S 1783 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERy11T NO. a.a ,a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V L8"3
BUILDING PROJECT IDENTIFYCAf1ON
SANITARY NO. APPLICATION SUURMIIIIAL DATE
OWNER'S NAME: PHONE CONTRACTOWS NAME: LIC NO:
NIC CONTROLp
�A ITECTE CINEER: LIC NU'. ADDRESS ❑
I G-I�'7 e'CJJ
CONTACT. PHONE BUILDING PERMIT INTO
i G� .1�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
L ( _%J¢4 C1- �` -n- ❑�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF. JOB DESCRIPTION
1 thereby affimt that l am license!under provisions of Chepmr 9(commencing
O�Z IWSminn 711W)afUivicion3ofthe Business and Pnsl'eseions Csxle,and mylicensein I R -IF�DENTIAL'
WOO w PERM13'ISSUANCIi s
FL�WF mull lumnand clfea. ❑SPDWU [I KITCHEN REMOUEI.
QUU License Class Lic.N APPLIANCES-RESIDENTIAL []ADDITION C]PLUMBING RI PIPE
F+ W Dae Contrncmr
y L ❑MU1:1'1-UNIT ❑STRULTURAI.
Dy A0.CHITIiCT'S DECLARATION PANELS
F 1 MODIFICATION
Z O trt2 Z I understand my plate shall be uses)as public recants `
OZ— UI'T02g1AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Professional 201 ["AMPS IMPROVEMENT SWIMMING POOLS
�W9 -� OWNER-BUILDER DECLARATION OVER IINX)AMPS ❑BATH REMODEL REPAIR El DEMOLITION
a I hereby affirm that 1 am exempt from w tie
the Contmam's License Lar the
�OLU following mason.(Section?0315,Ilu.sinesx and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
613 L y which requimc n permit m comwc6 alter,improve,Aemnlish,ar repair any stm"ure S�
prior to its iswancc, N.requires the applicant farsuch perming file a signed staemeot SPECIAL CIRCUITT/MISC.
Wothat he is licensed pursuant the Provisions of the Contractors Licnase Laos(Chapter9
' �00 COMMERCIAL:
d� (commencing with Su"ioo7UgD of Division of the Business and Professions Gde)or TEMP.METER OR POLE IN, .
EMo yy that he is exempt llmmfro 0 ant the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
MN Section 7031.5 byany applicant fora ismantwbjems theap,hcannoaciOl penally of POWER DEVICES / �TENANT a O 00FOOD SERVICE
t marc than❑vc hundred dollars(85110). IMPROVE, -
�4< 1,as owneraf Uc n,nrm Ioceswith wets us their sole conservation, SWIMMINGPOOLELE RI
O ❑ Pn•pe y Y nap Y g R ❑OTHER
veal Jnthenon,and the su cam Camisnm,Liecedarmx,duformlc(Sec.as an
s
W and Pry who b Cede:The ayes Romans,
License law ares oat apply s lf owner of OUI'LfiTS-SWITCIIIis-FI%TURIiS JUL 1 a
L 3 progeny who builds in wided t x tM1ereaq and who doem, such ante himself or Omagh
his own employees.providW that such improvements arc not intended nr nRered for NEW RESIDENTIAL ELECTR SQ Ir.
BOOR AREAsale.If,however.the building or impmveo®nt is sold within one year ofcompletion.the /I 1 &$Q.Ff.
owner-buider will have the harden of proving that he did not build or improve for put- V1' 1 Vr 4UrtlI�INy
nn a of sale.).
y 'TOTAL: /
1,u owner of the pmpmy,,Business exclusively Profession,with:t Thee)conuunots i- / L2,
!I/]-/_/-/•'
eruct the project pply to an oand Professions Cgde:i The C,there r.Li-
serine Law does not.pplyusmt with
accountants)
whatsedpnrimpmvw Contra.
