S 0382 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO eATION
G-ELECTRICAL P' IT NO
BUH.DING DIVISION APPLICATION/PERMIT 6-MF,Cf1ANICAI, v 0382
6UILd F.LT IDENTIFICATION
SANITARY NO, ADPL ATIONSUBM11I I.DATE
BUILDING ADDRESS:
/0 37 CRESTIOAil�
gyjo R'g NAME:ivACb �O��a�o� j3INNE: O / CONTRACfDR' �O� J LIC NO: N/CCONI'ROLp
EAC
ARCHITECl/ENGINEER: . KrS L C NO: t''Y( A DRESS: -S' ❑CONTACT: PxONE: BUILDING PERMIT INFO
❑ Consultant by Applicant(Initial) BLDG ELECT PLO MECH
❑ ❑LICENSED CONTRACTOR'S DECLARATION QTY, C PERMIT FEE JOB DESCRIPTION
I h..byaffirmthat 1 am licensed under provisions of Chapter 9(commencing
Zwith Section 7")of Division 3Ofthe Rennessand Pmfessions Code,end my license isRFCIII ENTIAL
PERMIT ISS(, in full faceand effen ❑SFDWL ❑KITCHEN REMODEL
�UCatena Class Ii0.M pPP1.lANCLNTIAh ❑ADDITION ❑PLUMNING RF:PIPE
yQW Dam Cnntmcmr ❑MUUTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANELSMODIFICATION
OZF n Z 1 understand my plans shall be means public records UP TO 21glAMPS
__ ❑INTERIOR El CHIMNEY REPAIR
Fl u] Licensed Professional 201-1000AMPS IMPROVEMENT [DSWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER I(M]D AMPS ❑BATH REMODEL/RF.PAIR [I DEMOLITION
Ly I hereby o(Seat that 1 am exempt from the Contractor's License law for the [I OIH "V
kX A L V which
requires a permit
it) o3L5,Busite.s and improve.de io li h.or: pieny ay or county SIGNS ELECTRICAL I Ar4I LL C which rcyuires n permit re anrewc6 ghee improve,demolish,ore a sir any twemrc
primarita issuance,also requires the applicant for such permit film signed statement SPECIAL CIRCUIT/MISC.
BvWfCO
at he is licensed piu: to the provisions of me Contractors License Low(Chapter 9 COMMERCIAL'
C thmm(commencing with Section 2(100)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
d that he is exempt therefrom and Ne basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 90313 by any applicant for o permit subjects the applicant to a civil penalty of POWERDEVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred out]ars(55001. IMPROVEMENT
k C ❑ I.as Owner of the property.or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the outwore is net marc ddRer
mocd for cele(Sec.70,1,1,Business
R13� and Professions Cade:The Concmrs License law does not apply m an owner of OUTLETS-SWITCHES-Fl%TURFS
4'a� n
property who builds or improves thereon,and who does such work himselfor thmugn NEW RESIDENTIAL ELECTR SQ PL
his own employees,provided that such improvements are not intended or offered for SQ,FT.FLOOR ARBA $/SQ.FT.
sale.IL however,the building or improvement is sold withinone yearn(completion,the
manor-builder will have the burden of proving that he did not build or improve for pary
poseof.leJ. T
1,as Owner of the property,am exclusively contracting with licensed emmusmrs m
construct the project(Sec.9D14,Business and Prufessiom Cdau Inc I-moms—N Li.
cense law does not apply to an ownerofpmpcny who builds or Improves thereon.and QTY. PLUMBING PERMIT FEE AID who contracts far such pmpursuant jum with a communist licensed pursuano the Contractors Yzk
License Law, PERMIT ISSUANCE
I am exempt under Sec. -B fm
ACI'ER-DRAIN&VENT-WATER(EA) 1.
ser Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby afFrm under penalty Of perjury one Of the following declarations:
.'r-1 I have and will maintain aCertificam of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,GOND. FS ECONS'fRUCT10N
aatien,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES-E'ER TRAP
I have and will maintain Worker's Compensation Insurance,as tequird by Section
37110 ofthe labor Code.for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.40UTLETS OCO GROUP APN
My Workera Compensation lmumnce currier and Policy number me: GAS-EA.SYSTEM-OVER 4(EA)
Currier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PELfi
(This section cad not he completed if the permit is for One hundred dollars($ILIO) GREASETRAP :BUILDING
CK FEE
or
cl
I certify thminthe pedOmtancc of the wwkfmwhich this Permit isiseud,l shell SEWP.R-SAND'ARY-STORM EA.200 I'f,
not employ any person in any manner so as m become subject the Workers'Compen- FEE
Z .tion laws Of Culifomia.Date WATER HEATER WNENT/ELEC 1t FEE
Q Applicant
y NOTICE TO APPLICANT':IL atter making this Certifcam Of Exemption,you should WATER SYSTEMGREATING E
(-' become subject 1.the Worker's Compensation privations of the labor Code,you must
�i forthwith comply with such provisions or this permit shall rte deemed revoked. WATER SERVICE
SI Q
CONSTRUCTION LENDING AGENCY NEW RIiSIDENTIAh PCMB, SQ.FT.
g agency per' Date ReceilVM
U O Lnercnr:rrrtn that them iN:canmmmmn lend. for hmmmanee er
IL F the work for which this permit is issued(Sec.3119],Civ.C.) ,1
Q U Lender's Name YT
>' W Lenders Address _ FTSILI I crafty tha1 have read this application end sato that the chose intomsmion is[O correct.I agree to comply with tall city and county ordinances and state laws mlating to QTY. MECHANICAL PERMIT FEE FEBbuilding coronation,and hereby authorize representatives ofthis city to enter upon the
above-mentiond pmpeny for inspection purpoNes. PERMITISSUANCEC FT:E(We)agreem sve.indemnify and keep hmmless the Cityof Coloni l notinel
liabilities.judgments,cost%and expenses which may in any way acerae againstsaid City ALTER OR ADD TO MECH. G FEE
in consequence of the granting of this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010 CFM( MECHANICAL FEE
SOLLELLERF, I:LATIONS
AIR HANDLING UNIT(OVER IO,OIX)CFM) CONSTRUCTIONTAX
r
Sintli o(Applicen✓Commcmr Dam li%IfAUST HOOD(WIDUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdons material HEATING UNIT LTO 100,000 BTU)
as defind by the Cupertino Municipal Code,Chapmr 9.12,and the Heahh sad Safety HEATING UNIT(OVER 100,000 BTU)
Crane.Section 25532(x)?
p Yes 0 N VENTILATION FAN(SINGLE R17S 1 D) PAID
Uric Receipt p
Will the applicant or future Wilding Occupant use equipment or devices which• BOILER-COMP CHP OR 100,(100 RTU)emit nuzardous air ecalmo mosfin
.deed by the Bay Area Air Quality Management TOTAL:
District? BOILER-COME(OVER I ISIXRI BTU) _
❑Yes 7 N
1 have reed the hazmdOus trequirements tattler Chapter 6.95 of me Cali- AIR CONDITIONER - ISSUANCE DATE
brain Health Salley Cale,Sectionsions 25553 25
05, 533 and 25534.I understand that it the NEW RESIDENTIALMECH. SQ.FL
buildingdmesnor cumnily have atnet thatprimnt ismy uarco ran Cerfiytonotifyve-Pthe cupam Y V
of thcyauirememx which must be met pnnno isauanee of a Certifcam of Occupancy.
/ Date 'TOTAL: ISSUED BY:
Owner or vuthn.IW:gem
OFFICE