S 0449 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO
It-NLRCTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT PINGPRODB N � T IDE MECHANICAL
S 0449
BUILDING PROJECT'IDEMTIF'll'ATION
RU LDINGARES SANITARY NO. APPLICATION SUBMITTAL DATE
ER'S NAME: PHONIi CO CTOR"NAME: LIC NO:
/ i NIC COM'ROLp
• u LIP F, /f'1,' 1-tJ EY/ u2 Si x-�3ao w aa,& /�E�,/f�iP�v iG q c. -
R HITECT/ENGINEER:C LIC NO: A wa,"a e, Tf' ❑
f N o c �l�( (/ /
CONTACT: PHONE: BUILDING PERMIT INFO
r3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT .0 ❑ MT:C
L c A� 6,1w7 c_k6 Y I]
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF. JOH DESCRIPTION
1 hereby a1Rrm that I um licensed under provision&of Chapter 9(commencing
O�Z with Section 7000)nf Division 3 ofthe Business wd Professions Code,and my license is RESIDENTIAL'
WOO PERMIT'ISSUANCE
F„1O� in full force and effect. ❑SFDWI. ❑KITCHEN REMODEL
�U� License Class Lic.p APPLIANCES-RCSIUF.NTIAL ❑ADDITION ❑PLUMBING RG-PIPE.
�G6 Date Comamor
ARCHITECTS DECLARATION PANELS ❑MULTIANIT ❑STRUCTURAL
yc+ Z I understand myplans shall Wusedm public monrd, MODIFICATION
OZ�O UP 1'O 31tl AMPS El INTERIOR ❑S CHIMNEY
MING POOL
FmCW Limmts!Professional - 201.1"AMP$ IMPROVEMENT SWIMMING I'OOIS
OWNER-BUILDER DECLARATION OVER TWO AMPS ��❑BATH REMODEUREPyR DEMV N
W< 1 hereby affirm Ihal 1 am exempt from the Contractor,License law for the Ipp dfHER /tA�f n/r N �0-Tif k
ipS O y U following mason.(Section 1031,5,Busines,and Prn(e,sion,Cede:Any city or county SIGNS ELECTRICAL V Z
to 3 LL.t' which requires a ,mit to conswcl,alter,improve,demolish,or re n sanctum Qd✓Le GST/�- W
qui pe p pair any
prior to issuance,also requires We applicant for such permit fleasign W rmenscnt SPF,CIAL CIRCUIT/MISC. b J.. lr
that he is licensed pursuant to the poAkionsofthe Contractor's License Lnw(Chapter9 COMMF ,
W..CSO (eommencingwith SectionTlgp)nf Division 7of Ne Busines and Prol'essium Gdep+r TEMP METER OR POLE(NST
a y C that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
%W 4th• Station 7031.5 by any applicant fora permit subjecw the applicant to v civil penalty of IYIWER DEVICES El TENANT ❑FOOD SERVICE
t more than five hundred dollars MOM). IMPROVEMENT
ZG ❑I,ax owneroftheprnPeny,ormycmployees wiWwuges uslheirmle cumpcnsation. SWIMMINGPOOLELEGTRIC
+p ❑OTHER
will do the work,and the structure is not intended or offered fortune(Sm.70,0.Busines
C[o OUTLETS-SWITCHES-FIXTURES
W eo and Professions Cede:The Commcmr's Litanm Law dues ern apply m an owner nl'
property who builds m improves thereon,and who does such work himself or through NEW RESIDENTIAL ELECTR SQ FT
his own employms.Provided shut such improvements arc not intended mothered for SQ.FI.FLOOR AREA S/SQ.FT.
sale.If,however,the building m improvemem is sold within one year of completion,the
ler-builder will have the burden of proving thin he did not build or improve for Pur
s
ofsle.).
