S 1335 —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PF: IT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 1335
.BUILDING PROJECT IDENTH KATION
BUILDINGADDRESg; SANITARY NO. APPLICATION SUB]1ITTAI.IIA'I'li
0013 %A Vt7 u OWNER'S NAME: PHONE: CONT'RACTOR'S AMC: 1, N
N/C-� /�I}���CjOI}NTTRROL#RC ITECL NGIN7�b LIC NO: DDRE$$: •IIM1 WGIY a C El
COM'ACT. PHONE: . BUILDING PERMIT INFO
"10Z1(o9J6U0 ❑ ConeeltaolFees Paid byApplieant(Initial) BLDG e ECf PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRICPERMIT FEE
I any arrrn n t 1 r 1 d p rch m -n l s - JOB DESCRIPTION
Mat wecon oanars y
RESIDENTIAL,WOe, PERIISSUANCE
b ,= ntell fomeutdefed.
L1 SCOWL ❑KITCHEN REMODEL,
1501
F' Licence Claes Lia# APPLIANCES-RISIDHNTIAL El ADDITION PLUMBING RE-PIPE
Dale COnlrECLARCHITECTS DECIARA...as PANF.1.5 ❑MULTI-UNIT ❑STRUCTURAL.landnrsmndmyplans shall be used as public records MODIFICA'PION
IIP TO 200 AMPS ❑INTERIOR ❑CIIIMNEYREPA[R
LionesedPro@esianal 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOLS
+�+� ...•]]]]]]
OWNER BUILDER DECLARATION GVHR 11100 AMPS El RY:MODEURF:I'AIR DEMOLITION
C W Q 1 hereby affirm that 1 am exempt from the Contractor,Licence Law for the
.U following mneme.(Section 7031.5,Bucinesn and Is cession,Corte:Any city cr county SIGNS ELECTRICAL ❑OTHER
141 W
Laivi which requires a permit to amenmet,alley,improve,dem k,Ja.or h air any ehneafn
�� prig t I '.: ots q hetppli tf : 'hpermit l Li g danmment SPECIAL CIRCUIT/MISC.
Sa that he licensed pre u [lie provisions offficC In S Larose la (Chapter9
(comocimir,wain Simam 70fsp.fDi,ivmb 3.fthc B imus,analP fir,nalcodid., TEMP METER OR POLE INS1'. MM CIAI'
0.i G re but h pt therefrom d t basis farm, II g d xe pt Any olurae o[ M IJI'fIQN 4I�❑��DEMOLITION
W an Sect 703LShy ny ppl f permitsbI nth ppl e 'lpernally f POWER DEVICES
W..y ❑TENANT - YRfU fMI'()D SERVICE
oat more mon lee hundred dollars[Ssdm.
I�I� VkMr NT
d OLosoew.,lL me pmperty,nr myemployeenwilhwupes uv meirsolncompnnsmion, SWIMMING POOL ELCC'fRIC S/J
w d P...l e n rk and e:TheComra es,LInded or Law
del.,it imply 7044,Business Wj
❑OTHE
and Pmfc alone Cndc:The Conwemrs License Law daea not apply m an owner of IDTLETS-SWITCHES-PIX'fURES IIY(J
�'a.. pmperty whooyea,or improves such
imp
and who doea such work himselfut through
his num cmale If, evea,the
provided mot such improvements um nm intended or clawed for NEW RESIDENTIAL ELECTR
owner-uilder qll have the bug or rden
issoldhe
none tbuild or improve
SQ.Pf.FLOOR AREA $ISQ.Up.
owner-builder will have the bunlut nfpmving met he did not build or improve far pnr- - .ACK>
pone ofsole.).
