S 0401 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPI,ICA'1'ION/PERMI'P PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'EIFICATIOV
- SARII rAHV NO. APPLICATION SUBMITTAL D,VI Ii
BUILDING ADDRESS:
O NER'S NA , .Irish NTHACB)R:�NAME LIC NO:
S NIC CONTROLp
'fluerlWellt _ ,GrrJJ ❑
tCHI'1IiCT/IiNGINI]iH: LIC NO: AIIIIRESs'.
FSc,litm�7(M)oi
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FLECT 1 .DMB CII
th
I.
❑ ❑ ❑
ED CON'I'RAG'IOR'S DECLARATION QTY ELECTRIC PERMIT FEE •SCRII'TION
1 em licensed unJer,pm nion,of Chapter 9(commencing
X12 lmeforce nmOof the liusinus unJ Pr x't G 'nJmy ,coneis ESIIJENTIAI:�ZWO PERMIT ISSUANC1iJ SInWL ❑KITCHEN REMODEL.Lina c,n U APPLIANCES-RESIDENTIAL VPLUMBING RI;PIPE
Z WCunmocmr
rn<a ❑MULTI-UNIT ❑STRUCI'URAI.
[-=y ARCI{OTCTS DECLARATION PANELS
to Z ,,inn,shall bemcd ax,ohlicrccoNx M(JUIFICA'I'ION
OZrP-a UPT0200AMPS [IEWERIOR OCHIAINEY REPAIR
H�F]W Llaenwd PraR.esiomd 201-1000AMFS IMPROVEMENT ❑SWIMMING POOLS
�C56 IherebY off rat OWNER-BUILDER
semlttLfron EthcC nlaONr's License Law for the OVER]"AMPS ❑BAfI1 RE.MODFUREPAIR E)DEMOLITION
LpWU OOI'llfiR
X,=- I'ollnwing rcvmn.(Session Jf13 L5.Iimmces anti Pnefgwinro Code:Nry city nr county SIGNS IiLECI'HICAL
W u-1- wit h requires permit t construct. lt improve.demolish. P any structure
Fr�W-1 pr t I dac a"fican,C hl .it it,it 'gcdstucncn SPECIAL CIHCUI'I'/MISC. �y IY�
thathe is licensedpursuant the P fth C m tar I Law(Chapters)
IW�a0
(commencing with Section 7000)of Division 3 of the Business d Prf,.lns CWe)ar 'IrMP MLTI:H OR PO 1NST. COMMERCIAL;
}a 1 o C that he is exempt therefrom and the boas for the alleged exemption.Any vlamtim.of ❑NEW BLDG/ADDITION ❑DE.MOLI'rION
X N Section 7031.5 by any applicant for a Perms subjects the applicant to Of civil penalty of I'OW'IiH UCVICE.
naI mom man live It l oddollars(8500), Cl .RANT FOOD SERVICii
F=Ghoz owner of the n la tit wa their sole com lion. SW'Ih1NING LIiLEC'1 RIC .1 O 11178 h1EYf
C pnopc y,or ntyemp yeesssi gcs as .Ines V ❑O IIIiR
F will Jothewon%ande: Due
him Contactors License
Lint, edforst applyc(See,to
llnerof
is m and sery whom Code:'rhe eves tit rco License haw Joes not apply s un owner of OUTLG -$WITCIliiS-ITXTUHES
his.,,y who Haile.or improves that
tb telt i Imo who does such work himself or Ihmugb
it's awn ersocc ath pnrvidal Ihnl such mens is sold w we nnl Iyewofd or oflcred Iia NE t1iSIDEN'rlAh ELI!CTH SQ i f.
mle.If.M1ou'm'eo the building orimPmvemam i.acid within one Year n(nmtpinion.Ihc SQ.IT FL(KJH AREA S/SQ.IT.
ownict-hoildcr will have the harden of proving that he did not huild or improve for par- PAID
rynen(wle.).
I,o owner of the property',ante exclusively rnmrecting with licensed commemo Ice TOTAL:
mscucl the project(Sec.7044.Business and Prol cions Gzlep The -untraIlor's I.i. �s
came Law aces not apply m an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE Ai16
wha,untracs torsanhpmjcaswah u amno
oacono)licensed puauanthe Contrartio, Alj
License law. PERMIT ISSUANCE: (� Y
❑I am exempt under See. .B&I'C for reason
ALTER—DRAIN&VENT—WAI ER(EA) VALUATION
i Owner Date
WORKER:.COMPENSATION DECLARATION BACK FLOW PROTECT.DE ICE
(1 1 hereby afftmt under cenalty of pe jury one of the following declarations:
II Ej l have and will mninmmuCrnlfictttcafCunncnnnzd Finutre for Wndcds Com DRAINS—FLOOR.I<OOp,AREA.COND.
