S 0422 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PL§i r No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANIC L J 0422
BUILDING PROJECT IDENTU'ICATION
BUILDING ADDRISS: SANITARY NO. APPLICATION SURMHI'AL IRATE
O NI!R'S NAME "K, g�ZL CONTRACTORS NAME/ EJC NO: IC -
NCONfROL1
�ANCIIIRTCI'/14iGINEER: "LIC NU: ADDRESS'. ❑
CONTACT': PHONE BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG I!L PLDAyt MI!C
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ !¢L'j\
T hereby affren ma 1 am Banned under INwimmu of Chap.9 lconurencing JOB DESCRIPTION
002 wire Sttdm TIMgll orDivisinn3rfNc EUnirle..,nd lnafeaaiaascme.and my bcrose i.5 RESIDENTIAI:
O O REMIT ISSUANCE,
war In full fora enlcR b ❑SIT)Wh [I KITCHEN NEl1ODl!L
FFaV V Liccn.m�C .N �I A APPLIANCES-RESIDENTIAL ❑ADDITION ❑PhUMRING RE.PII'F:
N Q Duc Cwmctm
FOrio ARCfIRECTS DECARATION PANELS ❑MUI,TI-UNIT [I STRUCTURAL
Z O Z 1 urrMxl ind on,Mann Jell he uses as Public rarxd, MODIFICATION
OZ-� UP TO Bp AMIS ❑INTF,RIOR ❑CHIMNIiY REPAIR
F.H..f'w uiacoei Prob.imal 101-HN0AMPS IMPROVEMENT C]SWIMMING POLLS
� I.T OWNER-BUILDER DECLARATION OVER IN" ❑HATH REMODEI/REPAIR 0DEMOLITION
C W 6 L hereby affirm Nal 1 am exempt from Ne Cmlr.ctor's Liccnne Law for the
x1x O L O following realm (Sern 7031.5.9udness end Pmfcraitma Code:Any city or county SIGNS ELECTRICAL C OTHER �i f+' � ) p jl�(�.,L
W 3 LL y which requires o permit to conWnuct,alter.iammve.ticmnlirh,or rel xn any svuarure
LL'cA prior mlu osuv dca requires meapplicana(«such .it to flca,,eadi emcnt SPECIAL CIRCUIT/MISC
F } the he is licemed Par*uaat mthe prov'tdias M the Contractor'a Lia.law(Chapter9
O Icnmrrcrlcing with SccYim9(kMll of Dvision Jnfthc BunitlanaM ltofasiw Codd or TEMP.MLT!R OR POLE INST COMMERCIAL
a ly o�C tlwt he ix exctrtpl Ihcrtfmm it the boli,for the ellcgcJ caempirm.Any violalinn of ❑NIiW BLD(iIAUUrfION ClDEh1O1.ff10N
iufl Semon 90313 by any applicant for a errnil.whjaccs Oe upplaanuo a civil penalty of POWER DEVICES El TENANT ❑FWD SERVICE
H Clot rtlme Jun five hurdred"Ems 15500).
H Z} IMPROVEMENT
Q O Loins we dine pmpc dmisYetinier north erial alhrir We 0414.Bu,,mm. SWIMMING PWLFIECIRIC
{f SO will Jnr Nc Werk.aMNe eCorrixnoti U,ven ,Law -nor.Wailc(Scc.'o an ownir of El OTHER
{i]
and I'mfwhiob Cndc:9hc Com nclors 1iccnwlawmoor wappymlf or
n( tIITRFTS-SWITCHES-17%PURI?S
a his own who builds m improves tlerthr4 uN Who doer such Work Himself m Nmugh
his nam emplgea,pmvidml that such ittenu alt minacndintendedrn offered fur NEW RF_SIDEf.T1AL ELECTR SQ FT.
sa1c.ILww¢Nc W
htilingmimpmvcrn,at rem is mN within use yrnrafcnmpminn.the SQ.IT.FLOOR AREA SISQ.14.
r.huilder will have tM Wrtdn of paving bar he did not hood or ilnpmve for
Imr-
P^rca of ale).
