S 1789 —APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF:J 17 g IT NO, /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. g
BUILDING PROJECT IDENTIFICATION i. V
BUILDING
ADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATE
lu
O!NEROWNER'SNAME. � ONa CON]'RACE R'S NAME: LIC NO: �
4 V Yr NIC CONTROL If
RCHI I EC UENGINEER: L LLIC'NOV I ADDRESS: '/` ❑ ���/
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG' ELECT PLUMB MECH
Ee-
'LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE.
1 hereby affirm that i am licensed undo provisions of Chapter 9(romm.ndng JOB DESCRIPTION
WOO with Section of Division 3 ofthe Bnsinessonl Professions Core,m my license is RESIDENTIAL'
FW_ in full tome and e(fed. - PERMIT ISSUANCE
¢UV License Class/���7'� �Lle.k 3 R � pSsb ElSFDWL ❑KITCHEN REMODEL
Fzul Date r:-Contractor e9UM Va,,4 CJJb1 APPLIANCES-RESIDENTIAL O-� ❑ADDITION [I PLUMBING REPIPE
Nap' ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F❑N PANELS
some rood my plans shall he sed us public recnMs MODIFICATION
socia ❑
crueUP TO 200 AMPS
' _ INTERIOR El CHIMNEY REPAIR
F, 1e 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
J
OWNER-BUILDER DECLARATION OVER 110(1 AMPS [IBATH REMODEL/REPAIR [IDEMOLITION
a l hereby affirm that I am exempt from the Contractor's License Law for the
W ad U following reason.(Section 7031.5,Business mud Professions Code:Any city ,or wumY SIGNS ELECTRICAL ❑OTHER
W y which requires a fin tit m consumer,noun improve,demoli.h,or repair any swdum
oraeI t ''. 1..rectuart applicantl . by h1 CI a g da temenl SPECIAL CIRCUIT/MISC.
hat he licensed pa the provisions oftheCranston a License Law(Chapter 9
wCpO (wt menc'rgwth Section 7000)mHoveseen 3 ofthe Busim,s and Professions Core)nr 'TECOMMERCIAL,
MP METER OR POLE INST.
that he is exempt Therefrom and the basis for the alleged execphhn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^vWi
Section 70,11.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
nut more than five hundred dollars(S500). IMPROVEMENT
F�Z�Q, ❑ Tws owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
pzt� will dhthe work,and themucmre isma attended... ad for sale o.. 4.7044.Business Ito
TZ
"ro ;rod Professions Code:The Contractor's License Law does not apply to as owner of OUTLETS-SWITCHES-FIXTURES Icbi�property who builds m Improves thereon,and who dues such w.,it himself or through
his own employees,provided that such improvements are n.l intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
,.[c.If,howevegthc bhildingh,improvement is...Id within one yvarof,ourpletum,(be - SQ.IT.FLOOR AREA $/SQ.Er
b '10 illhave theh den fpm gthth did (h 'ld p eft,our _
owe f:I) TOTAL: 1.,� 'JUN 10
❑1 nrfthe prianYam d ly nt ti6wthlicensed contractors to 5. 0
onvlthe project(St 7044Business dProtestation,Cd )fhConnector's Li �� �
La-
cense 1 J t hproj nt falconry h builds dp improves Contractors,coons QTY P MBING ERMIT PEE OJOC
' whr wnmets for surhp jsms wimaconnacmgs)liu.nsed pursuant mthe c �l r Ur OI VV
License Luse PERMIT I �J•J v
❑ I am exempt under Sec. ,B&P C me bisection
ALTER-DRAI J ATER EA) VALUATION
Owner Dam Q G
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTF. I
I hereby uffmn under penally of perjuryone of the following deelaratmns: - Ca r O xj
I have and will maintain a Certificate ofConeent to self-insure for Worker's Grmpea- DRAINS-FLOOR,ROOF, ND. STORMS TYPE CONSTRUCTION
scion,as provided for by Section 370 0 of the Labor Code.for the performance of the
work for which this permit is issued FIXTURES-PER TRAP $,3J ' ` �( ,
F] 1 have and will maintain Worker's Compensation Insumnee,as mui,ed qby Section - J ,v
3700of the Labor
e,fgo�r the performanceof the work for which this permit is ismed. GAS-EA SYSTI?M-I INC,40U'fLFTS OCC.GROUP APN
- My Wnrkurs Cr/r-�(;�i if)i. coincidentalpP� Ynum �
Carrier: YV �Z2 GAS-EA.SYSTEM-OVER 4(Ei)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(this section need not be completed if the permit is furan hundredddlam($100) GREASETRAP
or less) PLANCHECK PEP. Sr7Z� to
Loy any that inthe perfanyannanceo the astobekfin mewubjectch to the rmit is Workers
ed,I shall
Compn- SEWER-SANITARY-STORM EA.200 FE
nm employ any person in any tnanner so as to become subject t.the Workers'Chmpen- ENERGY,FEE
smion Laws hf Oditbrni,Date WATER HEATER W/VENT/ELEMR
Applicant ` GRADING FEE
r~N.. NOTICE TO APPLICANT.IL.after making This Cenilcute of Exemption,you should WATER SYSTEMOREATING
t~ heunne.subject m the Worker's Compensation previsions of the Labor Cale,you chat SOILS FEE
Wr�•t forthwith comply with such provisions or this penult shall be deemed revoked. WATER SERVICE
P
UO CONSTRt1CT10NLENDING AGENCY NEW RESIDENTIALPLMB. SQ.F3'. PAID Date Receipt If
1 hereby affirm that Permit
i is s construction 3 lending agency for the performance of
r-t mowers for which this permit ix issued(Sec,3097,Civ.C)
� I--�' Lenders Name - � TOTAL:
C.1 Lendet's Address TOTAL: `)��
I certify that I have read this application trod state that the above information is - �l J BUILDING FP.H ,Q
Fr m cai l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE / C
UZ building construction,and hereby authorize representatives ofthis city theater upon the ISEISMIC FEE
ubovomwer ncd property far inspection purposes' PERMIT ISSUANCE v
(We)agree m leve.indemnify and keep harmless the City of Cupertino am mt ELECTRIC FEB L's, y U
Ilahilities,judgments,restsand expemeswhich may many way ahemeagains sold City AL'fERORADDTOMECU
in consequence of Ne granting hfthis permit 6� I QO PLUMBING FEE J
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE `.5v
AIR HANDLING UNIT(OVER 10.000 CI'M) CONSTRUCTION TAX
Signature of ApplicantlContmcmr Dote EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant smmerhandle hazardous material HEAPING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 2553200? - HEATING UNIT(OVER 10O,00 BTU)
El Yes E]No - PAID�j[
VENTILATION FAN(SINGLE RESIDE Dano Receipt If
Will the applicantor future building occupont use equipmcm or device,which BOILERCOMP(3HP OR 100,000 BTU)
nit haostrob c air contaminants as definedrea -
by the Buy AAir Quality Management TOTAL:
District?
Yes EINo BOILER-COMP(OVER 100,000 BTU)
I have read the bnzallons materials roulturements under Chapter 695 oAIR CONDITIONERf the Cali- ISSUANCE DATE
formagHealth s&t carat Code Sections 25hati 25533and25534.1 understand thinifthe NP,N RESIDENTIAL MECf1. SQ.FT.
of the reenactments which
have s mete that it isua responsibility tonotifytheacuphnt 3
of the reyuiremenb which must be met prior it) of Certifirnte of Occupancy.
OwnermindonaoUgem Dow TOTAL: 6. ISSUED BYtr;,/�e
OFFICE