B 0422APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - SE BALL POINT PEN ONLY
CITY OF CUPF.RTINCI IBUILDING- ELECTRICAL t PERMIT NOig aux
BUILDING DIVISION APPLICATION/PERMIT%ADDR�9S;/
PLUMBING - MECHANICAL. SOOOI LL
LDING PROJECT IDEYf1F'ICATI IN
BUILDING ADDRESS: SANITARY NO. API'LICATIO� UBN^VyTTAL DATE
es o N14 g
OWN R:S NAME: P ONE:: AME: LIC NO:
QN/C CONTROLR
19-7
RCHITEC'OENGINF.ER: LIC NO: Tlb 6L, mole- ❑
CQNTncr. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MF,CH
LIC ED CONTRACTOR'S DEC(. NATION QTy ELECTRIC PERMIT PEE
I hereby M. that 1 am licensed under provisions of Chapter 9lommencing JOB DESCRIPTION
'O a,Z with Secction'/pgOof Doision 3ofthe Business and "OR'
al e.andmylarriseix RESIDENTIAL,
W O PERMIT ISSUANCE
FWO lull forceand/'�- - ❑SFDWL ❑ KITCHEN REMODEL
RUV License lass v Lic.p APPLIANCES-R[SIDENTIAI, ❑ADDITION ❑PLUMBING RE -PIPE
4, W Ume Co m
N t1 ARCIII'TF.CT'S DEC RATION ❑MULTI -UNIT C1 STRUCTURAL
I-, D on PANELS MODIFICATION
O an z 1 undersmnd my plum shall be used as public records
zoo UPT02MAMPS ❑INTERIOR ❑CHIMNFY REPAIR
�F Licensed Profitoioml 101-1000AMPS - IMPROVEMENT E]SWIMMING POOLS
OWNER -BUILDER DECLARATION OVER IIXM AMPS ❑ BATH REMODEUREP IR El DEMOLITION
Q0.' < 1 hereby affirm that 1 am exempt from the Contramnr's License Law far the 2A, w..r� 11 yds L
O y U fopnw;ng reason. (Section 7031.5, Business and Professin s Cade: Any ly nr county SIGNS ELECTRICAL OTHER F�.[z{c-, _�--
ILO
which requires a permit m conswc. alter, improve, demo a repo eny arvcmre � `� 1 T' 'J :�%
�' pnnrmiu issuance, ulsn requires the oppliwntfar such permit Ole gat) statement SPECIALCIRCIRT/MISC. Q -L..•. b.5
that be is licensed pursuant m The provisions ii Contractors. se Law lChapmr9 COMMERCIAL
°•'GAO (commencing with Sedion]WO)af Division Ser rad Profcisions Code)ar TEMP. MEI' ER OR POLE INST y—I'
y o y thin he is exempt therefrom and the ba;., for Ne a ad 's Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
.m. Section ]OJLS by any pliant fora pemtin ass eapph n loucivilpenaltyof POWER DEVICES ❑TENANT ❑ FOOD SERVICE
m t more than five bun cd dollars (yl V
l
pF56 1, os owner of Chep pony, or an
ravagesas their sole compensation,SWIMMING POOL ELECTRIC IMPROVEMENT
O willdoshework,and, estrvcwrcmBared for sale (Sec. ]DN, Nusinas❑OTHh:R
Ictal and Professions Cod :TheCons cow does not apply m ua owner of OUTLETS -SWITCHES -FI XTURFS
pmpeny who hadda r imrovaJac.such work himselfor through
his own employees provide ass improvemenu are nos intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale. IL however, t huildin mimpro embsold within one yearafwmpl<tion, the SQ. IT. FLOOR AREA $1SQ, FT.
owner -builder will Nen of pm ing that he did nos build or improve for Pur-
pnse of sale.).
