B 0171 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO. O 1 7 1
BUILDING DIVISION APPLICATION/PERMIT PLun1BING-MECHANICAL S0001
1/
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1b 20 [i0
W ERS NAME: ` CON'IBALR'I NAMG: 1 LIC NO: O
1 UU /N' c/iYl NIC CONTROL#
�ARC.ITECT/PaNGINEER: LIC NO: I)TS: 1 1 � ❑
CONTACT: PHONE: YTS BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC.
❑ ❑ ❑ I�
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I sum licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O8Z with Section 11N107 ofUtvtsto.3nfthe Nosiness and Pmfastam Clde.and my license is RESIDENTIAL,
41 p PMAN
W� irfullframind elle ❑SEDWE ❑KITCHEN REMODEL
�UO Lda,", C�IPss Cic.p APPLIANCES—RESIDE ❑ADDITION ❑PLUMBING RE-PIPli
[-Za1 Date.--IJ�1 Commdor
m66 ARCHITECTS DECI A ION [I MULTI ❑STRUCfl1RAL
Zonz Iundemand my plans shallMuudns public reatNs PMODIFICATION
ON—p ❑INTERIOR ❑CHIMNEY REPAIR
F ._8 Licensed Prfessional 2IMPROVEMENT ❑SWIMMING POOL
gkx� OWNER-BUILDER DECLARATION ❑BATHREMODEUREPAIR ❑DEMOLD'ION
L
—w%< 1 hereby colon that I am exempt from Ne Contractor's License law for the ❑OTHER
se d V following reason(Section 9031.5,Business and Rofrowax Cade:Any city.,county SIGNS ELECTRICAL
3 LL which requires a petmtt m con,wim,nhet improve,demolish.or tepid nay structure
CF O prior 1.its ismance,aIs,,requires the applicaum to,such#suit to file vsigned statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Contactors License Law(Chapter 9
0 (commencing with Section 7")of Di vision 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
L e the,he is exempt thercfmm and the basis for the alleged exemption Any Actinium oI ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES El TENANT ❑FOODSERVICE
FZ� not mom than five hundred dudins($500). - IMPROVEMENT
f�¢O
1,as owner of the property,or myemPloyees with wages as their compensation, SWIMMING POOL ELECTRIC
will do the work,and the commas is not intended moDared for sale(Sm.7044,Business ❑OTHER
tRy-C� and Professions Cade:The Contractors Limine Law dues not apply m an owner of OUTLETS—SWITCHES—VENTURES
a'3 property who builds or improves Hereon,and who does such work himself or through
his own employees,provided that such improve.."ore am intended or offered for NEW RFSIUENTIAL ELECI'R SQ FT.
sale.IL th
however, e buildingnr tmprom
veem is sold within ane year ofcompletion,the SQ FLOOR AREA ESQ.FT
evore,irmIdm will have the bounce.of proving that he did nm build or improve for per-
qaae of ante.).
h as owcar of the property,m.exclusively contracting with licensed contractors to TOTAL: -
construct the project(Sea.704E Business and Professions Cock:)The Contractors I.
cens,Law does not apply in an owner of property who builds or improves thereon,card QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contmdor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
I.mexempt under Sec. ,B&PCfachis reason
ALTER—DRAIN&VENT—WATER RI) VALUA ION
Owner Dae
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of Perjury one of the following declinations.
I
Ihave and will mainminn CeniMmeof Cnnsrnno ulf-insure for Worker's Cnmpen- DRAINS—FLOOR,BOOR AREA,COND. STORIES TYPES CONSTRUCIIOI
n,as provided for by Section 37W of Ne Latin Code,for the performance of the
k for which this permit is issued. FIXTURES—PER TRAP
I have and will maintain Workers Compensation Inatome,as required by Section0 of the Lobar Cade,fur the performance of Ne work fm which this permit is issued. GAS T S OCC.GROUPAPNWorkG(y CymCensadon lnsurr9pticer and Pnlicymyatlltprycj����", GA$'�F SYST (F.A71nter: r-I'oticy Nu: 1 JW CERTIFICATE OF EXEMPTION FROM WORKERS' GR DUSTRL WASTE INTERCE ORCOMPENSATION INSURANCE '�- BUILDING DIVISION TIES
(This secainamed not M completed tithe permit is furore hu.dmldollars(SEXH GRE APLANCHECK PEE
u.)
Toy any that in the my mannro as
for which thto penia irkma' omperl SEWf SANITARY—STORM EA.21N11T.
Tad employ any person in any manner so as to become subject m the Wmker%Compcn- ENERGY FEE
,$ station taws of California.Data Wp'TI: TER W/VEN'T/ELECTR GRADING FEE
rZ Q Applicant
NOTICE TO APPLICANT:IL after makingthis Camomile,of Exempti.n,you should WATE lNG SOILS FEE /
L-� hcrnne,subject to the Weduces Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or chis permit shall he deemed revoked. WATER SERVICE /
Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID pate aeipt#
U Q I hereby affirm that there is a...auction lending agency for the perfonmace.f
Ow work for which this pe.it Is Issued(See.309'/,civ.CJ
Q b" TOTAL:
Lenders Name
WTOTAL:
Lenders Address
Iy� G I certify th
at 1 have read this application and state that the above infatuation is BUILDING FE
comm.l agree ro comply with all city unit county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FE
U ,Z building construction,and hereby authorizempresematives of this city to enter upon the
aMve-mentioned property for inspection Purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agmo to saves indemnify cad keep harmless the City of Cupertino agnlrea
liabilities,judgments,emu and expenses which may in any way aceme agaiostsaid City ALTER OR ADD TO MECH. PLUMBING I'h
in consequence of the standing of this Permit. - -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL
1 NOON-POO.t�INH AIR HANDLING UNIT(TO HLO(N)CFM) MECHANICAL FE
SOU C [^I,A�^TIONs, /O//" ' / t/
AIR HANDLING UNIT(OVER 10.0011CIM) CONSTRUCTION TA
ig at u Applicant/Cnmractof U c EXHAUS"F HOOD(WIDGET) HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in future building occupant store or handle hazardous material HEATING UNIT(TO 100,0011 BTU)
.defied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT'(OVER 100,00t)BTU)
Code.Smdon 15512(v)P
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Daae Receipt#
Will the applicant or future building tecupa0l use equipment or devices which BOILER—COMP(3HP OR 1(10.(100 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management AL'
District! BOILER—COMP(OVER 100,000 BTU)
❑Yes [3 No
I have .it the broad.,mmerials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 255M.1 understand that if the NEW RESIDE- IAL MECH, SQ.FE
building does not currently have a mount,that it is my resp.nsibilay tar notify the occupant _ !r 2— ( '
' of the requirements which munaM and priormissuanec ora Cenifcate of Occupaamy. "".
Owner or aulamiaW."a, DateTOTAL ISSUED BY:�--(d
OFFICE