S 0927 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
JBU
TY OF CUPERTINO BUILDING.ELECTRICAL PF 11T NO
BUILDING DIVISION APPLICATION/PERMI'P PLUNIBINC,-.MECHANICAL 0927
BUILDING PRIIJFCT IDENTIFICATION
ILDIgC/Al)1)RES,S � $ANI1'ARY NO. AI�.ICATIUN SURMITT,\L DATE
ak
Elizw
NI ft' NAME:f, TNIA *A PHONE: COM1TRAC OR'S NAME: LIC NO:A(JVs _ NIC CONTRDI.#
CHITECTIENGINF.ER: LIC NO: ADDRESSNTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) UG ELECT PLUMB MICA
u LICENSED CONTRACTOR'S DECLARATION QTy, ELECTRIC PERMIT FEE
I nerehy elan"that I am licensed miler provisions aT Chapter 9(commencing JOB DESCRIPTION
woo with Section 7(M).fDivision 3ufhe B-imsxand Pn fa,sion.Cuda.and to,ovnsc is PERMIT ISSUANCE RESIDENTIAL:
1-W— in fall force and effect. ❑SFDWL ❑KITCH17N REMODEL
QUU License Class c# APPLIANCES-RESIDENTIAL DITION C3 PLUMBING RE-PIPC
I.,ZW Dam Commchr
hn6 a MULTI-UNIT ❑STRUC-I'URAL
ANCHITF,CTS DECLARATION
ZO'o,Z Iunderstand myplv",shall be used.,p.hl,l records PONTIS h1DDL1'IGATLDN
UP TO 2W AMPS
O Z..� ❑INTERIOR E]CHIMNEY REPAIR
.W LlcemeJ Prom.,ion.I 201-1"AMPS IMPROVEMENT E]SWIMMING FUELS
C C Q 1 hereby affirm hat I um lexelmpt for.E he C mlmclors License law for the OVER 10X1 AMPS ❑BATH REMOf�L/RIiPAIN 0 UEMO�TION
s K 06 U following rca,nn.(Sermon]Diff S,Rusinas end Professions Code:Any city nr mwntY SIGNS ELECTRICAL ❑OTHER
W 3 LL y which requires a permit to construct,alter,improve,detnnlhh,or repair any snucmre
F�Oa prior In t.issuance,also y the pplic t for suchTerror rile a signad.t tcncdSP[CIAL C IRCULTIMISC.
fy•]] that he is licensed pursu t to the previsions f The Contractors License L. (Chapter 9
W=00 co 6 with Sect f
700(f 0 ''i l of the Business JP f.. :GdeM P.pv TEME-DER OR POLE,INST. MPR '1 L:
d d e C thin Into.escup,thereto and the basis in he alleged esv npuoa A ry v'aW nn of 'iW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 byanyapplicam for a perionvoAjecns he applicant civil Penalty of POWI:R DEVICES TENANT ❑FOOD SERVICE
n more tha"live hundred dollars(351101 IMPROVEMENT
^_Q D1,a.s owner ofhe propcny,or oyemployess with wages a%heirsole compensation, SWIMMING POOLELECTRIC
will do the work,and the structure is nor intended or offered fr"ale(see 7(Wy.Business ❑OTHER
tarp w e.and Professions CodThe Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-PI%TURES
A.3^ propcny who builds or improves thereon,and who does such work himself lir through
his awn ent,lnyec,,provided the such improvcntenl, re not imended or offered far NEW RESIDENTIAL ELECTR SQ FL
sale.If,however,the building or improvrmeot is,add withinovcymrofm,mplction,the '7 SQ.FI'.FLOOR
AREA $/SQ.FI'.
e vnerbalder will have he burden of proving that he did nm(wild or improve for purIt
-
pWeolsulc.).
