S 0070 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. nnn �`
BUILDING DIVISION BUILDING PLUMBING- CAL.
MECHANI
BUILDING PROJECT IDENTIFICATION V
BUHAANGADDRfSS: SANITARY NO. APPLICN'ION SUBMITTAL DATE
(a/ 3 EN c vin G
OWNER'S NAME: PHONE: CON ME: LIC NO:
( / NIC CONTROLp
ARCH]TECT/I?NGllshb : LIC NO: A DRESS: ❑
1,Ifir S
CON'I'ACI': 1I'Ik)WZ: BUILDING PERMIT'INFO
BAIia M 1I(�` J2xr / I ' ❑ Consultant Fecs,Paid by Applicant(Initial) P DG ELECT PLUMB MECH
UU ll1l V1 Ir , U 1 { ❑ ❑ ❑
I-ICENSEDCONTRAMOR'SDITCLARATION QTY ELECTRIC PERMIT FEE
I hcmhy infirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ with Section 7000)
of Division 3 of me Business and Professions Code,and my license i.s RESIDENTIAL:
iD00 win PERMIT ISSUANCE
Fes,❑:F- in lull lima xnd cffcn `. Z / �Sd�O ❑SFDWL [I KITCHEN REMODEL
st Licem2"-. _ Lic.x AP AYPLIANCES-RESIDENT IAL []ADDITION ❑PLUMBING RE-PIPE
NZ W 1 Counselor
F,�y ARCHITECTS DECL A'1'ION PANELS []MULTI-UNIT ❑STRUCTURAL
Z O rn Z 1 understand my plans shall be,used a public records h1 DIITCATION
OZ4— UPT02(g1AMP5 ❑INTERIORIAINEY REPAIR
F�FuI Licensed l'ndcsxional 201-I WIIAMYS IMPROVEhfENT n5\ IMMING POOLS
x C C Q 1 hcrehy affirm maOWNER-BUILDER
am anempnfrnmEme C n Trauors License law for the OVER 1000AMPS ❑BATH REMODEfIREPAIR DEMOLITION
R:i.
U following reason,(Section 7031.5.Business and Professions Cade:Any city or county SIGNS HLIiCIRICgI. OTHER
y which requires a permit to construct alter,improve,demolish,ar repair any structure
E'�atat< prior m its issuance,also requires the applicant for such penning flea signed swtemcn, SPECIAL CIRCU IT/M ISC.
S9ae. M mut hcls licensed pursuant to the provonm4 of me Contractors Licensu law(Chapter 9
W (mnm,encing wins Scnia 17th%B of Division 3 of the Bari nu,nndi'n f—inin'Codc)o, TEMP.M ETHR OR POLE I N59t COMMERCIAL
L X e C than he ix,smnpt therefrom and he bras fur me nllcgcd enempnion.Any violu me of ❑NEW BLDG/ADDITION ❑DEMOLITION
X�4y Senent7031.5 hyuny applicant for u Bermn,ubjeeu a he applicant u,a civil penahy of POWER DEVICES ❑TENANT El FOOD SERVICE
not mare man live hundred dollars D5W).
F Z r IMPROVEMENT
�Sp 0Lmnwnerk.the progeny, rmyemployees with wagexnsmei(Sec. 0,14,Bsiness SWIMMING POOL ELECTRIC
g. will dnmework,and e,he CordisnotimcndM oroffered
to an Business ❑OTHEPs
u�l�� and 14nfea,inm Cede:The Contractors License Law dawn not apply no m owner of OUTLETS-SWITCHES-FIXTURES
a 3— property who builds or improves meretn,and who does such work himself or through
his own employees,Provided that such improvements am not intended or offered for NEW RE4IDENTIAL ELECfR SQ PT.
%ale.If.h,wever,the building or improvement is sold Within one year of completion.me FTF S1SQ.ET.
rnoailder will have the burden of proving that he did not build or improve for pur-
'e,,'ifsale,). CID r
❑I,ss owner of he property,am eaelusively contracting with licenced contractors to
TOTAL: U GUYCti11NU
instruct the project(See.2044.Business and Profession.Code:)The Continuo..Li-
sent.Law does non apply man owemof property who build.,,,improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts lin such projects with a commnogs)licensed pursuant no the Commemes
Liccnw Law, PERMIT ISSUANCE
0 I mn,xcmpnadcr Sec. ,B M P C linde,n,rocon
Owner DALTER-DRAIN&VI?NT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW I'kOTIiCT.DEVICE
1 hereby affirmunder penalty of e perjury one ofthe inlhwing declarations:
/ ❑ (have andwill forbyeCion 37 to of Ce Labor Coale,for the Worker'sce of m- DRAIN$-FLOOR,RWF,AREA,GOND. STORIES TYPECONSTRUCTIOD
scion,as hick this
for mi Section 3'100 of the tabu Coale,for me performance of me
work far which this mutat is issued. FIXTURES—PERTRAP
❑1 have and will maintain a perfas Compensation week
which
h required.......