M 1,as carer of the Pmpay,am exclusively emltractiny with liameo conn. to to TOT p p M ' Do.,ct the Enci(Seat, aea
,94,Inouand Pmfecsixu e:)TIontras Cade C —V- l�
cens,law docs TNN appy to anrwmer oflrcmcny who hUilda or improve'thereon.and QTY. PLUMBING PERMIT FEE
Who amtrartn for'mhpnjcanwith aLonmwbx(s)I iccrttd porstminothe Conuxcba`r � 2
Liana law. PERMIT ISSUANCE g
❑ IamaempOntkrSee. .B&PC(m Jusrcanm t4ALIq aI
ANTER-DNNN&VONT-WATT 11' Ua yVFty
Da" H I InIU
WORKER'S COM1IPENSAIRIN DECLARATION BACK FLOW I'R(l1'ECI'.DEVICE Q]
the will rm uMa Ccaift ofpcC aeofFie lf-i owing Wtt &tor¢: 9R. i
0Ihaas andidelforby aation37M of me Lal to Costa.fr the elfoman Comlem DRAINS-FLWR.RWI',AREA GDND,
STDRIP_S TYPE CUNSTRU6110N
Wim,as pmviebi for by Scniun 3]00 of me labor Costa.for the pcnfnrtnarce of the
k for which Nix permit in Isw W. IlX'NRIS-PER TRAP
1 have arta will mainwin Workcls Compcnwtion lin io ea as reyuiml by Section
0fl d the lahar Code.for the p,fornurce.fdewM for which Nil permil is iswel. GAS-FA.SYSTEM-1 INC J OUTLETS (XC.GROUP APN
MY Wurkef Cum nwion lyarancc carrier ud Pdiry nu
C.,. �in/�i i /. n./. Policybm.:N A.Ne' 3/-F74%L. GAS-EA.SYSTHMOVER4(EAI
Cl-B?IIFICRI1i 0lAFAEMPIION FROM WORKERS'
COMPENSATION INSURANCE BUILDING WA$TF,INTERCEPTOR
tlUILDING DIVISION FCCS
(This section reel rooa be«xnpcudifthepmmt ufm ore WmhN ddWs(SIDR) GREASE TRAP
m ImJ PLANCIIECK THE
I mrify Jut inlheperfia. aof1bawtxk fawhiah Oiapennitls ie wed,I,h.Il SEWER-SANITARY-SORMPA,]NIF-P,
nm employ enY Ryon m any munncr.w as m hcmme suhjmr no Nc wntkens'Compcm. ENERGY FEE
O z salon laws of Callmo ia.Date WATER HEATER WIVEN IELECIR
Applicant GRADING FEE
Z O
y NOTICE.TO APPLICANT If,after making this Cmif to of Excretion.. no JNmd WATER SYSfE UTREATING
become whject to IHe Workar'i.Coar,nmtitm pooi,onr of the Iatmr Calc,yoo muss SOILS FEE
LIJ fuMwim e.,I,with suchprurvikiom or Nis Permit Dull be Jecord revoked. WATER SERVICE
d
u z Oat Ott is a camNtaile LENDINGAGENCY
agency
NEM'RFSIDGTIAL RJNII. SQ,FT PAID Palo Reccio
U O Thar hi,hmi that there is aronm film leading asmryfm the perfumurccof
1Ta ti
he work our wnieH lM1ix perntil it iawM(Sa.UW].civ.C.) TOTAL.
IaWa'n N.
V Indcr'I G cenifyv TOTAL_1 ecnify Net 1 have read thin a and!c un and nuc cc,the 1 i relatinn is BUILDING FlH!
Za«rnngcomaemcrmtply, with allcity ard.mmymdinasofthie matcmw+ru,imnr QTY. MECHANICAL PERMIT FEF,
V z M1uildingc 4nxlinn,vrd M1erthY awhxim rtlNesenlativo of thlw city mercer upas the SEISMIC PEE
above mentiond prycny for imspmtinn pur,srnen. PERMIT ISSUANCE
(We)agree to."indemnify and keep hal leas me City d Co'Oao against ELECTRIC FEE
liabilities,jodgmant,costs and cx,Parr s which may in any way seems ii raid Ciry AEfERORADDTOMECH
n ummyuctec of the granting of this Im nk. PRAM If TNG PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAPR HANDLING UNIT(TO 10,000CFM)
SOURCE REGULATIONS. FIECIIANICAI,1}E
AIR HANDLING UNIT(OVER IONin CFM) CONSTRUCTION TAX
Signuureuf Appicanl/Canmacmr Date EXHAUS)HOLD(W/DUCI) HOUSING MITIGATION FEE
IIA9ARDOUS MATERIALS DISCLOSURE
Will Je alrpimu orfmtne htildinguccupvu sonar handle hvz3Mws maauial HEATING UNIT TO 100.0011 RTU)
as defined M the Cupertino Municipal Code,Chapter 9.1;and Ne Health aM Safety
Cock.Section 25531(04 UHAIING UNIT(OVER I00,N)0 BTU)
❑Ya ❑Nn PAN -
VFNTILAT(lN EW(SINGLE RES ID) Due Rcccip N
Will Jc ypliaet m future Wilding mcvlwnt Use egxi,earml or devices Which
emit hmeNous air conlamimmix as&,fined by the Bay Area Air QUaliiy Management BOILER-COMP(3HP OR IIHIIYMI B'IV)
Dadma 'r(rcnL:
❑Yes ❑Nn UOILIR-COMI'(OVER 010,1100 BTU)
I have red the haaxdous rwerials ic,, nlrnu under OTapn 6.95 d the Cali- AIR CONOITIONER ISSUANCE:DATE
Norma Health&Safcay Crider.Swims 25505.25533 aW 25.5-34.1 uMcntwJ that if IM NBW RF_SIDIWFIAL MSCI I. SQ.FI'.
W ilJing dms nth cummlly Wvc a ICMnh 11W l it ie n,y rzxpxlsinility to mllfy Je ureupant
dtm remerus Which T,,.tW ttet pier to iawurec ofaCmifiaaeW(kcopaocy.
g->7
Owner inner ami me TQrnL: IssueD By
OFFICE