00020013 - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMfr NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
-BUILDING PROJECT IDFINI'IFICATION
BUILDING ADDRESS SANITARY NO. A .ICAI'ION SUIMI'TA.DAI'li
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D\VNP 'S NAME: - r VI1oN@ —� '1'I$ACI'GR'S N VE LIC NO:
- NIC CONTROL#
LIC NO ADDRE S:
1 COO
CON 9 //r, Q. / _4. NFi _ ' BUILDING PERMIT INFO
�fV�[ C `4 j 6 7 , Consultant Fees Paid by Applicant(Initial) RhpG ..LPLUMB MECH
y — CT❑ ❑ ❑
LICENXEDCb A OR'S DECI.ARA'L'ION QTY ELECTRIC PERMIT FEE.
1 nercnv umrnt dnw 1 am Ii¢mea Dana.pr..viaiana of Cluipter 9 mannnea my JOB DESCRIPTION
H�oZ with5carom7flfl(Bnf Division 3..f Ne beire,o.rel'roresaian..Gee,ane mylinn'e Vs pF.RAfIT ISSUANCE RESIDENTIAL
W G in full!orae rod effect.
aUV License Cinss - Lick ❑SFDWL ❑KITCHEN REMODEL
F,Za Dam Contractor APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
p,Wm ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
zot2E Iinwnumdmy p' It be heads,pnhlicrecords MODIFICATION
O Z-0 UP IU 2W AMPS .J
F�E"ar Lmcnscd Protcamnul LJINTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT t
OWNI.1.excI-DERnt the ionewN ❑SWIMMINGPOOLS
Q I hereby affnn that I um exempt from the Cummanr's License law for the OVER IIX)f1AMP5 ❑BATA RI!MODIiI 2EPAIR ❑D1iM01.IT10N
�L O a U fallowing mason.(Section 7031.5,Business and Profcssians Code:Any city or county ❑M HIiR 1
It1 a W N which ragnims a Penh o connruet,alter,improve,Aemolish,nr repair ru t t SIGNS BLECI'RICA1,
FSO prothat hoi¢ e.pursuant
requiresin he 0ovisio ant softly Conamech mluLicese signedstatementSPECIAL CLRCUIT/MISC. 51� � Qt
thathelicensedp :u a m p fd C t t 'sl I lChunsr9N�
W...QyOy b with'eco.,7000) ID 30 he B , a dP I :, ,Code)in fF.MP.METI!Ii OR POLE IN 'I'.
Xm W than been, pl therefrom d don hansis for the alleged Exemption An,violation of El NI!W BLDG/ADDITI L
W"Eo Section 7031 5 ba l y any rill c. for a Perm t subjects the applicant to n civil penalty of PoWEH DHVICIIS
F 2.t' nal more In..five hundred Jnllaa($500E - [_1 TENANT ❑FC)OD R1iliYlG1!
=QDl,as owner..!the pmpeny,or my employees wiNwagesan nheirzale compenwtinn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the stmanre is not intended eroffcred for sale(Sea 7044,Business ❑Q1'HER
41 t.9 and Professions Code:'the Contractor's License Law docs not apply In an owner of OUTLC'i'S-SWITCIIIS-Fix TURES
popery who builds or impoves thereon,and who does such work him®If or though
his awn employ«s,provided that such improvements are nal inlendctl tar olTcr' for NEW R ESIDENI'IAL FLECCR SQ FT.
cvle.lf.howevaq the buildingooinnprovemem itself within one ye an denmpluliunnhe SQ.FL FLOOR AREA $/SQ.FI'.
owner-builder will have the burden of moving than he did not(wild or impove for par
1.
cr of the property, exclusively contacting with licensed enactor
construct nhepojem(Sea 9(114,,B mmfe
iness and Pnsinns Code:)The Contractors -
cenmLawdoesn(,,rpPlytounnora of prnparty who huildsmtmpnrvcsmernoi,a I QTY, 'PLUMBING PERMIT FEE
wha contracts for such projects with a commotarts)licensed pursuant in the Coordinators
License Law.
