S 1174 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PI IT NO, A
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MHDENTIFic 1174
BUILDING PN(IJIiCT IUENTIPICA'f10N
SANITARY NO. APPLICATION SUBMIT-FAL HAD
BUILDING AD ESS: Q
OWNER'S NAME: P ONE. C OR'S NAME: LIC NO: ON
/ S14/// ' '�'ed- Is,!> l43C6 `�",�q �aJ1Yl�f/`4/Tk/�/✓l�f1D4J 4,o` -724 N(c corvTRol.a
ARCHITECTMNG)tjEE: LIC NO: ADDRESS./D6J7 "V1164WZel A ZII JJ-L�e.t. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
7-'/�/ 4e. -9y6-1670 ❑ Consultant FmPaid byApplicant(Initiaq BL ELECT PI MLCH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions ofChi 9(commencing
CaZ wtfull Bttrce ani of Divisinn3uf the Business and Professions Code,and mylicense is PERMIT ISSUANCE RESIDENTIAL
4 In ./ ❑SFDWL ❑KITCHEN REMODEL
Licenteclns "`F Ue.N ��� APPLIANCIiS-RESIDENTIAL ❑ADDITION [I PLUMBING RG-PIPE
FG�D�jiA Dete�Conuactor
.jy ARCHITECTS DECLARATION [I MULTI-UNIT [I STRUCTURAL PANELS MODIFICATION
Z O Vj? 1 understand my plans shall be used as public record.
O Z..Q UP TO 200 AMPS ❑INTERIOR C3 CHIMNEY REPAIR
rca,N.,tw Licensed Prsifessianal 201-10IUAMPS MPROVEMENT [7SWIMMING POOLS
P OWNER.BUILDER DT:CLARAI'ION RATE REMODEUREPAIR (]DEMOLITION
Pj ,a OVER IgX)AMPS
6 I reals .Them that I am exempt from she Cn,,mosr'a Lianas Law for the OTHER -�—
XC FUF.. following reaam.ISection]BJLS.Business and Professions Crvfe:Any city^r coumy SIGNS F,LEC"rRICAL
W 4 q which requires a permit ,,consuua,alter,improve,demolish,ar repair any swco me
gprior to its issuance,also re9uims the applicant for such permit In file a signed statement SPECIAL CIRCUITIMISC.
uvvu�1s1 y that he is licensed purmaat n the provisions of the Cmdommea Limit.Law(Chapter 9
Cp0 (commencing with Section Won)of Division]of the Business and professions Code)or TEMP.MIT RR OR POLE INST. COMMERCIAL
q y m that he is exempt therefrom and the bums for the alleged exemption.Any InAmian of ❑NEW BLDG/ADDITION ❑DEMOLITION
uX7
Section 7031.5 by any applicant for u Permit subjects the applicant to a civil penalty of POWER DEVICES EITENANT ❑FOOD SERVICE
FFq.. y t mora than five hundred dollars($5gB. -
2 C F7 1,as owner of the property,or my employees with wages as their aide compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
•W will do the work,and the stmcture is not intended oraRcrcd for sale(Sm.]044,Business ❑OTHER
a-'i and Professions Code:The Communes License Law does rte apply to an owner of OUTLETS-SWITCHES-FIX'FURES
6 a.. property who builds or improves thereon,and who does such work himself or Ibnmgh NEW RESIDENTIAL ELECTR SQ F
his own employees,provided that such improvements arc oat intended or offered for SQ, .F AREA VSQ.FT.