Pea' SrORIF.J "1 YI'Ii CO ICr1ON
µmien,as Provided for by Section 37W of the Labor Cale,for the performance of IM1e
ark for which Ihis permit is Issued. Iq XTIJHIiS—I'F.R'1"RAP .70
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Sect u
37M ofthc Labor Code,for the performance ofthe work for whicbthis permit is issued. GAS—EA.SYSTIMFI INC.4 OU'llS OCC.GROUP AI'N
MyyMP't Ys"Cry.&,a+lI ln�su4n^y'rier and policy TO � GAS—PA.SYSTEM OVER4(CA)
e 'TA o Polley Na.: C
CER'1lPICA'TEXILM OE SALON'II NI1tAM WOHKHH$' /�/7
COMPENSATION INSURANCE GHLASI%INIIDSTRL WAS'T'E IN'1'ERCLIsI UR
BUILDING DIVISII)N PEES
(This section need not R completed ifthe permit is for one hundred dollars($100) OR EAS]i TRAP
it less.) PLANCIIECK FEE
Iartily tbm intM1ecerfntmanceofthe wad fnrwhich thisperout is o,cd.l shall SEWER—SANITARY—STORM I:A.2017
nn
ot nploy any corn 'n nunYncrsoasm hcnm.erdoca nt the Wnderi Cnntpen- ENCRGVITH
OZ emion lawsol Cadrailia.Dates WATER HEATER Is VENT/ELECI'R GRADING FEE
z o Appbeant '
NOTIC17'PO APPLICANT:If,after making this Certificate of Exemption,you dumd WATER SYS'1'Eb1?RGTING
become subject to the Worker's Compensation provisions of the Ldner Code,you must SOILS PI]3
fold with chili with such pmvi I,of Ibis permit shall be deemed revoked. WA'll?R SERVICE
ISI � Z CONST RUCTION LENDING AGENCY NEWRESUMNI'IALPI.MB, SQ.17 PAID
UC) Iherela
by arm than mu
here is amuation[ending agency for Performance of Date sceiptN
V. L•" the work for which this permit is i.med(Sce.301 Civ.C.) 09
C)V Lenders Name TOTA 1.: 12
TOTAL:
,r W Lenders Address
0. 1 certify Ill.,I lune read this application and xtatc that the above infunw
. mnn Ix NUILDINC ill
FM amort.]agrceue comply with all city and county mainanas and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby vmhorim mpriwourivcsofthia city to enter upon the
SIiISMIC PEE
uMrve-mentioned Property for inspection purposes. PERIOD r ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PER
fl.bditics.judgn¢ms,cosu and expenses which ntayln any way income ngaimlssid City ALTER ORADD TO MEC({. PLUMBING FEE
incosequence of the graining of this .fit.
n •/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.NON.POINT AIR HANDLING UNI1('10 DIM CFM)
MECHANICAL FEE
SOURCE REGULATIONS
AIR HANDLING UNIT(OVER 10,000Cly CONS'IRUM ION TAX
.Igoatarn (W
umms ur are EXHAUST HOOD HOUSING MITIGATIONIrli13
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future builder,oecuPantmore orlemdle haadous material BEATING UNI r(TO IW,(xx) U)
as defirod by the Cupertino Municipal Code.Chapter 9.12,anti the Health and Safety
Cale.Section 25532(x)'! IIIiA""PING UNIT fOVE NI,IXxI b'rU)
No
❑Yes ❑ VI?NTILATIONE (SINGLE RHS ID) I'ND ()air Resi#
rt Will the applicant or future hilding occupant use equipment or devices which
4 mminanuuulefred by the Ra Arco Air Qualit Marta BOILER-C P(3f1POR II xIBTID
�inmr oux sir con Y Y gomm� T(rrAL: x
Utstrim'! AlIL- -C OM P(OVER100,00(IPTU)
❑Yes ❑No
I have mad the hvardous materials requirements unJer Chapter(.95 of the Cali AGONDfITQNER lSSUANCP DATE
(omit[],rich&Safety Code.Sanlnns25505.25533 anti 29534.1 undr,mod Jtal it the NEW RESIDENr1AL MECIL SQ.Pr.
building does na currently have a¢nam.IM1m it ix my respnnsibiliry m molly the rcapam
f I e reyuiremc tswrobron or In ismanlaC
cc a �cpniti'mc I(kcuptncy. _
E,�rt�7
Owner or outhr grnl= t Dam T(HAL: _ISSUED BY
OFFICE