S 1807 --APPLICANT-TO FILL-IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO « J BUILDING-ELE'% (CAI. PF: ITNO.
BUILDING DIVISION APPLICATIONI RMIT PLUMBING-MHC "AL 1807
BUILDING PROJECT IDN. N
BUILDING ADDRE3S:065 �� SANITARY NO. APPLICATION SUBMITTAL DATE 5 --> .�� A�z� E-
U 'S NAA1L: L "" 10 L
PHONE: _& 0 CONTRA OR's NA%�� .IC NO:
\ NIC CONTROp
ARCHITECT/ENGINF,ER: LIC NO. ADDRESt I`1k/L StS� ❑
CONTACT: PHONE: ''�J`taCdJ, BUILDING PERMIT INFO
�N�j I� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC' PLUMB MECCH
LICENSED CONTRACTOR'S ULCLARAHON QTY ELECTRIC PERMIT FEE
1 hereny ofnrn the,I am fiamved made,provisions of chapter n(crnn.orientg JOB DESCRIPTION
BOZO with Semion]Ulq)of Div''in
the Husinoss and Professions CnJe,and my license is PERMIT ISSUANCE. RESIDENTIAL,
FEk. full force and effect. ❑SFUWL ❑KITCHEN REMODEL.
<—U Liccnsc Class Lich APPLIANCES—RESIDENTEAL ❑ADDITION ❑PI.UMBING BE PIPE
FZIy Date Contractor
op<6 ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECT'S UHCLARN'ION
p..G ti PANF.1.5 MODIFICATION
OOt-Z 1undernrand mY Plane conn he used.,.bill records
OZ— uP T02IXIAMI'S ❑INTIiRIOk ❑CHIMNEY REPAIR
Licensed Profic,cnn:d 201-1010AMPS IMPROVEMENT 0SWIMMING POOLS
G @,�
OWNER-BUILDF.k UIiCLARATION
OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 hereby affirm that 1 1. uxumpt from the Contactors License Law,lin the
�na U following rtawn.(Section]OJ LS,Business soil Professions Code:Any city or county SIGNS EL[CfkICAL El OTHER
1+13 k4 y which require,,a permit to construct,aker.impmve,demolish,nr repair any sworn.
F�'.w.06 prior to its issuance,aLm requires the npnlienm for suchpermino0lensignedoetement SPECULCIRCUIT/MISC.
'�,yy, that he is licensed pursuant.the provisiunsofthe Contractors License Law(Chupt«9
WiG�O (commencing with Section(NXIlofllivisimn 3mfthe Businecx oral Professions GWd ur TEMR METER OR PILE INST. OMMP
d q m y that he is exempt thcrefmm moil the basis far the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DIiM01.1'f10N
i� a• S.Im.7UJL5 by any applicant torn permit subjects the applicnnna a civil penally of POWER DEVICES ❑TENAN'P ❑FOOD SERVICE
y m more than rise hundred doll..($500). IMPROVEMENT
01,asownerefthe property,many employees with wages as their stile comnenwtion, SWIMMING POOL I3LECf
p. will do the oork.ond the structure is and intended oruffereJ fursale(Sro.70f4,Business ❑OTHER
m and Professions Code 'Me Cnntracmr's License Law dues not apply tee ua moor'of OUTLETS—SWITCHES—F
g.3.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided Shia such improvemcros are mon intended or uttered nor NEW RESIDENTIAL ELIiC[k 17.
sale.If.however.the building or improvement is sold within one year of completion,[lot SQ.FT FLUOR AREA ESQ,FT.
wnerbuilder will It...the hurden of proving that he did not build or improve for put- JULPo��AI�aD
pose of mlcJ, AVANT
y
❑ 1,as ironer of the propery,am exclusively contracting with licensed crmtr:tcrors , TOIA" n
consurra the project(Sec.7M4,Business and Professions Codc)'fhe Contractors Li- V l ll y/1 ♦urail�
crow law does not apply to an owner mf pmfeny,who builds or improves thereon,and QTY. PLUMBING PERMIT EE Ilse a/nfIYllNtYflw
who contracts for Such projects w ith a cmmnufo(s)licensed pars mar to the Contra"or% _ -..
