S 1100 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEMRICAL PI'L�+1'1'NO, 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J i�O
BUILDING PROJECT'IDENTIFICATION
BUIGRESS:/ �) C ,f / SANITARY NO. AI'PLICAI'1(/N SUBMITTAL
ru,
OW N 11 CO nCT R'S N
'A • NIC CONTROL#
,JW,� ,MENGINF .(U LIC NO: ADD ❑
COM. MIN E., - BUILDING PERMIT INFO
...,,.a E:1 Consultant Fees Paid by Applicant(Initial) BLDG F. PLUMB MECII
❑ r ❑ ❑
JI" LICENSED ACTOR'S DECLARATION QTY, ELECTRIC PERMIT' JOB DESCRIPTION
I -rehy a0inu that 1 sm wen.ad under povisiom of Chapter 9 frommencias
GaZ mgwfion](glB) put nJofthe Bucincssae Ymfexsian Co e,an irin cis RESIDENTIAL,
ILOO wr PF.RMITISSUANCE
FF�.. mlull fnrcc J �y ❑SEDWL [I KITCHEN RF,MODEI.
Q,U~k� License Lac' APPLIANCIS-RESIDENTIAL. ❑ADDITION [I PLUMBING RGPIPE
F•Z LL1 Dole Conte
m6n. ❑MULTI-UNIT ❑STRUCTURAL
F.]y RCIIITF.CTS 1 RA PANELS
Z O a,Z 1 understand my plans shill M use)as public records MODIFICATION
OZ0O UPT020n AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r-4 ' Licensed professional 201-10WAMPS IMPROVEMENT j]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS C)BATH REMODFURBPAIR (]DEMOLITION
,,a..II I hereby afRan that 1 am exempt from the Commmors License Law for the
kOyV following res n.(Section]OJL5,Business and PraNasinns Cadc:Any city m coumy SIGNS ELECTRICAL OTHER
u7 O� which reyuires a permit m comtruct,she,improve,demolish,or repair any torucwre
prior o its issuance,also requires the applicant for such permit o file asigmedsonmem SPECIAL CIRCUITIMISC.
oh that he is licensed unnocraft the provisions of the Contractor's License Law(Chapter 9
Xqx00 (commencing with Section 7000)odDivision3 oflhe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for One alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
W^N Section 10315 by any applicant far a permit suhjwts the applicant on civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
F not more than rive hundred dollars($500). IMPROVE •%
O ❑1,to ownerofthe Isometry,or my employees with wages as their sole compcmution, SWIMMING POOL ELECTRIC ]HER
will doth,work and the so,num is not intended or offered lar safe(Sec.]014,Business
W�3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pommy who build or improves thereon.and who does such work himself,,,through I'M 7T
his own employees,provided that such improvements are no intended or offered for NEW RP_SIDEN'UAL ELECTR SQ FT. SQ.IT.FLOOR AREA SISQ.FT.
sale.If,however,the building or improvement is sold within one year of completion,the
mer-hudder will have the burden of proving that he did not build or improve for put- PAI posenfsale.L A TOTAL: r 167
1,as owner of the property,am exclusively containing with licensed contractors at
construct the project(Sec.7643,Business and Professions Code:)The Connector'Li- /t a��
c Law does not apply toatnowner ofprowitywho builds orimproves thereon,rod QTY. PLUMBING PE MIT FEE A 28
hoco
wntractsforranch Pmj t ithaeontrwwr(s)licensedpursuant[nthe CommclOra a/11
License Law. PI2RMIT ISSUANCE CITY
_ ,(?
