S 1394 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL
CITY OF CUPERTINO PH TT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL � 1394
BUILDING PROJECT IDENT'IFIC'ATION
BUILDING ADDRESS'. SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
O 6 T
EWS AME: PHONE: CONTRACTORS NAMR: LIC NO:
'N O Ar ` QO NIC LCONTE La
ItCHI'I'ECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ ConSullant Fees Paid by Applicant(Initial) BLDG CECT PLUMB MfCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE JO ESCRIPTION
I hereby affirm thea 1 nm Iioena,dunder provisions of Chapter 9(etunmcncing
COO with Sectintlooft. ivioun3oflhe Business and Professions Cale,and mylicrnu is RESIDENTIAL:
WOO O PERMIT ISSUANCE
�ty F in full force and effect. ❑SPDWI. ❑KITCHEN RF.MODEI.
aUU License Class Lic.A APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
h.U;W Date Conlraina
",<a. ❑MULTI-UNIT - [I STRUCTURAL
ARCHITECTS DECLARATION
.r.,Orn PANELS MODIFICATION
p y Z 1 understand my plans shall be used ax puM1lic rcnsNs
Oy�Q UP To 2W AMPS []INTERIOR C1 CHIMNEY REPAIR
1=�CFCW Licensed Professional 201.10WAMPS IMPROVEMENT E]SWIMMING POOLS
2, OWNERRUILDERDECLARA'I'IONOVIik I(XXIAMI'S L1 BATH REMODF.UREPAIR El DEMOLITION 0.'a 1 hereby affrm Thal l am exempt from the Coltracmr's License Law(or the
�06U following reason.(Section]031.5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL El OTHER
'3O yG which requires a Permit to construct,alter,Improve,demolish,or repair any slmclnre
prior to its issuance,ala..requires the split icant for such permit to rile a signed statement SPECIAL CIRCUIT/MISE.
ohm he is licensed..rsaa.Gothe pmvasionsofshe Contractors Licenselave(Chapmt9 COMMERCIAL
Cola (commencing with Section](XXBof Division Sot the Husim,orJ Professions Code)or TEMP.MEI'ER OR POLE INST.
CL LL that be is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
-,y tiedion]03 LS by any applicant for upesmil subjanlhe epplicum loacivil penalty of WPI,UMBINGPERMIT
❑TENANT ❑FOOD SERVICE.
I_
t more than live hondood dollars(85001IMPROVEMENT
2:E 01.as owner of lbe pmpcngm my criployces wilh wages as their sole compensation. L ELECTRIC
y2 will do the work,and the slmcwreis nm imenJM or offered for sale(Sec.]IW4.Itusinesv El OTHER
01, $ and Pori essiona Code:The Cnntmcmr's Liccme Law docs not apply m run owner of OUTRESIDENTIAL
ELECIXTURIS
�'3.. prnpeny who builds or improves thereon,and who does such work himself or tMmgh
his own employees,provided that such improvcurents arc not intended or offered for NEWIAL F.LF.CIR SQ Fri.
wE.If,however the building or improvement is.mld withinnne year ofnsmpletiun,the .FI. AREA 5/SQ.Fr.