❑ I, as owner of she pope , am exclusively condowtng with licenwd contractors to TOTAL:
amtma the project (See. ] Business and Pmfea dca. Cale:) The Contractors Li-
wnseLawdoexnotapplytoa owner ofpmpeny whohuilds or improves thaeon.und QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conuwtnrts) licenxed pursuant m Ne Conimtor's
License Law. PERMIT ISSUANCE V
I am exempt under Sec. ,B& P C for this reason
ALTER - DRAIN & VENT- WA'T'ER (EA) VALUATION
owner, Dine —r 50
WORKF,R'S COMPENSATION DECLARATION BACK FLOW PR(TI'P,Cf. DEVICE
I hereby affirm araler penalty of perjury one of the following declarations:
C I have and will maintain a Certificate of Cenunun self inure for Workers Camara. DRAINS- DOOR. ROOF, AREA, COND. STORIES TYPE CONSTRUCfIob
soden, us provided for by Section 3700 of be Lahr Calc, far the prof ormace of the
work for which chis permit is issued. FIXTURES - PER TRAP
gKl]W
1 have and will maintain Worker's Compensation Insurance, as required by Section
of the Labor Cude. for the performance of the work for which this pemris is issued. GAS-E&SYSTEM-I INCAOUTLMS OCCGROUP APN
My Work edW'•Cr �I spce cPer ay u r
Car Polio No.: A[9D1
n18 GAS - EA, SYSTEM -OVER 4IRA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(This section need not he completed ifshe Permit is ounce hundred dollars IS [ad) GREASETRAP
or less.) PLANCHECK FEE
I ecAfy that in are perfrmanceof the work for which this permit is issued. )shall SEWER -SANITARY -STORM EA. 200 IT.
nntemploynnypersaninanymanners aLt22 4Wtit, the Workers'Campcn- ENERGY EEE,
z ration lavKp[Calif�ia. Dgl•—'rye• WATER HEATER W/VENT/ELECgft
Z Applicant t 5 `��L GRADING FEL'
NOTICE TO APPLICANT: IL fair making his Ccnnficate of Eaempuon, you should WATER SYST"VDIEATING SOILS EEE
become subjauo the Workers Compensation previsions of the Labor Cale, you muss
a ri fonhwirb comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
A Gi
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ. PT. PAID
V Q(hereby afGnn that them is a Construction lending agency for the performance of Date Receiptp
1^ the work for which this permit is issued (Sea 3097, Civ. C.) TOTAL:
0 U Ixmi Name
(4/ Lender. Address TOTAL.
Ly, 1 ormfy that I have rend this application and sate and the above mrom ttlon i.v BUILDING FEE
Lr cI come.I."rem comply with all city and county ordinances and sane laws reining m QTY. MECHANICAL PERMIT IEE
U building Construction. and herehyaushomc re,anummsivesof this cis, m Cut, .11. me SEISMIC FEE
above-mentioned prepeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
WC) agree m save indemnify and keep harmless the City of Cupertino against
hibilities,judgmctit c and expenses which may in any way seeme against said City ALTER ORADDTO MECH. PLUMBING FEE
;nemaka,enceofsh Inti 1 1 it
APPLIC "U NO A D (LLC LY WITH ALI. NON -POINT AIR HANDLING UNIT(TO I0A00 CFM) MECHANICAL FEE
SOUR f , R
_ AIR HANDLING UNIT (OVER IB,fIIXI CPM) CONSTRUCTION TAX
Sig uremApplicanVContmcmr DamEXHAUST HOOD(W/DUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will sheupplicantor future building oceupanssme.r handle hamrdaus material HEATING UNIT p0100,000 BTU)
a defined by Ne Capemam Municipal Code, Chapter 9. 12, and she Health and Safety
Cafe, Scoion 25532m)1 HEATING UNIT (OVER 100.000 BTU) {{I .A 'sl
❑Yes IQN. VENTILATION PAN (SINGLE RESID) PA
I f I Doc Racipt p
Will the applicant or future building occupant use equipment or devices which BOILER -COMP (3HI' OR 1(IO,akl BTU)
emit hawardous air contaminants a defined by the Bay Arca Air Quality Management
Dburia? BOILER -COMP (OVER 100.000 BTU)
Yes �No
I have reach randoms matermis repamournss under Chapter E95of the Cali. AIR CONDITIONER ff ISSUANCE DATE
fomin Health & Sa C minus 25 , 255 ]3 and 25534. 1 undersmnd that if Ne NEW RESIDENTIAL MECH. SQ. ET. !
building doesno rix h own tis my pensihility to notify the occupant
raphe re r ns- usth [uCeniri-jof. DerMY
OFFICE