E3aso
I am exempt a ,B&l'C for this ren U
ALTER-DRAIN&VENT-iWE vAtbatikswo
Owner Doe -- - �/Y%7
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ((..��1��
I hereby affirm under penalty of perjury one of the following declao[ione
lhaveandwillmaimainaCcoificamof Comentloself-insmfor Wader's CamWn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPIiCONSTRUCf1C
cation,as provided for by Section 3700 of the Labor Cook,far the Pnicarr arc,of the
work far which this permit is issued. FI%TUNES-PER TRAP - /�J ,
El have and ill main[in Workers Compensation Imumnce,us required by Section &4
3]fp of the r I a the perfu mance dficwork for which this permit is isss�ssujue. GAS-EA.SYSTEM-I INC.4 OUT OCC GROUT' APN
My Work n sou - CJ GAS-EA.SYSTEM OVER 4(EA)
Cortise �1� IV 1
CERTIFlCCO.OF EXEMPTIONTIONINS FROM WORKERS' GREASIJINDUSTRL WASTE.INTERCEPTOR
' COMPENSATION INSURANCE BUILDING DIVISION FENS
fTbiticoian toed maloccomple[edifthepermit is fnumehundorddolkrs(SH10) GREASE*1
PLANCHECK MEor less)
Icemfy that' the performance nf[he work forwhich this prmi[is ismeJ,lshall SEWER-SANITARY-STORM EA.2IX)FT.
not employ y manner so as to became subject o the Workers'Compen. ENERGY PEG
.Brion On foram.Dare WAT17R HEATER WNFNG/F.LECTR GRADING FEE
z O APPI is n m an
,o) NMI i TO APPLICANT.IL after making this Ccaiticou of Exemption,you should WATER SYSTENYTREATLNG
'N become subject to the Workers Compensation provisions of the Inbar Code,you rams[ SOILS FEB
Wforthwith comply with such provisions or this meati[shall he deemed revoked. WATER SERVICE
0
a' CONSTRUCTION LENDINGAGENCY NEW NESIDENTIAI.PLMB, SQ 1.7. PAID Dole R cipt#
C7.) 0 Thereby affimttyy((11ere isaarnsoonion lending agency lar the peHnrmwcc of
(, the work for w X, 11 is isoM(Sec.JOY),Civ.CJ TOTAL:
O U ISnders Na e
{fa Lender's Ad TOTAL:
I oily[hat 1 hove read this aPPlicolinn and sme that[he aMve information is BUILDING PF.E
I,I correct.I agree to comply with all city and county nNinanees and state laws relining to QTY. MECHANICAL PERMIT PEE SEISMIC FEE
U� building construction,and hereby outhorieu representatives of this city to enter upon the
aMve-mentioned property for inspection Paramus. PERMIT ISSUANCE ELECTRIC FIE
(We)agree to save,indemnify and keep Loonies the City of Cupertino,atmos[
liabilities judgments,costs and expenses which may i n any way secret,against said City ALTER OR ADD TO MECII. PLUMBING :E
f he granting of[hix pooh[.
APPLI T 'Jy�Ojry/(JJkI/ERS'1'ANDS ANDWILL CO .Y WIT! ALL NON-POINT AIR HANDLING UNI'r(TO I0.000CFM) MECHANICAL FEE
;oilns ��WtG�
AIR HANDLING UNI'r(OVER 10.000 CFM) CONSTRUCTION TAX
nmorc of APPlicu 7ARDOr Ilam EXHAUST'HOOD(WIDUM) HOUSING MITIGATION FI2E
HATARDOUS MATERIALS DISCLOSURE,
Will the applicant or future Wilding occupant more or handle haxardnus material HEATING UNI'I'(l'O❑NI,IIIIU BTUI
an defined by the Cupertino Municipal Code.Chapter 9.12.and the l lealth and Safety
Cee,Section 25532(0)+ HEATING UNIT(OVER IOo.01s)BTI)
El Yea VENTILATION FAN(SINGLE RCSID) LAID Dam RweiN#
Will the applicant or future Wilding proofread use equipment of devices which BOIL RR-COMP(311P 012 100,000 BTU)
mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER I W,IXq BTU)
C3Yes
I have d the hazmdnus materials mems under Chapter 6o5 of the Cali- AIR CONUI'TIONEN ISSUANCE DATE
qui
fomia Hw & sty Cale,Sections 25505.255Jn rad 255. undersmnJ Rol it the NEW RESIDEM'IAI,MECII. SQ.FT.
building s haw t auOss ilitywno[ify We prcupant
of the
D or au[horizW em Dow TOTAL: ISSUED BY:
OFFICE