S 1453 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF: IT NO.
BUILDING DIVISION APPLICATIONIPENMIT PLUMBING-MF.CHANICAE 1453
BUILDING PROJECT IDKNfr F'ICATItIN
DING ADDRF_S5: �Ny SANITARY NO. APPLICATION SUBMITTAL
-DAT(
WNERS NAME HONE: )N A NAM.: "JCO
N/C COMROLa
,, AR ITECfR3NQIN.ER: LIC NO: AU RfS. ❑
CO ACT: PHONE: p� mss( BUILDING PERMIT INFO
•p 74— �S ❑ Consultant Fees Paid by ppb nl(Initial) BLDC ' ECT PI MB MLCH
LIC :ED COM'RACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
I herby alum that I am licensee under provisions of Chapter (unnnsncing JOB DESCRIPTION
CaZ with Section 7(XX))ofDivision lot the Businessamd Professions Ctde.mld my liscou is RESIDENTIAL:
PERMIT ISSUANCE.
FOO in full force al / ❑SFDWL ❑KITCHEN REMODEL
aUZV Liccn,m LIC.X APl'LIANCIS-RESIDENTIAL. ❑AUDITION ❑PLUMBING RF.-PIPE
R, W Dem C, cmr
H 6 [I MULTI UNIT ❑STRUCTURAI,
rR RCTS iC1b roe PANELS
ZO Z croon It Ysq fth l' MODIFICATION
OZ C UP'f02(IU AMPS ❑INTIiR10R ❑C IMNEYRHPAIR
FN.�W 1, 201-HN1f1AMl'$ IMPROVIiMENT WIMMING POOLS
qC C C Q 1 hereb �1 inn thmN um BUILDER
the Contf�ONn License Law fnr tM1e (WER 1000AMPS ❑BATH REMODEUREPAIR D OL ION
yqopU.0 following re (Section 9031.5,Biumesamd Prto
ofeums Cale:A,city or cotom, SIGNS ELECfRICAL ❑OTHER
Y13 W y which requires a permit to construct,alter,improve,demolish or repair any stmclure
prim to its issuance,also mattirs the applicant for such permit tome a signed smmmcm SPECIAL CI CUITMISC.
that be is n
licensed pummano the provisions of the Contractors License Law(Chapter 9 COMMERCIAL:
Wa�� (commencingwith Sectiov 7000)of Division 3 of the Business and Ptnf<ssions Code)or '1'EMP.M B RPOLE INST.
d 6 ey that lie is cxcmph IhereGoat made basis fnr the alleged exemption.Any column ml ❑NEW B�lLQDGIADDITION Cl DEMOLITION
W^N Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER D ElTENAB F.WIIdtt3 D ❑FOODSERVICE
manmre them live hundred dollar,($500). IMPR V
[:) o
1,as wner of the p,,,ny,.r my employeeswith wmgen as their sole camperiatinn, SWIMMING POOLE79RIC ❑OTHER
willdothcwofk,and domonur is not intended moffered for.1,(See.7844,Business
3 m and Professions Code:Tho Commaors License Law does nm apply m nn owner of O11T1.Efs-SWRCHF.S- 'UR'
property who builds or improves thereon,and whit does such work himself or through
Id,own employees,provided Item such improvements ar not inumdell or offered fnr NEW RESIDENTIAL ELEC'R SQ F1'. Tb
nine.IL however,the building or improvement is sold within one y<arofI Rem"We FT.FLOOR AREA &5Q.FC
iter-builder will have the harden of proving that he did notbuilJrriinpmveforpur- �- laU�"[MIINV
pose of sola).
