S 0208 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL. S 0208
BUILDING PROJECT IIIENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DAL
BUILDING ADDRESS:
VZ1j � c-iz r.•�o " G 2`5 17
O NCR'S NAM�E/: I, ��/ PHONE: C w'C R S NAME: LIC NO / C
/ U(ea !/ht.✓F Ls3 ILt-�,,.�ari.�-t �Z.SJ (�J NIC CONTNOLp
ARCHITECT/ENGINEER: I.IC NO: ESS
LR L ZY //Y/�/C.�f��U Z-iT 9`,001 ❑
ON CI.- PHONF: BUILDING PERMIT INFO
// x ty ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
L/L<—t1E.ldEitC .�53—�3" ❑ ❑ }�P ❑
LICENSED CONTRACTOR'S DECLARATION Qry, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby off,.that 1 am licensed mule,provisions of Chapter 9(commencing
Q04 th Section]g101 of Division 3nfthe Husinesx and Professions Cade.and my license is RESIDENTIAL
F'S in full force and e]Tmt PERMIT ISSUANCE ❑SFDWI. ❑KITCHEN REMODEL
�VFpp License Class Lis.11 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�Zy7 Date Contractor ❑MULTIUNIT EI STRUCTURAL
ZFO=so
ARCHITECT'S DECLARATION PANELS MODIFICATION
v� 1 understand at pintu shall h used as public,ecoids
:J UP'f02W AMPS ❑INTERIOR El CHIMNEY REPAIR
rIsat�j Licensed Professional 201-1"AMPS IMPROVEMENT E]SWIMMING POOLS
�WOWNER-BUILDER DECLARATION OVER 11100 AMPS ❑BATH REMODEURF.PAIR ❑DEMOL ON
ypx� 1 It affirm that 1 am exempt from the Convector's License Law for the ❑OTHER
W O 4`1 following reason(Semon 7031.5,Business unit Profeadim,Cute:Any,city or came, SIGNS ELECTRICAL.
3 W
which requires.permit m ennswn,a1mr.improve,demolish,ser mpab any staremm
0 primni,issuanee,also requires Ne eppiicum for such permit to fileesiRneshstammem SPECIAL CIRC UIT/MISC.
� y Nm he is licensed pumuammthe previsions of the Contractors License Law(Chapter COMMERCIAL;
W�'p0 (commencing with Section7")of Division 3 of the Business and Professions Cashel'it TEMP.METER OR p(ILE INS,
d y p y that he is exempt therefrom anJ the Msix for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION []DEMOLITION
trX1 I�
Section 7031.5 by anyapplicanlfera permit subjects theopplicanunu civil penalty of POWER DEVICES ❑TENANT Ell
a.,
Z iN- oat mate than five hundred dollars($500). IMPROVEMENT
� 6n I,as owner of C
theprefer,ormyemployeeswith wages mtheir sole compensation. SWIMMINGPOOLELERIC � ❑O HER
will do the work,and the swnure is not intended oraRered for sale ISec.]044,Business
G � and Professions Code:The Contractors License law does not apply to an owner of OURLTS-SWITCHES-IgXTURES
property who builds or improves thereon,and who does such work himself o,through NEW RESIDENTIAL ELCCfR SQ
his own employees,provided that such improvements am not intended or offered for SQ.FT.FLOOR AREA &"V.,R.
