marmot HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Musico de,Chopler 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU)
�Yu VENTILATION FAN(SINGLE RESID) PAID
Dale Rcc.ipl k
Will the applicant,Onm future building occupant use ea Air Qu arm devices which BOILER-COMP CHP OR 1 03,000 BTU)
emit hazardous air conmminanls as red by the Buy Area Air Quality Management TOTAL:
District" BOILER-COMP(OVER IW,000 BTU)
❑Vcs
AIR CONDITIONER /T1 -
1 have recd the he ode,Se rums 255 5,25533 an underChapter1 it 6.95 of the Cali- ✓ v. ISSUANCE DATE
torn'.health Sts ty Cale,Sections 25505,25533 and 25534.I unrlers nd that if the NGW RESIDENTIAL MECH. SQ.EE .�
mi ingd oe,llyb ememnt,that,,is my responsibility tour�fyther wpunl
Hf the m 'c met prior m issuance of a Ceir /
umtrizedagent Date TOAL ISSUED BY:
OFFICE �JQQ