S 1207 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF. IT NO,
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL 0
BUILDING PROJFICT IDIUsT1FICATION
BUILDING2ADDRGS : ♦l ,, SANITARY NO. APPLICA'T'ION SUBMMIITI'ALDA'I'I'
OWN" ' NAME: HONE. W 2--�( g
CONTRA TOR NAME, LIC NO.
N/C CUNTROLp
R TLI T/B GINPP_: LIC NU: ApppP y, It F ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG _ IiLECI' PLUM ME❑CI1
CC �a Lt7/
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby stare mat I am licensed under pmvi.firs or Chapter 9 tctimmend"g JOB DESCRIPTION /
foo with Sconce an a ecDivisionJoftha Business unA Rufessinns Csale,and my license is C11+A'/
n full lisrce and effect PPRMI'I'ISSUANCE RESIDENTIAL
FZSUi1 U.amLucia w Lm.a GSFDWI. CHI-N REMODEL
H<0. Contractor APPLIANCES-RESIDENTIAL G ADDITION
11 PLUMBING RE-PIPE.
I.7 an ARCHITECT'S DECLARATION
Z O H Z 1 ondersmnsnd my plashall he used as public record. PANELS ❑MULTIUNIT G STRUCTURAL
O Z—Q UI'TO 21X1 AMPS MODIFICATION
Fa+. Lmeneed Pmmss men ❑INTERIOR G CHIMNEY REPAIRyY 7,.�4.I OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT [ISWIMMING POOLS
yyY Q I hereby anion that 1 am exempt from the Conaacnrrs License Law for the OVER 1000AMPS G BATH RF.MODEUREPAIR G DEMOLITION
X
0'U
L U fallowing feapm.(Section 7011.5.Bmmi and Pmfcsslure Code:Any airy or county
4411 ' which require a permit m cnn.trud.aeeq ire SIGNS ELECTRICAL ❑OTHER
prove,demolish,or repair any vmmurc
priono its issuance,also requires the applicant retouch permit to lileasignednatemenl SPI!CIALCIRCUI"P/MISC,
WN that hu is licensed pursmnr10 the Provisions ofthe Comment's License Ww(Chaptcr9
CCC�MO Nommcncing with Section/(=)DfDivisiun3 nfthe Businessand Ftofesslnm Cede)or TEMP.METER OR POLE INST. COMMERCIAL
d fy o ty
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Z
i Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES
Fp
not more than five hundred dollars($5gp. / 'NANT ❑FOOD SERVICE
1Hqyr�< ❑ Las owner of the property,or my employees with wages as their sale compensainat SWIMMING POOLELECTRIC ? P VEMENT
will do the work,and the structure is not intended oroflercd forsule(See 7044,Business Q GO
G3 m and Professions Code:The Contractor's License Low does not apply man owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such ann mvemento ore not intended nr offered for NEW RESIDEN'T'IAL ELECTR SQ Fr.
sale.If,however,the building(it improvement viscid within one year ofcompletiagthe SQ.FT.FLOOR AREA USQ.FT.
wmrbuilder will have the burden of proving that he did not build or improve for poo-
pose oLsale.).
G 1,as owner of me Property.am exclusively connecting with licensed contractors to TOTAL
construct the project(Sec.]1144,Business end Prol'essinas Code:)The Connaror's Li-
nselawdm+s not apply to an owner of pmpemy who builds or improves thereon,and QTY PLUMBING PERMIT FEE
whaeontrects for such Pmjecu with ammmcmr(.y licensed pursuant m the Contmnnrs
License Law.
❑ I um exempt under Sec. ,13&P Clm thio ,,an PERMIT ISSUANCE
OwnerALTER-DRAIN&VENT-WATER(EAI
Dom VALUATION
WORKER'S COMP ENSATION DECe fallowing
BACK FLOW PROTECT.DEVICE,
thereby alarm under penalty of ofConernofthefnsure tar dedoradons:
,grl R.as pons will mai by etion hand of are Labor
to Code,for The Wodsr'.ce of the
DRAINS-FLOOR.ROOF,A R EA,COND.