- as ow r onhe proper},am exclusively contracting with licensed contractors to
mswct he project(Sec.7W4.Business and Profession,Cale:)The Contractors Li- wA
se Law does not apply to an ownerofpropery who buudsor improves thereon,and QTY. PLUMBING PERMIT FEE CJf/
who cnmracls for such projects with a conuactor(s)licensed pu ammo to the Cmaracmr's
Ultow Law, PERMIT ISSUANCE
❑1 am exempt under Sm. .B&P C for this tvson
Owner Dale _ ALTER-DRAIN&VENT'-WATER(EA) VALUATION
WOR I3R'SCOMPI:NSATIONDF,CLARATTON HACK FLAW PROTECT DEVICE: r O r�
I hereby M.under penalty of perjury ane of the fallowing declaration, 10
I have and will maintain a Certificate of Consenuosif-Lnsare for Workers Compen- DRAINS-FLUOR.R00r..AREA,COND' STORE: TYPECONSARUMIOI
soliun,as provided for by Section 3701 of Labor Cala for the performance of the
work for which his permit is fotwd. ITS PORES-PER'rRAP
C] 1 have and will maintain Worker's Compensation Insurance.as required by Section
3710 or the labor Code for performance of the work for which this permiti%isved. GAS-EA.SYSTEM-I INC.J OUTLETS OCG GROUT' APN
My Worker,Compensation Inwmme conic,and Policy numler are:
Carer: Policy No.: GAS-PA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This secmiounced notbecomplead iflhcpennil ivforouchandreddollar,($IW) OREASETRAY
lir les.) PLANCI{ECK FEE -.W
I verify Too in the p•rformmceofthe work for which his permit is i...0,hall SEWER-SANITARY-STORM EA.2k)ET.
nal employ any person inany mationo :two hocome attaces to the Workers Compal ENERGY FEF.
Z ,.tion Law,of California.Date WATER HEAT/
TER WNENELELTR
z O Applicant GRADING TEE
h
NOT ICI7 TO APPLICANT:11,afar making this CeriGcam of Exemption,you should WATER SYS'IEoTTHEATING
hecamcwhwo m he Worker,Compensation previsions al'be Lobar Cale,you must SOILS IEE
forthwith comply with such provisions or this perm i shall he decnod revoked, WATER SERVICE
UUz CONSTRUCTION LENDING AGENCY NEW RCSIUENTIAI.PLhtli. SQ.I'I'. PNU
0 IM1oreby uf0nn hal there isuconswniun lading agency for the perfommnceof Dom RecP It
W. F he work for which his permit i,issued(Sec.3097,Civ.C.)
O U Lender,Name TOTAL:
Larder,Address
1 certify hat I nova read this vppliemon and,min hal he above in0anuniorm is BUILDING FEE
.H."0./1 corredlagaemrnmply wih 111 city and rwmy ordinances and Lame law,rotating ei QTY. MECHANICAL PERMIT FEE
U Z building cormaction.and hereby actuator representative%of this city it)enter upon the SEISMIC Fla:
obese-nmominnwf
property for inspection purposes.
(We)agree to qva indemnify and keep haeme„the Cay of Cupenim,again,) PERMIT ISSUANCE ELECTRIC TEF.
Iiahilitics,judgmons.ems and expenses which may in anyway accme again wid City ALTERORADDTOMECH.
in n,o ucnce of the granting al his permit. PLUMBING IEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IR000CFNH
MECHANICAL 1'EE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.0X10 CFM) CONSTRUCTION TAX
Silmmre oJ'A,plieur/Courract Date EXHAUSTHOOD(W E)UC) HOUSING IG TI
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantsmm or handle harnrdous material HEATING UNIT(TO 1010110 RTU)
as dri ied by the Cupertino Municipal Code.Chapter 9.T 2,end the Health and Safety
Coda Section 25532(a)1 BEATING UND(OVER 101.(101 BTU)
C]Yes E]No PAID
VENTILATION PAN(SINGLE RESID)
Will the applicant or Iuturu building occupant me equipment or devices which Data ff��Receletipt((p
:milbmnNnus olr amtvrninun0 vs do fined by the Bary Arca Air Quality Morapwrmrt BOILER-COM11(311P OR 100.000 BTU) r UNtfTIINQGA1.:
O:.rr'
❑Yes C)No BOILER-COMP(OVER 1)0.1100 BTU)
IhwcrevA mhc harmdaus rnvterivlu rn uiremmns under Chu ler 095 of the C.li- AIR CONDITIONER
p ISSUANCE DATE
i forma Hulh& mar Code.Sections 255115,25533 and 25531.I m notsmnd oc if the NEW RESIDENTIAL h1ECH. SQ.FT
of the re docs.not currency bust a te......hat o is ua ce(it a Certiy ca notify he Occupancy.m
of the requirements which must M"tet prior w issuance nl x Certificate of Occupancy.
Oacroomauthorieel.,cut Date L ISSUED BY
OFFICE