S 1833 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING.ELECTRICAL Pfi IT NO.
BUILDING DIVISION APPLICATION/PERMIT DING PROJECT
TENIIC �J 1833:
BUILDING PRl)J F:CT IDEN'1'14'ICATION
ItUi1.DING ADDRESS: SANITARY NO. APPLICATION SUIIMITIAI.DATT
l 70 S Db� N2a -✓
OWNER'SNAME: PHONE: COM' Cy��R'S NSp+F:: LI NO: NIC CON9'ROLq
7/DLJ/ ,.'f�lll,5j�
ARC111TEC f/ENGINEER: LIC NO'. �A�DI)RD all /0"'
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB m rCH
eLLM w za ')66Z ❑ ❑ ❑
LICENSED COST"RAC'FOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed uncle,provisions of Chapter 9lcmmmcncing
OaZ with 7lMq)af Division3of the l3usinecr and Professions Code,and my license is RESIDENTIAL,
W p p wt PERMIT ISSUANCE
IyF inlhllfarceand ]ec 6 m B'J ❑SFDWL ❑KITCHEN REMODEL
¢tatUU 1,¢eIs Y x APPLIANCES—ftFS1ULNTIAI. ❑ADDITION El PLUMBING RE-PIPE
N Z W Use r Conlmelor
rosea, - [I MULTI-UNIT ❑STRUMURAL
D 1, ARCIII"ITCrS DITCLARAT"ION
ZOI^Z IanMraand an,plansMall he used,s public minors 1ANEIS MODIFICATION
04-4- UI"TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201404MIAMIS IMPROVEMENT C]SWIMMING POOLS
Zy7-i OWNER-BUILDER DECLARATION OVER IgM1AMP5 ❑HATH RENO 'I/REPAIR ❑DEMOLITION
tX w Q I hereby affirm that 1 nm emmpt from the Commemr's License Law for the
W U following reason.(Section 9031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑Of11ER
w ar V.V which requires a pinnal In construct,alters improve,demolish,or repair any swemrc
qFq s- prior m its issuance,also requires the applicant for such permit m file a signed smenent SPECIAL CIRCUIT/M ISC.
2n}� tlmt he is licemeJ pursuanno me provisions of the Convector's License low(Chapter9 6 �
W y'+o0� (commencing with Section 70(m)of Division 3 tribe Business and Pmescimns Cade)or 'TEMP.M Mr;R OR POLEINST. COMMERCIAL,
•
a n ev flm he is escrapt IbereRom and the basis for nm alleged enemy;ion.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
m Section 9031.5 by any applicant for a permit subjects theapplieunt to acivil pmmiry of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Spnot more than Five hundred dollars($500). IMPROVEMENT
❑1,as owner nfthe propeny.army employre..with wages ns their solecompensation, SWIMMING POOL ELECTRIC ❑OTHER
F- wi lido the work,and fic,lo lure is not icleadeslorottered ffrsale Ism,7194,Business
and Professions Cade:The Gmtomba's Limme I.aw duce so'Illy ,,an owner mf OUTLETS—SWITCHES—FIXTURES
C 3 propeny who builds or Improver lherean,and who does m in work himself or through
his own employee,,Provided Thal such improvements are nor intended or offered flit NEW RESIDENTIAL ELELTR
sale.If,however,the building or improvement is sold within one yemofcanipleion,the SQ.FT.'1.D SISQ FT.