sale.ILow
hever the building or improvement is sold within one year of completion,the
er.builder will have the h mbe of proving that he did not build or improve for pus as
pnsc^faalej. AL: A 26 gNg'0
F11,as owner of the Property,am exclusively contracting wiM licensed correctors to
construct the project(Sm.TAH,Business and Professions Cade:)The Contractors Li- TY
se lawdoes not apply to an owner ofpmpery who hut[&or improves thereon,and QTY, PLUMBING PERMIT FE I r U�• LUr
who emntmcIxforsuch project,with acontractool)licensed pursuant to the Contractors Cfi l llY(J
License law. PERMIT ISSUANCE
1 am exempt under Sec. .Ii&P C for this reason
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby aRrm under penalty of perjuryone of the following daelonnitim:
`Q I have and will maintain a Certificate of Consent to self-insure for Workers Compete. DRAINS-FLOOR,ROOF.AREA,CORD. - STORIES TYPE CONSTRUCTIO
amian,as provided for Isy Section 37M of the Labor Code,for the perforatancc of the
work for which tbo permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insmmnee,as required by Section
37Mofthe labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLIHTS OCC.GROUP AI'N
CarrMy Worke 1pc yynlp.4.9jy InI cY N^yQ �Ls GAS-EA,SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASOINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION EL'ILS
(This section necdne becamPletad Bran pemtit is fission hundred call...(SUM) GREASE TRAP
PLANCHECK PEE
or lea.)
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FF.
nm employ any P1�;tIs
�No
�� many mannerp//snbe=cut the Worked ComPcn- ENERGY FliIi
Z tartan Laws of
i Date D c/ 4 Y WATER HEATER WNE NT/ELECfR GRADING FEE
7O7 O APPlicam YY�D� —Jy
rte- y NOTICE TO PPLICANT:If.nflcr�aking this Ceni��ie of lixcmpuon,you should WATER SYSTEM/IAEATING SOILS FEE
[-+ ^t become subject to the Workers Compensation provisions of the Labor Code,you most
Cat �s forthwith comply with such provisions or Nis permit shall he deemed revoked. WATER SERVICE
y Q
d
CONSTRUCTION LENDING AGENCY NEW RF:SIDEN'HAL l'LMB. SQ.IT. PAID
Iherebyaffirm that premix.construction leadingagency for the performance of Date tp
ua F the work for which this permit is issued(Sec.3097,Civ.C.)
O I.endeh Name TOTAL.
{Uit TOTAL:
Lenders Address
y 1 certify that I have read this application and state Wal the above information is BUILDING PEI?
h
correct.las=to comply with all city and county ordinances and state laws rc)ating to QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z building consouction,and hereby authorize representatives ofthis city to enter upon the
above-mentioned Pmpeny for inspection puTnses. PERMIT ISSUANCE WCONSTRUCTIONTAX
(We)agree n save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD'FO MECH.
in consequence of the granting of this permit.
APPPPL�IICCAAj'§N/1LT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I IkWO CFM) E
SO /' I I NS,/] O l/
AIR HANDLING UNIT(OVER 10.00CFM)
'gnomreof Applemat nnsractar Date IiXHAUST HOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant an future building necupaatsmre nr handle hazardous mntedal Hf:AT1NG UNIT(TO 100,000 BTU)
os defttaA by the Caperton Municipal CMe,Chaise,9,12,and the Health and Safety
Code.Section 25532(0)? HEATING UNIT(OVER IM),000 BTU)
❑Yes CIN. MTMPAL
AN(SINGLE RE SI D) PAID Iymc Receipt
Will the eppliture or helium building rccupanl use equilibrated or devices which BOILER OHP OR Ifp,gXl BTU)
•emit mountaus air contaminants is defined by the Bay Arca Air Quality Management TOTAL:
Disuia? P(OVER 100,(X00 BTU)
❑Yes ❑No
I have read the hmardems materials requirements under Chooser 6.95 of the Cali. ER ISSUANCE DATE
famia Huahh&Safery Code,Sections 25505,25533 and 2554.1 understand that if theIAL ME H. SQ.FT.
building does not comedy hast,a en:mt.that it is my responsibility to notify 0e occupant
of the m,,ulmnenu which must be met prior to Issuance of o Certificate of Occupancy.
Owner or commixed agent Data TOTAL ISSUED BY:
OFFICE