S 0519 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELI?C'IRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0519
BUILDING PROJECT IDBYfIF'ICATION
BUILDING ADORE. SANITARY NU. APPLIC TION SUB 11TTAL ATE
�/ 9
OWNER'SNAME: ,e UPS[: _�D/ CONTRACTOR' / LIC
0q,V-.;o? /J NIC CON'I'ROLe
-�RCHITECrIENGINEER: LIC NO: ADIJghJ'Vnp � V ❑
COST 7E � � PHONE/w�!./ BUILDING PER IT'INFO
✓' �W/ ❑ Consultant Fees Paid by Applicant(Initial) ILDG I]LIiCyT P NIECE
❑ w
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby off rmt dam I Ana licenced niuer pmvish,m.of Chaplin 9(aemmenemg .JOB DESCRIPTIO
GCz lir Section 7lXNBof Division Sol the Business and Prof.:nm 'ode.' JI licemsc is RESIDENTIAL:
F�� with
force andef P12RMIT ISSUANCE a
�_ m ❑SFUWL ❑KI rCHEN RF,M(yUlil,
aUU Liccnm Cou APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE,
F-Z W Ua¢ Cnmmnn
mQa ❑A1ULTI-UNIT ❑STRUCTURAL
RCHITECI'S DECLA TI
z0onz I understand my PI.a.Otall be imed as puhhe reaudx PANELS MODIFICATION
OZ=� UP1'02E0AMPS [I INTERIOR [I CHIMNEY REPAIR
F I?F'a1 Licensed Professional 201.1"AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUIhUIiN UIiCLARA'HON OVER UXX1 AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
tY ffLL 6 I hereby affml that 1 am exempt from the Contractor's Licenu I.aw fur Ih<
adL V following reamn.(Section]031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL El OTHER
W 3 W h which regnimx a pemdl to u,nstruet,aper,im)nnve,demolish.or repair any ammuro i
F u'Cg prions its issuance.also requires the applicant for such Permit to file a signed statement SPEC1 AL CIRCUITIMISC.
f,�y IbutheislicensedpunuarnotheprovisionsoftheCmuccine,LicenseLaw(Chapter9
H (c.nerencing with Section Tippler Divixiun3of1 he Bmincn,and Fort ,,ion,Corr)or TEM P.MR IER OR POLE I NST. COMMERCIAL:
Ar a e C that he is exempt(wet um and the boon,for the alleged escmptian.Any violdinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
x�m Section]031.5 by any applicant for a permit subjects the applicant macivil penalty of POWER DEVICES ❑TFNANT FOOD SERVICE
t more than fisc hundred dollars(8510). IMPROVEMENT
f=C ❑I,ns owner of the pr^perny.or my employees with wages as their sole contpensadan, SWIMMING POOL ELECTRIC ❑O'BIER
1z will do the work,and thcstruaure isnot intended oroRered far sale Side.70L Business
Wand Pn fc,'in I,Code:The Contmclnr'r License Law does not apply m an r
owner of OII'LETS-SWITCHES-MIXTURES
A. propany who builds or improver thereon,and who does such work himself or through
his own employees.pmvidvI that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ Fr.
sule.11,however,the huiloling or lmpnrvmnem is Told withlnorre,ew f en....eion.the SQ.PI'.ILOOIt AREA 3/SQ.Fr.
owner-huilder will have the burden of proving that he did not build or improve for par,
lava of sulc).
O L m o secr of the popery,a .claoody c mI...in,with licensed contractors to TOTAL:
..,tract the projen(Sec.7034,Business and Professions Code:)The Contractor's Li.
