B 0607 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDG-ELECTRICAL. PERSHTNO.
BUILDING DIVISION APPLICATION/PERMIT PLUb1RING-MECIIANICAI, SSW
BUILDIN'G PROJECT IDENTIFICATION Fllhfl V
BUILDIN�G A/Py�DR//ESS //�� /� ,j� SANITARY NO. APPLICATION SUBMITTAL DATE
'vER;S NAME: PHONE: CONTRAMOkB NAME: LIC NO:
ciV Elw 267 253-1/6eo t N/C CONTROL#
„prTEC1'/ENGINEE LIC NO: ADDRESS: �' 1 ❑ 50
/
CO CT / G PHONE:$3 ^ BUILDING PERMIT INFO
t /� u L /` ^LLC�� /3�Xr XZ ❑ Consultant Fees Paid by Applicant(Initial) L@ I>O ELECT PLUMB XIECH
r LICENSED CONTRACTOR'S DECLARATION Qpy ELECT RIC PERMIT FEE `Lief_. ACyI•
1 hereby affirm that 1 an licensed under provision.of Chapter 9(commencing JOB DESCRIPTION
tlmz with Section 70M)o1 DiAtimi3mfthe Badness and PmficWion.code.and tar Bcenw is RESIDENTIAL:
WOO PERM IT ISSUANCE
Fly.. in full force and effect. ❑SFDWL ❑KITCHEN RIiMODLI.
aU(j License Class Lic.p APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE PIPE
hQ W Dae Contractor
ie�w ARCHITECTS DECLARATION PANELS ElMULTI-UNIT ❑STRUCTURAL.
ZO, ei I understand my pla—hall be medal public wind, e MODIFICATION
OZ—O f UP To 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-I00f1AMPS IMPROVE\11?NI' EJ SWIMMING POOLS
OWNER-BUILDER DECLARATION
a C 1 hereby affirm tM1vr I am exempt from the Cnvtmmnr's Liccnsc taw for ubc OVER 1000AMPS
Q El BATH REMWEI/REPd IR DEMOLI'T'ION
W 3 ha.F following reason.(Section 7031.5.Business and Professions Cads:Any city ter county SIGNS ELEM RICAL ❑OTHER
h which requires a permit to consWct,alter,improve.demolish,or repair any amaurc
F�06 prinr,it,ieeuane,also ria,iresdhe npplicnm for-tach pnimnw,Ble a,boud,uamment SPf.C1ALCIRCUIT/MIS
Ey}'q That he is licensed Pursuant to the provisions of the Contractor's license Law lChapmr>
W--pO (commencing with Section 7000)(it Division ofthe Business and Professions Code)(it 'TEMP.MITER OR POLII IN, COMMERCIAL:
a =c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of L�NEW BLDG/N)DI'I'[ON ❑DEM01.1'I']ON
Y.^toSection7031 S by any applicant for apermit subjens the applicant acivil pewlly'al POWER DEVICES ul^rn ❑TENANT ❑FOODSERVICE
not more than Eve hundred dollam(55100.
F Z>tIMPROVIiMEN"I'
Q Fl 1,a<awner of the progeny.ur my employees with wages as their ode mmpensauon, SWIMMING POOL F.LECfRIC
p=.m w,it Jmhework.and the,trucmre is net imendediomlered fe.mk(Sec.7ffbU Lathers OUTLETS-SWI'fCf1E5-FIXTURES OOI'HER
u1 uvd Pmfensimn%Code:The Cnmmnm's Um cars,Law does not apply an ownerml
pro,ely who build%or improves thereon,and who does inch work himselfor I, la
his own employees,pmvided that such improvements are not intended or trained for NEW RESIDENTIAL ELECOt SQ Er
sale,11,however,the building or improvement is sold within one year ofecmpletio me SQ.FT.FLOOR AR AREA S/SQ.IT
er-builder will have the hnrdenaf,owing that be ad nal bund or improve for par-
pose of snl#J.