and QTY PLUMBING PERMIT FEE /V
who commas forsuch pmJe"s with u cnmracror(s)licensed pursuvm m the Contmctor'x
Licca.Law. FERMI"F E.ISSUANC •JJ
❑1 am exempt unJer .Ii&P C for this mason
Owner AA ALDER-DRAIN&VENT-WATER(HA) VALUATION
"WORKER'S COMPENSATION DECLARATION BACK FLOW PRCIzC`L DEVICE
�I❑ I hereby a0inn under penalty ofperjury one ofthc following declarations: CJ•.J V
I have and will meiinninvCeniOcme of Conscm mself-insure lar Wnrkee,Compen. DRAINS-FLOOR.ROOF AREA.COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700of the labor Ede,for the performance of the
work for which this Permit is issued. 6 FIX'I GRES-PER TRAP Valli (/
Is
❑1 M1me and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe labor Calc,lar the performance of the work for which this permit isis,med. GAS-EA.SYSTEM-1 INC.4 OUT OCC GROUP APN
My Workers Conryensation Insurance carrier and Policy number am:
Currier: Policy Na:_ GAS-EA.SYSTEM-OVER 4(EA) C •�tn._�_�/-
CERTIFICATE OF E- FA PION FROM WORK(?RS' GREAS[IINUUSTRI.WASTE IN'I'ERCEPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Miss ection l nm Wcoonplemd it the permit is forone hundred dollms($0110)
or less.( neraGREASCTRAP PIANCHECK FEE 5• / •3
I cenify that in the performance afthe work for which this permit ix issued,l shall ' SHOVER-SAN]TARY-S IURM IA.200 Ff. e-k�p
no employ any person in say manner so vat m becmne subject tache Workers'Compcn- ENERGY FI7E .<V I•
Acartoon Laws tWp.lifArtJa. A WATER HEATER WNENT/F:LEC R
Applicant_YyY�A1—Fv GRADING PEE
NOTICE TO APPLICANT.IL.Rer making this Certificate of Exemption,you should WATER SYS'fEMl1'REAI'ING
[-a ; become subject m the Workers Compensation pmvisions of the labor Code,you must SOUS PBB
WIOMwdis comply with such pmvisinnsothis permit shall he!atoned revoked. WATER SERVICE y
a ❑ / /
CONSTRUCTION LENDING AGENCY NEW RISIDEN'f1AL('LMB. O SQ.Ff. N AID 1J2
UO (hereby affirm that there is a construction lending agency fon a,performuroc.1 Date ReceiptM
W the work far which this permit is neural(Sec.31197,Col.C. TCA(.:
❑Vlender's Name gtYl'AL,
Lk) Lenders Address
fir+. y I cenify that 1 have read this application and sate that the above 000..matien is BUILDING FEE •�
i.V) core".(.gree to comply with all city and county mdinancesandsote laws Mount, QTY. MECIIANICALPERMIT FEE SEISMIC FEE
V 7 building construction,and hereby a dsome tepresantutivcs tadis city m enter upon the
above-Ormad"ed pmpery for inspection PuToses. PERMIT ISSUANCE. ELECTRIC FEE aZ
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE .�
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING I/NIT(TO IR000CqCFM)
MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IO,INNCONS'fRUC1'ION TAX Signature ofApplicaoWContranor Dme EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEEHAZARDOUS MATERIALS DISCLOSURE
Willthc applicantorfuture Wilding accupantsmre or handle hnsoms mamdal HEATING UNIT(To 100.0I BTU)
as defined by the Captain Municipal Gde,Chapter 9.12,and the Health and Safety
Cale,Section 25532(u)? HEATING UNIT(OVER 100.1)00 BT
❑Yee &No "RESID)AN(SINGLERESIDI PAID Rx<iPtM
Will the applicant or furore building occupant use equipmem m devices which '(311P OR I W,Op BJ'U)emit haenNouv air mnmminants as defined by the B.Y Area Air Quality ManugemenlTOTAL: YX
Dnaricl? (OVER HOONNI PTU)❑YesNo
I have read the hmallous materials tequiremene-umlcr Chapter 695 of the Cali- ER ISSUANCE DATE
fomia Health&Safety Crile,Sections 25505,8533 and 25534.1 understandthat if0a HAI.MECH. SQ.ET.build$gdnes cute rrently have a tetum,that it ix my respamdbilny to notify the menpant a M1ich must he met priormissuance nfu CeniGcae sXe W���,�,Owner'o/ , nr red ageTCAL: ao ISSUED tlY:
OFFICE