❑ lemexem IdarSo,. ,11&P C for lhix mason PERMIT ISSUANCE.
ner? �� Dane ALTER-DRAIN&VENT-WATER(HAL VALUNNON
VGRKER'S COMI'I!NSAI'I(N DECLARA'MON 13ACK FLAW PROTECT'.DEVICE l O
1 hereby afford under notel ofperjupreofthefolhavingclaclarmions: J
/ ❑ I have and will main....aCenificum of Cot.anus sedf-insure for Worker's Connpen- DRAINS-FLOOR,RE)OF.A R HA,CONE). -S' )IiIHS TVI'P.CON5'rBlICT10N
soli....,as provided for by Section 3901 of the LahrCoole,I'm tba perlhrmunre of the
work far which this Kormil is issued. FIXTURES-PER TRAP
❑ I have and will ami main Worker's Compensation insurance,as reyu ired by Section
3900n1'the Lan Cwlc.far the p«farnwme of the wea k for which this permit is issued. GAS-EA.SYS'IENI-I INC4OGD.I3'I'S OCC GROUP APN
lily Worker3 Compensation Insurance carrier and Policy number are:
Carrier: Policy Na: GAS-EA.SYS'I EM OVER 4(EA)
CERTI FICA)17 OF EXE,MPI')ON FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDGSTRL WASTE INTERCEPTOR
(This section need not he enmpleted note least is formic burin tdollanv l$1011) BUILDING DIVISION FEES _
or less.) GREASE TRAP w ---
Icenifythatintheperfonwneaofthework for'fecomewubject in'heW is rkees d,'shall ENERGHGGK II!E
SEWER-SANITARY-STORM LA.21X1 FT.
.111lontLEE any person ifie In vDa m;mncr xu usmhecnmesnbjert In'he Wurkcrs'Cnmpen- ENERGY FP.i:
Z Applicant
Taws of Callfnmi..Dale
0 Applicant
WA'I'1!k HEATER W/VI!NT/EI.I:CTH
7 I-t - GRADING FI31i
A r/�
NO]'ICE TO APPLICANT:Works L Compensitin isvisioicute of Hxaboroc yaoushould
ost WgTEI<SYS'IIiMaRIlAUNO
a ; become subject m Lha Worker's Compensation provision.of We labra Code,you mann SOILS Ilio
� Q fonhwiO comPlY with such provisinm or this mcrtnit shallbedeemed rcvokeJ. WATER SERVICE
.D Z CONS'1'kUCfION LENDING AGENCY NEW HCSIDI!NTIAL 1'LA1R. SQ.Icf. PAID
C.) 0Iherehy affirm lhm there isacnnswaion lending agency for the perfnmmnce of Date Reach,0
the work for which this nannit is ol—I(Sec 3097,Civ.C.)
Carseat',Numc
V TOI'AI.:
FH.) Lenders s TOTAL:
6s Icenifcoodyy thin 1 M1hvc read(his application and seta that the ahnvc information is PIJILDING PL'I?
(A cortect.l agree mcamply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building constructed and hereby authorize reprcsenwtiues oflhis city(center uponthe SEISMIC FEE
.hovemcntiouN Finnerty,for iasp«aion Purposes.
OVE)anemia save,indemnify sad keep harmless the City of Cuperrino against PERMIT ISSUANCE. ELECTRIC FEE
Iiabililia.judgmenls.cosfsand expcnmr which may in any wayeccmc ugainmsaid City ALT ER OR ADD'1'0 NIECE,
scquenceofl •rantingofthisperrail. PLUMBING FEL:
APPLICANT )Ilk CANES AND WILL COMPLY WI'I'If ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM(
SOI RCE RF oULATIONS, MECHANICAI,FEE
. AIR HANDLING UNIT(OVER I0,00I CFM) CONST RUCTION TAX
Signau caf c;uNComrnumr Dam EXHAUST HOOD(W/DUCT) HOUSING MI'T'IGATION PEE
t HAZARDOUS MATEHLAI S DI. 'LOSUHH
Will the applicant or fumm building occupant om or handle hazardous material I IEA'I'INGUNLI'(TOIIXk000BTU)
as defined by the Cupertino Municipal Code,Chapt�r 9.12,and the Health End Safety
Code,Section 25532(a)2 HEATING UNIT(OVER 100.000 RTU) -
❑Yes C]No
V 17N'T'I I.ADON PAN(51 NGLE R FSI DI PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt M
ha,ardnuo air conmminums as defined by the Buy Area Air Quality Management ROLLER-COMP C IHP OR 10,000 RTU)
District' 'I'O'I'AI-
El Yes QNn BOILER-COMP(OVER 100,000 BTU)
Ihavere: rtRM.mrdeas aomrials requirements under Chapter to of the Cali- AIRCONDHIONER ISSUANCIi DATP
foaia Ikahh Safay Cade,5«nimnx 5505,2551) _a553J.1 uEkr:fy the tom if the NEW RESIDENEHAL MECH. SQ.PT
builJingd .nm cumnlly huventenant,tk _aoibility to notify the necupanl
al'thow m•vhich," hemep onoi, anmoa.Cenilicvm al'Occupancy.
rcln� V
Owner ozeJ.gem Dare TOTAL:
ISSUED BY:
OFFICE ,.•