er-huildet will have the burden of,raviog that he did net build or improve for par-
Cl
of sulc.l �p1,��1O�1
1,as owner of mnt e propeny,aes,laskaly coatrecting with licensed cont crofts m TOTAL: JUL 1 3 AN
con.armf the Imjem Sm.lime,Business and Prof c.ioiu Codc:)The Communes Li-
maro,Ww drex asomiply mum ownerof propeny who hands.,improve,framon,and QTy, PLUMBING PERMIT FEE
who cnmrdas fnwch pnrJccu wins awmuumnns)IicenwJ pursuuono the Contracmrs CIIY ur ousel IND
Licenx Law. PERMIT ISSUANCE
❑Pum exempt under See ,B&PC for this ream
AUTER—DRAIN&VEM'—WATER(EA) VALUATION
Owner Dale
•, WORKER'S COMP17NSAI ION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑I hove and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS—FLOOR,RODE.AREA,COND, STORIES TYPECONSTRUCTION
satidn,as provided for by Section 37M 0l The Labor Cale,for the perfamnnce of the
work for which this permit is routed. FIXTURES—PER TRAP
A I hove.,,it will notation Worker's Compensation Insurance an required by Section
3700n1'me"No,Coca,forme peroommate of the work for which this permit is issued. GAS—17A.SYSTEM.I INC.4 OUTLETS OCC.GROUP ARK
My Wor Y lion h¢y�fw/; JPalic n rre:0 GAS—IiA.SYSTEM OVER 4LEA)
Camber: MU/VIII carne Policy Nn
CERTI FICATE OF EXHMITION FROM WOR KERS' GREASFIINOUS'PRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDINIDIVISIONFEES
IT his section need not be c r,dmd if the pennlO.s Intone hundred dollars($100) GREASETRAP
lir less.) PLANCHECK FEE
I certify thatintfie performance of me work for which mix permit is issued,Isha11 SEWER—SANITARY—STORM HA.201 FF.
not employ any Person in any manner so as To become subject to the Workecr'Compen ENERGY FEE
Z
salon Laws of Califnmin.pee WATER BEATER WIVF.NT/EL,GCfR
z Applicant GRADING FEE
.y y NOTICE TO APPLICAN'n If,after making this CcNfieme of Exemption,you should WATER SYSTENlfBIiATING a SOILS FF:E become subject to the Workers Compensation provisions of me Lalor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked. WATER S177RVIC17
U0 CONSem is ac ONLI?NDINGAGENCY NEW RESIDENTIAL PLMI3. SQ,FT PAID Date Rrecipt9
L)0 I hereby which
affind that is sue (Sm.ion lending agency for the performance of
(,
the work for which this Permit is issued(Sm.3097.Civ.CJ
Lcndds Name TOTAL:
O U Lenders Address TOTAL:
W
1 certify that I have read this application and slate ma The shoes infatuation is BUILDING FEE
(n curet.I agree to comply with all city and county ofdmaiims and mate laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby moherim representatives alibis city meson upon the /�e�y SFISMiC FEE
above-mentioned propeny for inspection purposes. RAIR
ERMIT ISSUANCE IV VA ELECTRIC FEE
(We)agree m save,indemnify unit keep hornless The City of CuPenimo against
Iiabilitics,judgmems,costs andexpenmswhieh may in anyway ocave against wad CityCFERORADDTOMF.CH,
PLUNKING ITE
in wnuyuence of the granting of this permit.
APPLICANT UNDER 'TANDS A ) 1 L COMPLY WITH AL NON-I'OIM' IR HANDLING UNIT(TO 10.(100 CFM)
SOU�RC�<EGULA//,•J/qNS. // MECHANICAL FEE
HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION'TAX
S'gnamrcolApplicaApp0aaVCo racnor >amXHAUST HOOD(WIDUCIG HOUSING MITIGATION FEE
HAilARDDUS MATERIALS DISCLOSURE
Will me alplicarer future building oecup;tm stmem handle liarrdous mntenllEATING UNIT(TO 100.000 BTU)
ns defied by the Cupertino Municipal Code,Chapmr 9.12,end the Health and Safety
Cdla Section 25532EU • HEATING UNTr(OVER 100,000 BTO)
C3 yes M<1' ' VF.N'IT IATION BAN(SINGLE RES]Of PAID Date Receipt#
� Will the applicant or future building accupanl use eyvipmcnt of devices which
emit hm.adous air conmmiter as final by The Hay Area Air Quality Management BOILER—COMP(31 IP OR I OO,mM)BTOI
District? TOTAL
❑Yes Nn BOILER—COMI'(OVER IIM),(NM)BTU) �j ^/ w
9 K
must mv
I have re: e humm
dons erial.r reyuiremenrs under Chapter 695 of the Cali- A]R CONDITIONER -940ISSUANCE DATE
fomin Health&Safety Code,Sections 255(15,25533;rod 255.00.1 understund mal if me NEW RESIDENTIAL MECU. SQ.EL
buildin oke not cu n0y hvven ymot Lis my resPtaibility¢r notify Theoucupam
n(t mem icht t,riormissuuncenfa Cendicuter rxca ancy.
r lir a t tont d u g nt ateTOTAL- / ISSUED BY:
OFFICE