owner-builder will have the burden of proving that he did nm build or impmre fm par- /
parse of m1e.). ID
❑1,ns owner,of,bc pmperi,run esclrsivnly contracting with licensed cuntracm.toTOTAL: e D
construct the project(Sec.7014,Business and P..fesJons CWI The Contractor's Li-
c sc law acs on apply..an rwnensf property who bulldsm impnmes thereon,and QTY. MBINGPERMIT FEE /JAp
who contracts for such projects with uuamrumogs)licensed pursuanuoane Conrumuh R trip
License Law. PERMIT ISSUANCE
❑lam exec der Sec. .B&P C for this reason lc
Dam
ALTER-DRAIN&VEND-WATER(HA) UC VALUATI
V
n KERS COMPFNSAT10N IIECIARATI(IN BACK FLOW PROTECT'.DEVICE C/I/
hand Is of maintain
ai under penally to ptrlury enc of @u(nllowing Workees Co
❑ Three anAwill mainminaCenifcatc of Conannnself-inwrcfrr Workers Cnmpen- DRAINS-FL(HIR.ROOF.AREA,COND, STORIES TYPE CONSTRUCTION
.season,as provided for by Section 3700 of the labor Code,for the performance oT the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Co art enation Insurance,as required by Section
370dofihe tabu Code,Ibnhe pmfonnsnccofthe work for shich,his permit is issueA. OAS-EA.SYSTIiM-I INC.40UTLEIS (X1C.GROUT' APN
My Worker's Compensation hounmte comer and Policy number am:
Carrico PMicy No: GAS-EA.SYSTEM-OVER 4 MA)
CERTIFICATE 017 EXP_MPUON FROM WORKERS' GREASEANDUSI'BE WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This cation nadnm W completed if the permit is(Drone hundred do)[.(S IW) GREASETRAP
or Icxs.) PLANCIi[CK FEE
I cenify that in the perfmm�unceofthe work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner m a to become subject to the Workers Cmmpen, ENERGY FEF.
,� mlirn laws of California.Doe WATIiR it LATER WNENT/ELECI'R GRADING PEE.
z Applicant
NOTICE TO APPLICANT:IL ager making This Certificate of Exemption,you should WATER SYS'TRM/1"ATUs'
( nNi must SOILS PIiE
--t become subjm m the Worker's Compcnratinn provisions nl'thc lalwt Cude,you
I�-t IrrlhwiW comply with such provisions nr this pomata shrllbedeemed revoked. WATER SERVICE
Q
a' CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.P. 1'AIU Date R to
V0 I hereby affirm that here iso corchu um kndingagency for the perfmmance of
D-t she work for which his permit is issued(Sec.31197,Civ.C.)
U Lender's Noor TOTAL:
r Ixnder's Address 'T'OT'AL:
9,sL cenify Ihm 1 have read this ad ram ah
ppliera.s.anal the aMrve infnrnnion is BUILDING FEE
t�-iy wrreCl.l agreemcomply wish allcity and countyoNinances and state laws reWling to QTY. MECHANICAL PERMIT FEE SEISMICFI
fJ Z buildingcenstmctiom,and hereby uuthorim represernowlsofthis city enter upon the
ra above-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)aq.to soot,indemnify and keep hamdess the City of Gtpenino against ELECTRIC NI
IiaMlhies,judgments,coI and expenses which may in any way acme against said City ALTERORADDIOMCCH. PLUMBING FEE
in consequeme of the granting rf this ptmon.
Nl'UNIIR ' AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT TO I11,000 CIM) MECHANICAL Fif
SOURCE EGU A IONS.
L AIR HANDLING UNIT(OVER 111,001 CPM) CONSTRUCTION TAX
.gnw rc licant/Commcror Dam EXHAUST HOOD(W/DUC'1) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant.store or handle hazardous nmteriul HEATING UNIT GO I WINN)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safely
Code.Section 25532(a)7 HEATING UNI'((OVER 1 flog)BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Dom Rreoiplp
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 1000 XI BTU)
emit hazardous air contaminants os defined by the Bay Area Air Quality Matmgemenl TOTAL:
Ulstria^ BOILER-COMP(OVER I W,000 BTU)
❑Yes ❑No
I have real the hamodrus materials requimmenm under Cbapler6.95 of the Cali- Alk CONDITIONER ISSUANCE DATE
forma Health it,Safety Crude,Sections M:R)5.M533 it 21534.1 undersmlN that it the NEW RESIDENTIAL MECH. SQ.Pf.
building Jas not currently neve a learnt that it is my respmsibility to notify the occupant
of the requirnmend which muni be met poor to issuance of a Cenificae of Oc uparcy.
Owner m aulbonmd agent Dale TOTAL: ISSUED BY:
OFFICE