S 1593 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUO.DING-ELECIAICAL. Pli fT NO
BUILDING DIVISION APPLICATIONMERMIT PLUAIRING-MECR,%NICAI• 1593
BUILDING PROJECT IIFENFIF'ICAI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITTAL DATI
1x4 !2 3 12e 442-A /3lv G�tiLC�
0 NE ' NAME PHONE: C ';jTRACTO ,1
'NAME: 1 N NIC CONTROL is
C evrd�
ARCHITECT/ENGINEER: LIC NO: All LSS. ❑
0 on ' ea✓���.e
CONTACT PHONE: BUILDING PERMIT INFO
❑ Carvedianl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
still
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby offinm had I.,it licensee under provisions of Chapter 9(commencingPERMIT ISSUANCE JOB DESCRIPTION
°aX with Section 7(Mj.fDIVislen3oflhe Businessland Professions Cole.ond my licemels RESIDENTIAL'
W O
F, O in full force and cRec OSFUWL El KITCHEN REMODEI.
aZu Lice Iss Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F R W Da a t Camra r
Velli PANF.1.5 ❑MULTI-UNIT' OSTRUCI'URAI.
'T.' :CI. ATION
F. - MODIFICATIONZOrVnz lundcrewnd: a e e remcords
OZ- UPT0200AMVS ❑INTERIOR ❑CHIMNEY REPAIR
Licenud l'rofesfo 201-10MOAMPS IMPROVEMENT ❑SWIMMING POOLS
��dd ppp OWNI!R-If UILD D[CLARAI'ION OVER Rx)OAMPS ❑BATH RF.MOUEI/NEPAIN [D DEMOLITION
C Q 1 herch uflirm that 1 am cxaam Drom the Camrraor's License Law for the
O y V following reason.(Section 9031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
3 F which requires a permit m bowtown, her.improve,demolish,or repair any swcture
COMMERCIAL
u'O prior to its issuance,alb,requires the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC
5accc y that be is licensed pursuant m the provisions ofthe Cummeor's license Law
1+Inap0 faommencing with Section 700(nof Division 3afthe Business and Professions Cale)ar TIiMP.METER OR P[11.L'INST. - :
d dx o dot he is exempt Parefmm and the basis for the alleged exemption.Any violation of O NEW.BLDG/ADDITION OLFFION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [I TENANT ❑F00 SERVICE
~�Qnot more than five hundred dollars(S500). IMPROVEMENT
I,as owner of the norm laces with waesas their sole cons n.mtion, SWIMMING POOL ELECTRIC
=O ❑ Prop' Y Yemp Y b , OGTHER
wdl delta work,Cods:
Comisnotintended Lawdohostile(Sec.to
Business
W and ary,%hiom Cale:TM Commences License law does not apply to f owner of OUTLISIS-SWITCIIPS-FIXTURES
progeny,who builds or improves thereon,and who does such work himself or thrd lot
his awn employee,provided that such improvements an,not iye,rof a affercd for NEW RESIDENTIAL F.LIiL;:R SQ Ff.
sale. hawwer,the building orimprovnnem ixsnlA within one ywr nfcnmpletinn,the SQ.FT,FLOOR AREA pgQ.f4.
owner-builder will have the burden of proving that he did not build or improve for put-
' prseofaale.).
O I,as owner of the property,am exclusively contracting with licensed contractors to A
cunswm the pmjea(Sec.7(W4,Business and Pmfcssinis Cale:)no Co nnalons Li- D
craw,LOW does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBI GP IT
ocontracts for such Projects with a contaminants)licensed pursuant to the Comm[mrs M 5
L Icanse L:Iw. PERMIT ISSUANCE •,I ®ryl"Mtl
Iantexnimmder Sec. ,B&PCfmthisneuson -erW{J
Owner Dote ALTER-DRAIN&VEN -WATER(EA) Is c);:� (.,VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT..U. ICC /X I' oo
I hereby affirm under penalty of perjury one of the following dMamtlons: (((JJl
❑ Ibave nnJ willmuintuine Certificate ofConunl to sell-imurelar Wn.kers Comper DRAINS-FLOOR,ROOF,ARCA, ❑NII. TORIES 'TYPE CONS'rRUCI101
ration,ur.provided for by Section 3900 of the Labor Code,for the perfominala of the
work for which Nis p nant is issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insumnce,as requited by Section
3700n0he Labor Gude,Do the perfn ace ofthe wnrk for which this permit is issued. GAS-HA.SYSTEM-IINC.4OUTLFTS OCC.GROUP APN
My Workuta once .urierand Policy number arc.
