S 1239 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY(}F CIJPERTINO BUILDING-ELECTRICAL. PE IT NO Y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 123.9.E
BUILDING PROJECT[IDENTIFICATIONNUILDING ADDRESS: SANH'A RY NO. APPLICATION Sl1131,1I1-fAL DATE:
IfW C: / PHONE: C N' A O '$N ME: _ 1 I �C NO:
NIC CONT'ROLp
Alt {I CTIE GI CCR LIC N ADDRESS: iyQ`gym ❑
0 3
CONTACT: PHONE BUILDING PERMIT INFO
v� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
A visE 0S— ❑ ❑ ❑
LIC uN 'D CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 air licensed under ow,,nn r cnmmensem,
==Z with Section 700Tof Division JmUbe Businessur koor,C J.anditylecrecix RESIDENTIAL'
WOO PER
ISSUANCE
Fit t full force and effete ❑SFDWL [IKITCHEN REMODEL
QOV License Clas. ic.# APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
y�W Dam Cm or
Ifl " SDF.CL 10 ❑MULT ❑
I-UNIT STRUCTURAL
Flt/ PANELS MODIFICATION
mZ Ionil Miny pl tic reunds
Z O res— UP T02W AMPS
❑INTERIOR ❑CHIMNEY REPAIRoz�q
LLI I: sed Pr .tonal 201-1 1(")AM D BATHR MODH ❑DEMOLITI NOOLS
OWNER-BUILDER exempt
DECLARATION
_5VFR IIMXIAMPS ❑BATH REMODF:IINEPAIR DEMOLITION 1
L 6 1 hereby,(tient then 11. exempt from ibc Canon,Co :Any c Law for the
6 U following reason(Seaton 7031.5.Raciness soil I'rofessinm Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
which m nit m conswct,alcor,int p Y x 1,
W oi y quires o pen pose,demolish,tar re air an wcwre
prionits issuance,also requires the applicant for such permit est fileasigned swmmenn
Q nSPECIAL.CINCUITIMISC. L '
C (hat he is liccnud pursuanum the pmvisinnz of the Cmmrncmr's License Irw(Chapcer9
(commencing with Section 91XX0 of Division)ofthe Business unJ Pm(ensions Code)or TEMP.METER OR POLE INST. COMMERCIAL;
Q.ax o C chat he is exempt tbee(mm and the basis Lor the alleged exemption.An,vlmlminn of ❑NEW BLDG/ADDITION
DEMOLITION
IY^vi Section?031.5 by any applicant fora permit subjects the applicant ma civil pcnahy mf POWER DEVICES �7�Q.[�,R. ANT ,❑1 OOD SERVICE. .
t more than five hundeeldollar,S5000. / IMPRGYIiMENT 1
Fs Q ❑1,as nwnend Ne propcny,or my emplmyaswith wages 6s their solecompcnvtimn, SWIMMING POOL ELECTRIC
a will Jo the work.medtb ,unaeue le not intended proffered forwho(Sco.7(Wt,Buxinass g ❑O'TIiL'R
a3� and I'mfessions Code:The Contmcmrs License Low does not apply to an owner o1' OU I'LETS-SWI'1'CHI?S-FI%l'URES s
property who builds nr improves themna,and who does such work himself or through _
his own employees,Provided that such improvenunu are not Intended or offered lar NEW RESIDENTIAL ELECTR SQ FT. '1 r
SQ FE FLOOR AREA EtSQ.FT.
sale.IL haxxver,be building or improvement is sold within one year ofenmpletion,the
owner-milder will have the burden of proving that he did not build or improve forpuo- l•3 �` }
pose of sola). TOTAL:
❑Lmowner ofthe property,am exclusively IF Uk,ing with licensed vacancies
ector, i- .1 1
onset La the project(Sea]nano Business and property
who
furi ds or
The es thennr's Li- - ♦ ,i�r{'l
nselnw does nsuchapply man owl a cof rournperty wceresddsmimpnwes Contractor's
QTY, PL IiRMIT 'FEE
who cnnoecnx for such projcros w'uhaanoucmr(s)licensul pursuant it) Conoaccor's �' ' s.