sale.if,however,the building or improvemor ie sold within rote year of completing the
erervhuildcr will have the human of parsing that he did not build or improve for put. p� A m
poseofsale.). TOTAL P 1 a
I,as owner of the property,am exclusively contracting with licensed contractors to
consorct the project(Sec.704,Business and Profession Cade)The Convenor's Lt. PLUMBING PERMIT EEE ���
came Law does not apply to an ownerofpropeny who huilshs or improves thereon,and QTY, C Mill
� -
who contracts for such projects with a comructer(s)licensed pursurm m the Contractors 0/
Opens,Lal, PERMIT ISSUANCE CI _
01,,,�(A 'g� thrt/ Or �r � ALTER V
4Ptl(7
WORKER'S COM PENSAT N DECLARATION BACK FLOW PROTECT.DEVICE
I hereby ill mai under penalty M perjury one of the following I.,W Worker
I Co
_J lhave and will mainminaCmificam of Cnnummulf-inmrc for Worker's Compen- DRAINS-FLOOR,BOOK AREA.GOND. - STORIES TYPE CONSTRUCTIC
tion,as provided for by Section 3700 of the Tabor CMe.for the pm.arrom ,of the
rN for which no,pmmit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Ne False,Code,far the performance ofma work for which this permit is issued. GAS-EA.SYS'fP,M-I INQaOU'fLETS OCC.GROUP APN
My Wod:er's Compensation Insurance carter and Policy number are: GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERSGRBASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(Thissection need not becompined ifthepernit is for one hundred dollars(ST(B GRF.ASETRAP PLANCHECK FEE
mlem.)
I,crafydr,inure pvrramprow.fNe work for which this permit is issued.)-hall SEWER-SANITARY-STORM BA.200 FT. ENERGY 17EE
not employ any person in any manner so as to become subjeal w the Workers'Compen-
OZ action Laws of CnGfnmia.Data WATER HEATER WNENTELECTR GRADING FEE
O Applicant
Fan NOTICE TO APPLICANT:If,after making this Cenifieme of Exemption,you mato WATER SYSTEM/I'REATING SOILS FEE
2become subject to the Workers Compensation provisions of the Labor Coca,you must
a forthwith comply with such provisions or this permit shat)be deemed revoked. WATER SERVICE
D Q
CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLMB. SQ.IT. PAID
.0.7. Z Date ReceiptM
V O l hembywhich
that them tae issued(Sea
agency for the performance of
{f+F the work for which Nis permit is issued(Sec.3097,Civ.CJ TOTAL:
O Lender's Name TOTAL:
Lenders Address BUILDING FEE
1 certify that I have mad this application and suite that the above information is
r. V0.) coned lagreeto comply with all city and county mdimnecsmm stem taws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building contraction,and hereby authorizerepmw%tatives afthis city to enter upon the
r4 above-memioned proper,fu inspection proposes. , PERMIT ISSUANCE ELECTRIC FEF.
(We)agree to save,indemnify and keep haneaka,the Cr y of Cupertino against
liabilities,judgment,cast,and expenses which may in any way accme against said City AITERORADDTOMECH. PLUMBING FEE
m cons ante of the gra g of this permit.
, PLI NT ER A DS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO Ig000 CPM) MECHANICALFEE
T C.
4X/
l AIR HANDLING UNIT/OVER 10100)CFM) CONSTRUCTIONTAX
ignaturc of ApplivanJComrazmI W Dot EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARIXIUS MATERIAL DISCLOSURE
Will theapplicam or far..building oce.lait store or handle hammers arman.] HEAT]NO UNIT(TO 1000"RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and be Head,and Safety HEATING UNIT(OVER INLp00 BTU)
Cods:Section 25532mlt
❑YcsVENTILATION FAN RESID) PAID
o Date Reuipt p
Will the applicant ortore building occupant use equipment or devices which BOILER-COMP(314P OR 100,000 BTU)
emit hazardous air contaminants res defined by the Bay Area Air Quality Management TOTAL:
aide'? . 1, BOILER-COMP(OVER IIX),M BTU) _
❑Yes �No
AIR CONDITIONER ISSUANCE DATE
I have read the hammers materials me,marmems under Chapter 6.95 of the Cali-
. fomia Heath&Safety CMe,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECIL SQ,FT.
bur us a on have. a m.drounriyospansibiiity I otify the occupant
oft .1P' m Isomer., me of app
mer or autho zed.gem s V J Du TmnL: ISSUED BY:
OFFICE