[1,as owner of the properly,am exclusively contracting with licensed mrtma tms 10
construct he project(Sm.90,14,Business and Prolessinn,Code:)The Contactors Li-
cense Low does not apply to an Owner Of property who builds or improves thereon.and QTY. PLUMBING PERMIT �� FE � '
whocnmmets fnrsuch pmjedswiNamntrutorts)IiccnsW pursumonithe Contactors
�//!0� O
License law. PERMIT ISSUANCE '
❑ 1 tiro exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(
Owner Dam
Wm under
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTLCT.DEVICE L
1 hemby affirm mai under Certifyhf perjury-or ofthe insure for Workers
a
❑Ihave and will maintain aCeniOcate nfChnsenunxlLinsurcfor Workers Compel- DRAINS-FLOOR,ROOP.AREA. ND. STORIES TYPE CONSTRUCTION
much,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this Permit is issued. - I'IXTURES-PERTRAP
FI I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy NO.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE I N'FERCIiPI'OR
COMPENSATION INSURANCE (LDING ISION FEES
(Thio acmihnncad rot IN,completed iftbe permit is forone hundreddollum(Sled) GREASETRAP
nr less) PLANK
C
I cenify that in the performance of the work for which this permit is issued.I%bull SEWER-SANITARY-STORM EA.200 FT.
.Or employ any Cameo,in any ramorm sr,as m hcom
ee subm ject the Workers Cmmpen- ENE Y
zZ smion Laws Of California.Date WATER HEATER W/VENTIF.LECTR OR NG FEE
O APplicvm `
NOTICE TO APPLICANT:If,aftm and ing alis Cem6roc or EsmaInu r,you should WATER SYSTEMITREATING
become,object m the Worker's Compensation covilm,of the Lida,Code,you most
SOILS Il:
foMwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT. Date Receipt p
V C) Ihereby af&m that them is a construction lending agency for are performance Of
Its the work for which this permit is issued(Sec.3119,Co.CJ TOTAL:
F" Lenders Name TOTAL:
ULenders Address, BU DINGFE1
W
I cell 1 have read]his application and state Nm the aW,e information is
cmrecLlagrwmcompiywitf ollcity and county ordinances and slate laws relating to QTY, MECHANICAL PERMIT FEE 5 SMICFEE
V building construction,and hereby authorize mpresematives m ilbiecily theme,upon the
above-mentioned property for inspection purposes. PERM I ISSUANCE ELE EE
(We)agree to sae,indemnify and keep harmless the City of Cupertino against _
liabilities,judgment,costs and expenses which may in any way amore against said CityALTER OR ADD TO MECH. PLUMBING FE
in consequence of the gaming of this permit.
PLICA ' 1NDERSTANDS AND WILL COMPLY WITH Ai).NON-POINT AIR HANDLI NO UNIT OO 10,000 CFM) MECHANICAL FEE
S .lie N. /
AIR HANDLING UNIT(OVER I(Lpp CFM) CONSTRUCTION TAX
SignammmAppllcmVCanwetur - Dme EXHAUST HOOD(W/DUCT) HOUSING MITIGATION �E
HAZARDOUS MA ERIALS DISCLOSURE
Will theapplicum or future building uecupantstore or handle hazardous material HEATING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.00) U)
Code,Section 25572fa)7
❑Yen VEN'INLATION PAN E INGLF.RE.SID) PAID Date Re eipt k
Will me applicant or future building Occupant use equipment or devices which BOILER-COMP QHP OR IOB4O00)BTU)
mo bawd..,air macho runts vs defined by the Bay A.Air Quality Management TOTAL:
Distnm9 / BOILER-COME(OVER 100.0010 BTU)
❑Yes &H-
AIRCONDITIONER ISSUANCE DATE
1 hove read]hc Cod, us rmledd,rcquire33 an under Chapter understood
of the Cali-
Tomas Health&Safny Code.Sedation,255(15,25573 and!25574.1 understand that if the NEW RESIDENTIAL MECN. SQ.IT.
h ding ] edy 'r mWnnant,t tit ismyrespon,ibilirym fyth main,
Mg
i be me]P noissuvnce ofa Ceni��eypurcy.
Owner Or authorized agent Date/ TOTAL: ISSUED BY:
OFFICE