Carler.�LL�su Policy No.: GAS-EA.SYSTEM-OVER 41P)
CEKI'IFI ATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE.INfERCiiPTOR
COMPENSATION INSURANCE. RUILOING DIVISION FEES
flnie union need nntbe comPlnNifthe parotitis for one hundrWmulars(SEYEGREASETRAP _ - _ -----
or les,,) PLANCHFiCK FEF.
I anify that in We performance of the work for which this prnit is issued.lshull SIIWIiR-SAN]FARY-STORM EA.2q)FT.
not employ any pervm in any n araar so us,,become subject m the Wnrkeri Compen- ENERGY FEE
O ',Z maim Laws of Califomia.Date WATER HEATER W/VFNT/ELECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:II afro,making this Cerificatc of Exemption,you should WATER SYSTEM?BEATING
iSOILS FEE
1-'
forthwith
comply
the Workers Compensation ertalt hal of the Labor Code,you must
�� Idnhwith comply with.aucM1 provisions or this permit shall he deemed revoked. WATER SERVICE
Q
Q' CONSTRUCTION LENDING AGENCY NEW RIiSIUFN'TIAL PLMB. SQ.FT. PAID Daeceipt N
U QThereby aRnn lhm tberc is aconstmction lendin6 agency lunM perhnmunae of
F the Work for which this permit is iouud(Sec.300.Civ.C.) -
ULaii 'a Name O'rAL:
Landers Address TOTAL:
1 certify that 1 have rend this application and state that the uMrve infnrmmion is BUILDING FEE ��
correct.l agree to comply with all city and county ordinances unit sate laws relating to QTY. MECHANICAL PERMIT FEE
buildingconsauction,and hereby authorize mprceanmtiven ofthis city matter upon the SEISMIC FEE
above-mentioned poupany for irepatio/k ,"'
PERMIT ISSUANCE ve
(We)agree m. e,indemnify aales the City of Cupertino againstELECTRICliabilities,judgmensand aspen: in ,ywoyaccrucngaimtsaidC,ty ALTER OR ADD IO MECH. PLUMBING FEF,in conMIS
gof pAPPLND. MPLY WITH ALL NON-POINT AIR HANDLING UNITtTO 10,(tl1(1CFAt) MECHANICAL FEE
SOUR . AIRHANDLING UNIT(OVER IONqCFM) CONSTRUCTION TAX
Signe '—tiDote EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE.RDOUS MATERIALS DISCLOSURE Dumb,building acceptant store or handle hazardous material HEATING UND'(TO Io(000 BTU)
m defined by The Cuperino Municipal Cale,Charter 9.12,and the Health en I Safety
Cade,Senian 25532(a)T HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID -
VENTILATIONFAN(SINGLERESID) Data ReceiptIs
. Will the applicant or future building occupant use acluipment or devices which BOILER-COMP SHPOR 100,000 BU)
T
emit hamrdaus air cnntaminanu as defined by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 10D.0001311i)
C]Yes [:1 No
I leve read tiro hazardous materials to under Chapter 6,95 of the Cal i- AIR CONDITIONER ISSUANCE DATE
re.2553 a P
buniu gdoes&Sa4ty Cuda,Sections 253at i 25533 and 25534.1 to parry the
that if the NEW RESIDENTIAL MECH. SQ.IT.
building does no icurrentlys which have a¢ et p Nm o is ua ce ofnaCarthy m notify the tr[apant
of the requimments which must be mu prior to issuance nfn CatlMnm al Occupancy.
Owner or authorized agent Date I TOTAL ISSUED BY:
OFFICE