Ase Law docs not apply to an owner of propcny who builds or improves therwn,and QTY. PLUMBING PERMIT FEE
who,aurae,,lorruch Pnajects with a cornmetor(s)filrewal pursuant I^the Contractors
Liceme Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C far Nis mason
ALTER-DRAIN&VIINT-WATER CA) V.LUATION
Owner Date 230
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hand w affirm under penally to perjury enc of the imm wing dcehmnions:
L]Ihavc andwillmainwinaCcnificale of Consent for WorkcrxComlen- DRAINS-FLOOR.ROOF. A.COND. STORIES TYPECONSTRUCTION
cation,as sided fur by Scatiun 37M of the Labor Code,for the performance of the
work which this pcnnn i.issued FNrURES-PERTRAP
hat and will maintain Worker's Com atian Insurance,as required by Section
3 W ofthe LeM Code forthe more
the work for whichthis permit is issued. GAS-FA.SYSTEhf-I INCA OUTLETS OCC.GROUT' AIN
My Works'. ' rawr I sir l Policy nn McswlrYlDM
Canner: n nc o liey No.: GAS-EA.SYSTEM.OVER4 CA)
CERTIFICATE OF EXEMPTION FROM WORKERS' CRLiASFIINDUSTRh WASTE INTERCEPTORCOMPENSAI]ON INSURANCE BUILDING DIVISION PEES
(rhic,uetlon need notM e m .nedifdre permit 1,guone hundred do)[.,($1000 GRE4SETRAP
or less.) PLANCHECK USE
Ices ily thin in 0u performanccol'Ihe work fur which Wiepennit is issued,I rhdl SEWER-SANITARY-S'I ORM EA.20X1 FE
nm employ any Myon in my manner w as tin become subject m the Workers'Cumpcn- ENERGY FEE
0 Z xmm.Laws of California.Dae WATER.I11iATER W'NEN ELEC R
Z Appbeam
GRADING FIiIi
O
y NOT'ICF.TO APPLICANT:IL after making this Cenificate of HIma you.should WATER SYSTEMS'REATING SOILS FEE
a ; become object to the Worker's Compensation previsions of the Labor Code.you muss
forthwith comply with such provisionslir this pcmul shall be dcened revoked. WATER SERVICE
0. Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FL PAID Date Resvipt a
U 0 forhereby which
this
lher there issue (See.3n landing agency for the perbmmancc of
C•-' the work for which this Iermit is issued(See.3119].Civ.CJ
I<ndr' L:
Name TOTAL
V Under',
Address TOTAL.
s�O 0. 1 verify that 1 have read this application and Marc that the abinv infntmrn I i. BUILDING FEIi
F-' Ncorrect.I agree m comply with all city and county ordinance'and nate laws miming to QTY. MECHANICAL PERMIT FEE
7
V a buildingconomedirrand hcrchy mmoriea represenmatives oflhN city metier upon lire SEISMIC FEE
shove-mandened propcny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep ha didecs the City of CLper ire aprimt ELF.CI'RIC Frh
liabilities,judgments.costs and expenses which nary in any way accrue against said City ACI'ERORADDTOMECH.
in consequence of the granting of this fiction. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOD 10,000 CEM) MECHANICAL IEE
SOURCE REGULATIONS. pp
AIR HANDLING UNIT(OVER 10.000 CFM) y.� t TRUCf10
Signmereof ApplicanVContmcmr Dote F.XHAUS'EHOODIWIDUCq OUSING FEE
IIA%ARDOUS MATERIALS DISCLOSURE
Will theapplicml or future building occupant smrc or handle hmallous.,coal HEATING UNIT(TO 100,0ID BTU) July,j
a.defined by d a Cupenlno Manic Code,Chapter 9.12,and the Health and Solely
Code.Section 25332(nl'r HEATING UNIT(OVER 100,X10 BTU)
❑yes No n Wt
vv PA' 11VV
VENTILATION PAN fSINOI.IC RESIT» Uum Ruciptb
Will the applicant or future hudding occupant use equipment or devices which
emit hazardous air comtionsfiner!. xa./IneJ by the Bay Arca Air Quality Management BOILER-COMP OHP OR I(A"I1TU) TOTAL.
District? YYJJ/ BOB.F.R-COMP(OVER 10X,(1(10 B'1'U)
❑ ��4++
Yd"
Nn
AIR CONDITIONER
I have read the ha'zuNous m:nerinla rcquircntenN under Chapter fiJ5 nl IM Cali- pISSUANCE DA'5'—
'a
'I;
'amid HwId Safety Code.Sections 25505.25533 and 2553x.I understa I that if the NEW RESIDENTIAL.MECH. SQ.FT. 32 ft"A ��_ p
buildingdd to ydlyhareem I.IN Iitiz my rcspxrwiility ototif hco :pmt
of lM1c rne6demsrlltiyn nprionoi.xuuncc ofa Ccni Uis�
Ow uril�nrjautl oJmzcd/aBefnt� �� TOTAL: ISSUED
OFFICE