B 0394 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CDPERTINO BUILDING-ELECTRICAL PERMITNO. S O 3 9 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOO1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL UATI
/�// o/u
OW�NFR'S NAME: (� PHONfb:: CO LTOR'S NAME: /�,/f LIC bfo:
1/ IVa,'d Pt4s S In Grw ;73 -1 SQ �/'Y^Lp V / y/ljs N/C CONTROL.#
ARCHITECT/ENGINEER: LIC NO: AD�a�, J• �//2ti �� f ❑
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E:::
PHONE: ` BUILDING PERMIT INFO
❑ Consultant Facts Paid by Applicant(Initial) BLDG ELECT PLUMB/MUCH
253 -a I � ❑ �
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE JOB DESCRIPTION
1 hereby elft..that I oro licensed order provisions of Chapter 9(commencing
wo, Section7N)ofpivision 3 afthe Business and Professions Code,and my license is RESIDENTIAL:WOO PERMIT ISSUANCE
1, full force and effect. ❑SFDWL tS,�JNE
KITCHEN REMODEL
aUU License Close LiaN APPLIANCE'S-RESIDENTIAL. ❑ADDITION 1M"NG RE-PIPH
F�W Dau: Cnnwclur
rq q 0MULTI-UNIT []STRUCTURAL
ARCHITECTS DECLARATION
F IumlersmM myplaavmitil themed as public records PANELS ( MODIFICATION
CZrO UP T02W AMPS TOR CHY REPAIR
om Licensed Prnfcssioel 2D1-IDDDAMPS IM F: O (JING POOLS
9d9am, OWNER-BUILDER DEC ARATION AVER I AMPS ❑BATH R O IIREPAIR ❑DELITION1 1 hereby a�irm Thal l am exempt from the Conlmctors License Law far ther,
igSOgV following reason.(Section 7031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL HER
u+3Ii, which requires a Permit to consumer eller,improve,demolish.or repair any stmeture 7 ' �
I-u'O pricomimism.nee.also.quires meapplicantforsuch pnmil m file n sigoedsmamem SPECTALCIRCUIT/MISC.
2�{} that he is licensed pursuant o the previsions of the Conrractars License Law(Chapter 9 Q�
��C�O (commencing with Section 00001 of UivisionJaf the Business and Prnfevions Gdc)nr 'I'EMP.MET ER OR POLE INST. fOMMERGIAL:
W m
mm that he is exempt therefrom erW e baric far me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ')(]DEMOLITION
4•
Section 7031.5 by any applicant for apmmit subjects the applicant a a civil Penalty of POWER DEVICES [3 TENANT ❑FOODSERVICE
m oat more bun five hundred dollars($500). -
=6 1,as avnensfthe norm employees with weesas their sole cote lion. SWIMMING POOL ELECTRIC IMPROVEMENT
(, i
O ❑ ProPe Y Y P Y 8 Penxu ❑OTHER
a$� 'lDhOh.wolconOe noucmm is not intended orolfercd forsafe(Sm.J04 ,Business
yl dao and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who build or improves thereon,and who deo such work himself or through
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one year of completion,me SQ.I4.FLOOR AREA It SISQ.FT.
nerboilder will baseline burden of proving that he did not Wild or improve Pbr Pur- 4"
e of sale.).
TOTAL:
0 L as owner of the property,am exclusively contracting with licensed contracron to r
construct the project(Sec.7044,Business and Professions Coder)The Contras urs I.i-
nseLawdoesnetapplytoanownerofProprnywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
.1mommacts for such p.jeets with a cantracm(s)licensed Pursuant m the Connectors
License law. PERMIT ISSUANCE 3 s
❑I am exempt under Sec. .B&P C for this..an
ALTER-DRAIN&VENT-WATER(EAI VALUATION
Owner pate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
F-]
I and will
miler penally of perjury one of the inllowingsure for fttlmr's Co
Ih, sand will mainby ed..Gane of Catem to Code,fureforermor'ti Camper- WAR�.FLOOR,RODE AREA.CONU. STORIES fYl'E CONSTRUCTIOI
court,ms hick thi for mi Section 30(q of me Labor Curie,far me performance of thework for which this pmnil is i ored. -PER TRAP1 have and will maintain Workers Compensation rk(or hi h required by Section
30W of me LuhorCodc,for thee,prrerformance n(me work for which this permit is issued. SYSTEM-I INC.40l1TLUT5 OCGGROUP APN
MyWa sCo LtV nyirter Pat is nTatb�cq.,Cartier / n9G 0 .SYSTEM OVER4(EA)CER ICATEOFEXI PTIONFROMWORKERS' NDUSTRL WASTE INTERCEP ORCOMPENSATION INSURANCEBUILDINf,DIVISION PF,IiS(This section need rut M completed ifthe permit is far..handreddmlma(SI0ffiRAPless.) PLANCHECK IrF.E
I eerily that in me peonconaee ofine wrk for which this permit is issued]shallSANITARY-STORM RA.200 FT.not employ any person in any manner so as m become subject m the Workers'Compen- ENERGY fiE
Z cation Laws of California.Date EATER W/VENT/ELECTR GRADING FEE
O O Applicant t
UJ NOR'IC17 TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENUTREATING
SOILS FEE
became,object to she Workers Campementioa provisions of the Latour Cale,you must
ai
to
nhwa"ourglywah suchprovisionsmthispendlshatl bedeemalrevoked. / WATER SERVICE r L
W Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII SQ.ET. PAID
I hereby aBirtn that them is a construction lending agency for the perfornmar.of -Dam R<ciPtN
Wthe work for which his permit it i...vd(Soe.309T,CIv.CJ TOTAL:
Lender's Name
0 Icoder.,Address OF L
rectify that I have read this application and slate met the ahnve information is BUILDING FEE
i.r h correct,l agree In comply with all city and county ordinances and slam laws.]..ing m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V z building continuation,and hereby aumorice rtpresrngeuves afthis city to emeraprnthe
F-t above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hmmlesa the City of Cupertino against
liabilities,judgments,conga and expenses which may in any any mome against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting oft .rig.
APPLICANT UN E AND' WILL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT(TO 10,IXX1 CFM) MECHANICAL FEE
SOURCER. NS.
S/3-99 AIR HANDLING UNI'f(OVER 1Q0017)CFM) CONSTRUCTION TAX
Signa ofA Aiemit/ < r 7Do. EXHAUST GOOD ONMUCO HOUSING MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oocuPaat store or handle hazardous material HEATI NO UNIT ITO 100,003 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT LOVER 1 W,OW IIID)
Code,Section 25532(u)?
❑Yes �N VENTILATION FAN(SINGLE RMID) PND --
Uma RuciplM
Will me applicant or future building occupant use equipment or devices which BOILER-COMP CHIP OR 100,000 BTU)
.
,not h,I.A us air contaminants as defined by the Ray Arta Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,01X)BTU) O
C]Yes
I have read the haz7d.om materials under Chapter 6.95 of me Cnli- AIR CONDITIONER ISSUANCE DATE
and.Health&Safcty Code.Sectio 25505,25533 amt 25534.I undealand that if the NEW RESIDENTIAL.MECH. SQ.FT.
buddingd.es not mI h that it my resPonsibilily to notify the occupml
of there :prion aC ificme of Qcupwcy.
Owne t sed age m !/ _�am TOTAL: ISSUED BY:
OFFICE