1,as owner of the prnpenY,um exclusively contracting with licensed mmmrsors to 'TOTAL:
construct the project(Sec.7044,Business and Professhms Code:)The Contractor,Li
-
ceoneLawdoesnotapplytoanownerofpropertywhobuildsorimptoves(hereon,and QTY. PLUMBING PERMIT FEE
who commcls for such projects with u amvactorts)licensed pummord to the Commodities
License Law. PERMIT ISSUANCE
❑1 or exempt mode,See. .B&P C Italia,..at
ALTER-DRAIN&VCM'-WATER(EA) VALUATION
Owner Date ^
ei
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty or perjury one of the following declemtons: V—
Ej Ihave and williminminaCedificatcofConsenl to self-insure for Wmkers Comfort- DRAINS-FLOOR,ROOF.ARBA,COND. STORIES TYPECONSTRUC3'I0t
saliva,as provided for by Section 3701 of Ibe labor Cndc,for the perfommnce of the
work far which this pandut is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensmion Imamate.as requined by Section
3700 of the Labra Cale,for the performance of the work fnr which this permit is issued. GAS-EA.SYS'1'GM-1 INC.4OUTI.EfS (>CC.GROIIP APN
My Workers Compensation Insurmce carrier and Policy number am:
Carrier. Policy No: GAS-F.A.SYSTEM-OVER 4(EA)
CCRTH ICAT 001 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION ES _
Glus section need not be completed ifthe permit is for onchondfed dollars($100) GREASE TRAP
ar less.) PfANCHI!CK TLE
I certify that in the performance of the work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
oat employ any person in any manner so as to become aubjecno the Workers'Cnmpem ENERGY FEE
Z satin.Laws mf Colif nnia.Date WATER HEATER WNEN'L'IELECIR
Z Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenilicme of Exemption,you should WATER SYSTENIVI REA'I'ING SOILS FEE
became ml jvO lathe Workers Compensation provisions of the Lobn Code,you moa
W L+ forthwith comply withsuch pnovisioreor this permit shall be deenedrevoked. WATER SERVICE
Q
.ati. z CONS]RUCTIONisac ONLENDING AGENCY NIiW RF.SIDFNfIAI.PLMB. SQ.FL PAID
UO (hereby amnn that rsoconswaion lending agency for the pednnnwcc of D°" Receip'N
the work for which this permit Is Issued(sec.31191,Civ,Cd
TOTAL:
0 U LendersTOTAL:
Name
Lender's Address 1.:
1 cenee that 1 have read thirty and county ordinances site that the above instm:niv.is
ItU1LDING FEE /
to corrcrs.Iommot comply wim all alsond cepre,mvesof and suite rowsr Upon the QTY. MECHANICAL PERMIT FEE
U building umxwrsinn,and hereby auMoriu mpresenutives of this city to enter upon the SEISMIC FEE
above-mentioned progeny for inspersion purposes. PERMIT ISSUANCE
el ngrr a save.
indemnify and keep harmless the City of C.Iar ins against ELECTRIC F E
uhilhies,judgmc .sand pemes which may immy wuymcmcagainameid City ALT ER OR ADD TO MECH. PLUMBINGZEE llulc
imcooseque ' of reg,nti his .it.
APPLIC T It DE AND WILL COMPLY WITH ILL NON-POINT AIR HANDLING ON['F(TO I0,000 CFM) MECHANIC FEE
SUU .'RF, LA
AIR HANDLING UNIT(OVER 10.00B CFM) CONSTRUC'DONT
re cu Commmor Ihim EXHAUST HOOD(W/DUC) HOUSING MITIGATIONF
HAZARDOUS MATERIALS DISCLOSU i
Will the applicant or fmar building cecupam sir or ban Iehaztrdousmatedal HEATING UNIT(1010(1,(1(10 BTU)
101/ as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heahh and Safety
Cale.Seelion Z 532fa)'! HEATING UNIT(OVER 100.00)BTU)
E]Yes ❑No PAID
_ VIiM191.ATION IAN 'Liz RFSID) Date Recciptp
�1 Will the epplicam or furore building mcupma ecu equipment or devices which HOII ER-COMP(IHP OR IIp,1MN1 BTIO
emm il hamedoair contaminants as defined by the nay Arca Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100.001)BTU)
E]Yon, E)No
I have read the hmardovs materials mvitmmcuts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fmmla Hmlth&Safey Cole,S<miona 255o5,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FL
building does not cure toy have a tenant,shot h a my re,nomobiliry to ooify the occupant
of the requirements which must he met prior uP ixsmunce of a Certificate of Occupancy.
O serol a nhmiud agent Dale T(rTA: ISSUED BY:
OFFICE