1,as owner of the progeny,am exclusively contracting with licensed contractors to Tf
instruct[Tic project(Sea 9014.Business and Professions Code:)The Commeror'x Li-
wmeLnwAoesnotnpplymvn�wnernfpropcnywhobuildsarimprovesmeerm,wd QTY. PLUMBING PERMIT FEE
ho contracts for such projects with a conuactons)licensed putsuavno the Contractor'.%
Liccnsc taw. PERMIT ISSUANCE
(] tan cxmnp nnJor Scc. .B&PCI'or this Hasan p
Dam l AL'IE -,NT-WATER IEA) VALUA9'�IUN `
WORKERS COMPENS ION DRCLARATIO BACK PL W
I hereby nllirmundcr penalty of per ry enc of the following declarudmm- J
0�(lhaveandwiil maintain a Cenifcacof Carl to%df-insure for Workers Compete DRAINS-FL( BReR OP
suliorl.as Provided t r by Section 37011 of the Isbor Code,Rothe peRannuale of Nr, STORIES TYPE CONSTRUCTION
work for which this p,,all k issued. FIXTURES-AR TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3701 of the labor Code.for the performance ofthe work for which this proud is issued, " OCC.GROUP MIN
My Waders Ctrmpcnsation Insomace carrier and Policy number am:
Currier: Polley No.: GAS AA
-ICAS-EA.SYSSYSTEM-OV
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE IND ERCEPTOR BUILDING DIVISION FEES _
('I his section need not becomplctW ifthe permit is formal,hundred dollars 6100) GREASETRAP
or lens.) PLANCIMC tE
Ioyany Lha lathe Penormaanymanneeo as ds,
work
mewhich ubject to the W rkers Cd.omKn1 SE EA.200 FT.
nm employ any person in any manner so os ro become subject m the Workers Compcn- ENERGY 3P. ft�
Zz scion laws ol'California.Date WATER HEATER WNE:NT/ELECI'R
Q Applicata ) GRAI I F s
y N(YI'ICC;TO APPLICANT:IL after making chis Ccnifcme o(Exemption,you should WATER SYSTEM'REYHNG
a > hcmne subjttt to the Wacker.Co. is provisions of the Labor Cm1e,you masa S 'E
� Imnhwilh comply with such proveu...ms or nr this permit shall be JeemeJ rtvmkN. WATER SERVICE
Q
�z CONSTRIICI'ION LENDING AGENCY NEW RESIDI3N1'IAI.PLh11s. SQ.FT. PAID �-
V p IMmhy off nn that there isaconstrvmion lending agency for the performance of Dam kcccipt
W the work l'or which this permit i%issucd f5ee.3W].Civ.CJ
O U Lender's Name 'IOITh:
U.1 Leader's Addmss I'
1 cenily that I have mad this application tad sem the the aMrve information is BUILDING FEE
.F. rail correct.l agree to cmnply with all city and county ordinances add state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building constriction,and hereby umhorie represemativesof this city to enter upon the SEISMIC FE.
"r abore-mentioned progeny for inspection purposes.
(We)agree m save,indentaand fy keep hmmlea Ne City of Cupertino against PERMIT ISSUANCE ELECTR 'E
liabilities,judgmcnrs,ced.%andexpenses whichmay many way accrue zgainu said City ALTER OR ADD TO MECH.
in canscyuencc of Nr,geeing trf lM1is pcnnil, PLUM '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(!010.(X10 CFhf)
SOURCE REGUI.A'fIONS. MECHANI AL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONST ,CTION TAX
Signature of ApplicanUConuacmr Date EXHAUST HOOD(W/DUCT) HOUSIN ITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicamor future building occupant store orhandle hazardous material HEAT]NO UNIT(TO 101,0!10 BTU)
as defined by the Cupcnino Municipal Code.Chapter 9,12,sad he Henhb and Safely
Gd,,Section 255321ayl HEAT]NO UNIT OVER 100.000 BTU)
]Yes o
VF.NTILA'I'ION FAN(SINGLE REX U) PAID _
X11 the applicum m furore building mmupant use equipmem or devices which Dare Recdpl#
',it harnrdaus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR I00,000BTIA
Dierictp TOTAL:
C3Yes VIN., BOILER-COMP(OVER 10).000BI'U)
Ihave read the hazardous materials AIRCONDITIONER SSUA ' E TIE
rt.25533 noiunder Chapterrsta ifthe Cali- [��(�
' fomite Ilcalth&Safely Crude,Sections 25505,25533 unJ 2553J.I umll,rsad that if 0l, NEW RESIDF,NTIAh MUCH. SQ.PT. 7r
ht Jin Al ^ Iy M1avcolcnnnr.rhe it i%my responsibility uo nnuly rbc uccupvm
fuer, a
o r w h u emetp'mto issue untor /t/ qc ply
owner ter authmnzed agent 9 h �9Dm!
ISSUED BY:
OFFICE