.Section
MYthe LaborCW4for me per(o,mmme of me work farwhich this permit is issued. GAS-13A.SYSTEM-1 INC.4OUTLETS OCC GROUP MIN
My Wnrker'$Co gemaion lnsutreecy,t and Policy u r GAS-EA.gYSTIiM OVER4(EA)
Camcr. Kj- �'IA, .Policy Nu.:
CEHTIFlCA EOF EMPI'ION FROM WOR F-RS'
COMPENSATION INSURANCE GREASE%INDUSTRL WASTE INTERCEPTOR
(This section need not he completed if me Bennis is for one hundred dallas($100 BUILDING DIVISION FEES
or lc,,.) GREASE Tkgl' PLANCHECK FEE
I enifymat irms performanceoflhe work for which mispmed is issued.)shall SEWER-SANI'T'ARY-STORM EA.200 BE
net omploy any person in wry manner so as m beconm vimcc ome Workers'Corpcn- IiNERGY FEB
Oz cation l.aw,ot Cdilina,. Dane WA'I'IIR I EAHIR W/VENTELECTR
z Applicwn t GRADING FEE
NOTICETO APPLICANT.If,after,making this Cerafi,ae of Lsxemption,you should WATER SYSTEMnJUTATING
> become subject ,,the Weaker',Compensation provisions of the Luhor Cnde,you most SOILS FEE
forthwith comply with such provision,,,obi,peimilshall be deemed revoked. WATER SERVICE
a �
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
L) P Ithereby whivhrn mmmere isxedDicsllon]coding agency for me Performance of Dae Receigtp
Li. me work for which this permit is issued(Sec.3097.Civ,CJ
0 U sander's Name TOTAL:
G Lender's Address TOTAL:
Q. I comfy thin I have read this application and ream mat me above information is BUILDING FEE
rn corr,e,.l agreemnnnply wins all chy and county oNinences and stmt laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby antenna representatives of this city m enter upon me SEISMIC FEE
al,ave-nummncd progeny for inspection putpows. PERMIT ISSUANCE
(We)agree h,save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiubililiet,jtd'unces,cnBsand expenses Which anyway seem,slidnslssid City ALTER ORADDTOMECH.
sequence ol'the gmnning of n PLUMBING FEE
AnNI ANDrmI .COMPLY' 1111 ALL NON-I'OIN'I' AIR IIANphING ON]'1'(f010.(100 CFM)
SUUItCli 12' ,Aft MECHANICAL PEE
GAIR HANDLING UNI I(OVER 10,000 CFM) CONSTRUCTION TAX
Si an m ufAEAt waulmarachn I Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
PAZ RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupan store or handle hoaardous material HEATING UNIT CTO 100,0011 BTU)
m dented by the Caliendo Municipal Cade,Chapter 9.12,and me Health and Safety
Cade,Section 25532m)? HEATING UNIT(OVER 100.00)BTU)
❑Yes EJ No VENTILATION FAN(SINGLE RESID) PAID
Will me applicant or future building occupam use equipment or devices which Date Reccipt x
it hazardous air contamimit,as defined by the Bay Arca Air Quality Management BOILER-COMP OHP OR 100000 BTU)
Disbi,tp T'O'IA L:
❑Ycv 71 No BOILER-COMP(OVER 100.000 BTU)
1
I have read the hazuMou.s materials myuiremcros under Chapter 6.95 of me Cali- AIR CONDI'I ION17R ISSUANCE DATE
form:.Hu,Ith A Safety Cnde,Seasons 25505.25533 and 25534.1 unden,ind mm if the NEW RESIDI3N'I'IAL MECH. SQ.BE
building die,not 0...can,have a tenant,that it is my resisomihilily to notify the escaped
of the requirementsishichanus,he met prima la...rearmofa Cenificamol Occupancy. J— -
Owner or admitted agent Date TOTAL: ISSUED BY
OFFICE