Licen Law. PERMIT ISSUA -
❑lam exempt under See. .R&PC for his reason
AI:I'Ell-GRAIN& WATE A VN.UATION
• Owner Dae I.,
WORK HR'S COMPENSATION DECLARATION RACK FLOW I'H(JIECf.D C
I hereby affirm under penalty of perjury,one of the following dcderations: r I"1
❑I have and will maintain a Cenificate of Consenuo self-insure for Workers Compcn- DRAINS-FLOOR. ST IES TYPE CONSTRUCTION
onion,as provided lin by Section 3700,k the I.ahor Code,for the pc...tance of the
work for which this .if is isoed. FIXTURES-PER TRAP
❑I have and will reunion Worker's Compensation Insurance,as required by Section
3700 mfthe Lcbor Code,for the performance ofnhe work for which Nis permit is issued GAS-IiA.SYS TEM;I INC.a OU'1'LITS OCC,GROUP APN
My WokCCaa P� cote carrier and Policy n
Car r... . �C- nsa sun Policy Na. are: GAS-17A SY$'TEM-OVERa(EAI
CERTIFICATE OP EXEMPT ION FROM ORKERS' GREASE%INDUti WASTE INTERCEPTOR
COMPENSAI ION INSURANCE BUILDING DIVISION FEES
(9TEssextionneelnmplded ifshe permit is forms,Mandrel dollars O$1 of GREASETRAP 9rr' --
orless1-• PLANCHFCK FEE
J
Icenifytbm`nJfiepv mnceofnhework forwhich this Pennh is isnucd,lsh°II SEWER-SANITARY-STORMEA 20017.
not employ any ��tt manners y . oww jo� y ke c'ac�,.�a. ENERGY FEE
scion Laws alil i WATER HEATER W/VhJzLECfR GRADING FEE
z Applicant
% NOI IC. _ - :1,after a ng ni cmc vemption,you should WATER SYS'IENITREATING SOILS FEE
become subject to the Workers Co. rsoion provisions n a .nlxn Coda you must
0.Q forthwith comply with such provisi ns or this pori itshall he deemed revoked. WATER SERVICE t1119aDF
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCIvin SQ, 1NM\N I,e Receipt#
U O (hereby a(firrn that here is a construction lending agency fmnhe perfnmmntt of Y �/f
the work for which Nis permit is issued(Site 30`D9 Civ.C.) ys,ai L IIDILI TOTAL:.
�r I" Lenders Name -
0 LJ Lenders Address TOTAL.
0. 1 certify that I have mad this application and state that the abuse information is BUILDING P
Ln correct.I agree to comply withau city and county ordinances and state laws elating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
LJ Z building canswctimn.and hereby uahocize opeo,maives of this city m enter upon the
aiNve-mentioned popeny for inspection purposes. FERMI IISSUANCE ELECTRIC FEE
(We)agree to ova,ivdemnlfy and kap ho and...the City of Cupertino against
Iiabiloc,.judgments.cnstsand expense,which may is any way accmeagainst said City ALTER OR ADD TO MECO I. PLUMBING FEE
in onsequence of the granting of this Norm.
APPLICAN'I'UNDERS'IANDS AN D WILL CO M PIN WI IH ALL NON-POINT A I R I EANDLING ON IT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 110,0X10 CIM) CONSTRUCTION TAX
Signature of ApplicaucContmcmr Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheappiicantcur future building acupant store or handle bmium us material HEATING UNIT(To 100,000 BTU)
Os defined by the Cupertino Municipal Code.Chapter 9.12,unit the Health and Safety I{yp9'ING UNIT(OVEN 100,000 RTU)
Cure,Section 255321a)'! _
1 ❑Yes 0 N VEN'ILLATION FAN(SINGLE RP_SID) PAID
Dam RttcipT
Will the applicant or future building by
By Ant,
,mot Management
BOILER-CDMP(JHP OR IWAIXl BTU7
emir huurJnus air conbnninams as Defined by the Bay Arex Air Quality Management TOTAL:
[)iso1 0 BOILER-COMP(OVER(WAW BTU)
❑Yes r7 No
- I have readthe hioui,as,materials mens under Clingier 6.95 dao Cali- AIR CONDITIONER ISSUANCE,DATE
requirements 2 - , Z -9
litmia Ilcalih&Safety Cnde,Sections 25505,255]1 nod 25531 I deand then if he
NEW RESIDENTIAL MF.Cfi. SQ.ITT.
buildingdoes mX cunen0y have a tetmm.that it is my msporeihiliny m notify she occupant
ofthe mquirementswhich must to motion,o issuance.1 CeetificacId Oetchem . ` /�
Owner nr aunha .,Outd uge
Date TOTAL: ISSUED By.�{,[/� U
OFFICE