Ir
R.as providW for by Section 3'/lq of me labor Cndc,for the performance of the STORIES '1'YPF.CONSTRUCfION
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and all)maintain Worker's Conspensatas ion Insuar required by Strand
370d orthe L#Mn Cese,forthfmm
eperancenfthe work for which thispemnit is Round. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Worker' so Insurance Brenerand Policyn t r 0
Carrier: Policy No.: GAS-PLA.SYSTrM-OVER 4(EA)
CERT FICATH OF F.XI!MI'1'ION FRO WORKERS'
COMPENSATION INSURANCE OREASEBNDUSTRL WASTE INTERCEPTOR
(This section need not he enmpleted Haw pemrit is for tide Imndred dollars(SIM) BUILDING DIVISION FEES
nr less.) GREASE TRAP PLANCHECK ITE r— - - _--
Icenifythm
atintheperformanoftheworkforwhichthisPermitixi.ssued,l shall SANITARY-.'
gat employ any person in any manner so as m become snhlect to me Workers'Car Carper- SEWER STORM EA.200 Pr.
z P ENI!RGY o,
action Laws of California.Dam WATER HHATER W/VENT/ELECTR
O Applicant GRADING Ill
NOTICE TO APPLICANT:IL Co musing mix CcnrEs of of Exemption,you should
(~ 'y-t become subject to the Workers Compensation previsions of the lobar Code,you mon WATER SYSTF.MITREAB'ING SOLI 4 FEE
�i fomhwith comply withsoch Provisions or this pcmnitshall be deemedrevoked.
1 0 WATER SERVICE
5 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. T PAID
V O Iherchy alRrm theuherc isaconmmetion lending vgency for the performance of Dare Receipt#
G4 (• the work for which this Permit is ismrl(Sec.AR)],Civ.C.)
Lenders Name
O w Lenders Addrcxe r TOTAL:
L1t 1 ramify that 1 hove read this application and slate thm the alwve Infotmatimr is 41 BUILDING PCE O
to correct.l agree m comply with all city unit county ordinances and state laws relating to QTy MECHANICN.PERMIT FTE
UZ building commotion,and hereby union,repmsematwes todmi,city toenmrurym the SEISMIC FTir:
above mentioned pmlw•nyf in.peetimr purpooee.
TWO agree toss, cmnify a ad keep M1annless the City of Cu ninaa t 1'IIRMIT ISSUANCE ,
liahilitic gams ELECTRIC FEE
jut ments,rrske an expenses which may in any way acerae against said City AI:TER OR ADD TO MECH O
in emuu n I"ig tog dm's permit PLUMBING FEE s
APPLIC NT INDI" S N S AND WILT.COMPLY WITH ALL NON-POINT qIR HANDLING UNIT
SOURC UL I S. (TO IO'(IGICOU MECHANICAL FEE
AIR HANDLING UNIT(OVER 1I,000 CFM) CONSTRUCTION TAX
Signal of APPli ontmc ar Dale EXHAUST HOOD(W/IUCD
HAZARDOUS MAI'HRIALS UISCLOSURI! HOUSING MITIGATION FEB
Will the applicant or future building occupant smre to,handle hazardous material HEATING UNIT(TO IBQ060 BTU)
as defined by the Cupertino Municipal Code,Chapter 1),12,and the Health and Sully
Code.Section 25.5326a)'/ II HATING UNIT(OVER 1110,(01)HI GI
G Vee [:]No
VENTILATION PAN(SINGLE RCSIU) PAID _
7LI
Will thea licumor lumre builJin Uvte Rcccipt p
pp lbytheBayAea Air eQntorMingemint BOILER-COMPtishaevdous air cameminantsmdefincdb the Ba Area Air unlit Management (.HPDR IW,gXI NTD)
District? TOT L:
71 Yes GNo BOILER-COME(OVER IIX),(NX)B'DID '
1 have read the harnrdoos materials requircnsents under Chapter 6.95 of the Cul i- AIR CONDITIONERfirl ISSUANCE DATE
WldigdoesnoSafety Ceche a tiad25585,25533and25534.1 undersumd four it the NEW RESIDENTIAL MECH. SQ.FE
Wilding does not currency have a met p mato is ua c eprmaibandice notify the Occupancy.
7'
of the requirements which most he mm prior ro issuance of n Ceniceum of Oscnpvncy.
Owner or amhotized agent Data TOTAL: ISSUED BY:
OFFICE