License Lin, PE•RMII'ISSUANCE? CITY Ur
❑ I am excmft under Sec ,B A,P C Smith.avom klVrCfT MVV
- ALTER—DRAIN A,VENT—WAMR(EA) VALUATION
Owner ME. �a `_/'w
WORKER'S COMPENSATION DECIARATION RACK FLOW PROTECT.DEVICES
[hereby effort under Penally of perjury one of the following declarations. i� f
❑Ihave dwiilmuinwinaCenifcum of Consent to self-insure for Workers Compen- DRAINS—FLOOR.ROOF AREA,GOND' S'FOR1ES 'TY PF.CONSTRUQ'rim
ratio s provided for by Section 37M of the Labor Cale,for the performance of the
w0 kawhiclandspewitisissueJ. FIXTURES—PER TRAP
1'rove and will maimain Worker,,Compensation Insnrnuce,as ectm cd by Section
3700)ofrheLnlwr Cale,firat perfowancetif Bre work Im Ishich this permit is issued, GAS-13A.SYSTEM-ILNC401TLETS OCC.GROUP MIN
My Wuk Cnmpensatioy l smmmce artier and Poli r C GAS—EA.SYS'1'PM-OVfS ER4IGA)
Curies Policy Nn:
CL'R 1F Al'E OF EXEMPTION IRON WORKERS' GREASFIINDUSTRL WASTE IN'fl?RCEVI OR COMPI3 SATION INSURANCE BUILDING DIVISION_FEES
(This section need not be completed it the permit is forma hundred dollars($11U) GREASETRAP or less) PIANCHECK FEE
lanifythat othe perfowanesm'die larkfaromidt thispennit is issneJJshnll SEWER—SANITARY—STORM EA.200 VL
not employ any person in any manner so as nm become suhjW So the Workcn Conipen, ENERGY FEE
Z motion Luwx of Califonda,Data WA'T'ER HEATER W/VENT/ELECTR
GRADING FEE
z Applicant
NOTICE TO APPLICANT:IL after making this Cerif¢me of Exemption,you should WATER Sys rY.M/rRL>AfINC, SOILS FEE
heemac suhjem m the Worker's Compensation provi,ime,of the Lahm Code,you must
fdl forthwith comply withsuch provisions or this pent shall be deemed revoked WATER SERVICE
EL
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID Dme Receipt K
U O l hereby affirm that there is a nmxt.ction lending agency lot the performance of
Fthe work for which this penin Is issued(Star.9097.Civ.C.)
Lenders Name 'TOTAL:
WLender's Adds,, TOTAL: it
y 1 certify that I have mud this application and state that the above information is BUILDING FEE
h
correct.l agree to comply with all city and amity ordinances and.mate laws relating to QTY. MECHANICAL.PERMIT FEE
U Z building construction,and hereby nuthonm mpresemtator,of this city.enter upon the SEISM IC ITE
xr alwveane dionJ property far insfeaion purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hominess the Ciry mf Cupertino against
liabilities,judgments.costs and expenas which may in any way were again.said City ALTER OR ADD TO MECH. PLUMBING FEE
in sequence of the gmming of this penult.
APPLICANT UNDERSTANDS AND WILL COM I'LY WITH ALL NON-POINT AIR HANDLING U NIT(TO 10,000 CPM)
MECHANICAL TEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IU,IMq CFM) CONS]RULTION TAX
Signature of Applicant/Conrecmr Date 1XIIAUST HOOD(W/DUCT) HOUSING MEDGATION EEL
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fu.re buildin,arcuparrt sore ur Smote ha.rdons material HEATING UNI'1'(PO 100,000 BTU)
as defined by the Cupertino Munidp Cale.Chapter 9.12,and the Health and Safety
I Cade,Section 25532(a)] HEATING UNIT(OVER IWJOg)BTU)
0Y. PAID
VENTILATION PAN(SINGI.IiHESID) Unm ReaiptM
Will the inflation or future ob a Jing mcufanl ase equipment or devices which BOILER—COMP(JHPOR IIq,gq BTU)
emit hu,ni dour air cnmaminants as fined by the Bay Areu Air Quality Management '1'O'EAU 11
Dis ' BOILER—COMP(OVER IW.(W BTU)
Yes
I taereaJ the ha dour materials nanimmems under Chapter 6.95 of Cali- AIR CONDITIONER ISSUANCE DATE
India Ith a e y le,$uf n +SBS,25531and 255)4.I undsnrd t t if the NEW RESIDENTIAL MECH. SQ.FT
builein docs corm haven n Wmhiuny rexpnmibllitymnotif the -wpant
of he quire ends w s ist ny mo i uuncc of aCeninrI all
Ow -r initiatives enn U e TOTAL: ISSUED BY:
OFFICE