❑1,as owner of the pmperty,am conclusively eonwding with:)The
mmmnom i- 'lYr U
,ii e t at protect p 7040 Business d rt .. Code:) pr Contractor's ti- -
Able
L d t Folli fp property n h Td: p thereon, to QTY. - PLUMBING PERMIT EB
whoumwelx for st rib prOjm¢with.eovmstn(s)licensed pursuant meC wu
License e
Luce. PERMIT ISSUANCE
tom exempt ander Sec. .B&PCfor this chosen
Owner I Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.BE
1 hereby affirm under poorly of perjury one of the following acclamation,
- ❑ I have and will maintain a Cendius,of Conserv m self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA, STORIES TYPE CONSTRUCTION'
action,as provided for by Section 37000 the Lobar Code for no"domtonce or the
work for which this pemtil is issued. FIXTURES-PER'TRAP
El I baso and will maintain Warke's Cnmpanxwlnn Insurance,as or,mod by Section
3700 of the Labor Code,tanheperfnrma is ofthe wnrkfnr which this pemtil it issued, GAS-EA SYS11714-1INC.4 OUTLETS - OCC.GROUP APN
MyWork uon rshmneec r and Policy number arc:
Carrier: m IFI FEX PolicNo.y GAS-EA.SYSTEM dVER4(BA) t
CERTIFICATE OF COMPENSATION
I N FROM WORKERS
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE.INTERCEPTOR
(Th' . d need notbvwmplHedTma permn is ford h d dd fl ($100) ` a B ,D ISIONFEES
ort s) GREASE TRAP PL .KP
Iccnifytha'n the petherreameof,he work forwhuh the permn is i...W,[shall SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner so as to become subject to the Workers Cheaper- I.NHI YFBE .�
Oz ration Lows of California.Dam WXI HB HEATER WNENVELECPR
Applicant GRADING PEE
az.1 , NOPICH TO APPLICANT.If,after making this Creme to of Exemptlon,you ehonld WATER SYSTEM/IREATING
a become subject to me Walker's Compensation provisions of the Lahor Code,you must SOILS FEE
forthwith pmlply with such provisions or this permit shall be deemed revoked' WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.PC. PAID
W
UC) Ihcrcbyafnardou mere fs It cumatroclion leadinug
gcncy forlho performance hi Date ec pt
the work far which Wis pcfmitls issued(side 3097,Cie C.)
Ixnder'n Name T AL:
Lender's Address - TOTAL:
fy 1 carmy bar 1 have mad this Fpr t d dite that the above information, - - - - BUILDING FEE
m correct.I a, el ply all all city aid room,addhoures andon laws bdraingto QTY - MECHANICAL PERMIT ',FEE
V
building coast mil int.and hereby authorize p malives of this city to enter o Pon the SEISMIC FEE'
above-memianed property far inspection purPnses. PERMIT ISSUANCE
(We)agmv n save indemnify and keep hamless in ity orCupenien against tA.N.CTRIC
Iiubilitics,Judgmeme,co d pcnses whidt yinan ny awmengoinsl wid City ALTER OR ADD TO MECH.
hn'onseyuenceo non dlhlspeaK PLUMBI FEE
APPLICANT ST AND LL CO '.Y WITH ALL NON-P)INT AIR HANDLING UNIT(TO IIkOw CPM)
SOURCE :O O MECHANICAL
AIR HANDLING UNIT(OVER 14(wH CPM) CONSTRUCTIONT
Signawr )1APpIjmnt/Conbmmr Date EXHAUST HOOD(W/DUCT) HOUSING MI'IIGATI PEP.
HAZARDOUS M ERIALS DISCLOSURE .
Will me applicant or fvwre bu' ing acceptant store or handle huaordous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Munici t Code.Chapter 9.12,and the Health and Safety
Coda Section 25532(x)? HEATING UNIT(OVER 101,000 BTU)
El Yea L]No VENTILATION FAN(SINGLE RESID) PAIDWill --
Dote - Receipt#
Ordaus air ter m oo nal as defined y the n yA ea Air Qu litshe Maocs which BOILER-COMP CHP OR 100,WO RTU)
mit District? us air ebnluminanls as defined by the Pay Area Air Quality Managemem _ TOTAL:
DistalcR
El Y,1 ElbeBOILER-COME(OVER 100,000 BTI))
Ileave read the baaaMousmaterials no,cirements under Chapter 695 of the Gd i- AIR CON Of LONER ISSUANCE DATE
Norio Health&Safety Code.Sections 25505 25533 and 25534.1 understand that it the NEW RESIDENTIAL.MPCU SQ.ET.
bundingiEws not currentlyh t nt,that it:thyms,sonsuddityt idly meeocapam
afthe mr,mothroo,oti I m be nmtprit t :hars,or.C nl .t fOtvpancy.
Ow th ehl ag t' Date TO'T'AL: ISSUED BY:
OFFICE