S 1411 APPUICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEp(y��IT NO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL J 1411
BUILDING PROJECT IDENTIFICATION •L
BUIL DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I/11
O ER'S NA PHONE: CO TR CTOR:S AME: LIC NO: NEC CONIROI.4
FEN//
1 RCIII"I ECT/ENGINEER: LIC NO: ADORE S: / ❑
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M
❑ ❑ DV ❑
LICENSED CONTRACTOR'S DECLARA'GON QTY ELECTRIC PERMIT FEE
1 hereby afftmt that I am revnew ender pruwieiuns..r cooper 9 fwmmenamg JOB DESCRIPTION
awOWZ whh Secdon9000)of Diwisinn 3oRhe Buslnrssnnd Professions Code'redmy license is RESIDENTIAL:
FEW In full tome vnd eR 3 PERMIT ISSUANCE. ED RESIDENTIAL,
❑PIT rc EN REMODEL
�UU Luenxa h s lie# APPLIANCES-RESIDENTIAI. ❑ADDITION El PLUMBING RE-PIPE
F-Q WW Data Comrucmr
ARCHITECT'SDECLA I N MULTI-UNIT ❑STRUCTURAL
PANELS
ypyZ I undersmndmy plansshall bo esniaspublicreatrds MODIFICATION
O Z..-a UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r4tzl ❑ceased Processional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
at OWNER-BUILDIiR DECLARATION OVER INSTANCES ❑BATH REMODEVREP IS [I DEMOLITION
% W Q I hereby of on thin am exempl from the Counselors License Law for the
3.O W U following reason.(Section 9131.5,Business and Professions Code Any city or county SIGNS ELECTRICAI. ❑OTHER
3(y F which routines v peril to construct,alter,improve,demolish,or repair any stinum
F�ryOry prior to its issuance,also requires the applicant for such permit n file a siSnedsmtentcm SPECIAI.CIRC 1'1'/M1 SC.
Y mitt[to is limn.nd umen In the powimeof the Com.....License Loss(Choper9
p0 (commencing with Section 0000)of ,.
Division 3 oftbc Business and Professions Code)or TEMP. OIINST COMMERCIAL:
d y se C that he is exempl therefrom and the basis for the alleged exemption.Any violation of El BLDG/ADD ION 11 DEMOLITION
LLXl W Sen ton 9(31.5 by any upplicum to,. ormit sadoz,,0te opplicvnuo a civil Faulty POWER CFS
-.y El TENANT ❑FOOD SERVICE
Esqnot ntoe than lift hundred dollen y employees
❑ Lo the work,and
the pro perly.r armyycmntended with wage,
red for alei(Sec.compensation, SWIMM GP CTRI OTHERIMPROVEMENT
qty'
will do the work,ane The stxucmmis not imended or olFemO for sale($w.]044,linsiness El OTHER
Ia1 and Professions Code:The Commcters License Law does not apply to an owner of OUTLETS-SWIT RE
pm,a ny who builds or improves thereon,and who does such work himsclt orthrough
his own employees,provided that such Improvements we not amended or offered for NEW RESIDENTIAL ELECT SQ Ff.
Mala If.hrwever,the building or improvement in sold within one year ofeompletine,the SQ.Fp.FLOOR AREA $/SQ.Ef.
owner-huilder will hewn Ne warden of proving That he did net build ar improve for Pur-
posenfsalcJ.
❑ I,ns owner of the propeny,nm exclusively comment, ,no lkemed contactors to TOTAL:
coast m.I the project(Seo.TOT,Business and Professions Code:)The Contractors Li-
untseLaw does not apply toannotarial property who builds^rimprowes thercon,and QTY. PLUMBING PERMIT FEE
who rooves¢for such pn9ens with a contractors)licensed pursuant e the Contactor-s
License Law. PERMIT ISSUANCE
❑ I ran exempt under Sec. ,B&PC for thio reason
ACI'ER-DRAIN&V> '1'- T' )
Owner Dae VALUATION
WORKER'S COMPENSATION DECLARATION HACK PLOW PR EC 1
40 I Treaty affirm under penalty of perjury one of the fallowing declammimic
I have and will maintain a Cenihcate of Consent o self-insure for Workers Compete DRAINS-FLOGRO PJM,Ift STORIES TVPIT CONSTRUCTION
whom,as provided for by Section 39(X1 of the Labor Coda,for me perfonnmce of the
weak for which this penin is issued FIXTURES-PEAaff its
❑ I have and will maintain Workers Comperwnum Insurance,as returned by Section
3901 of 0e Lahm-Coda,for the performance ofthe work for which this crout is Issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Work 8s t pensmi ism,rucieurric, 1 Policy n mrd
Garner Policy a CAS-EA.SYSTEM-OVER 4(EA)
CP.RTIPICA Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASEIINDUSTRI.WASTE INTF.RCF.P'IOR
or Icxs.)
(Tlassnano^need a,,,br complied if In.permit is toe ane hundred dollarsGREASE TRAP
($I0do BUILDING DIVISION FEES
PLANCHECK FEE
1 certify be,in Ne cryfonmmee o as 1 work for which This photo is issued.)per-
SEW ER-SANITARY-STORM EA 200 PT.
nom entpiny any person In cry mamma so as to Iwcrma svbiect In the Workers'Contpen- ENERGY FEE
'�. sation Lawsof Caldernia.Data
WATER HEATER W/VENT/ELECTR
7 Q ICrm GRADING NEE
NOT
L7 ► NOTICETOAPPLICANT':It,aftermakingib is Cisions f of Exemption,you should WATER SYSf1iMIfREATINC
hemne cuomply the Workers Comns or this provisions of The Labor Code•you trust SOILS FEE
au I'nnhwilh comply with such provisions or this permit swell be tlemnal cranked. WATER SERVICE
Q U
CONSTRUCTION LENDING AGENCY NEW RF.SIDF.NTIAI.PI,MB. SQ.IT. PAID
U Q thereby affirm that here is aconswetion lending ogenry for ltarfmae
nrncerf Do #
W the work 6r which this pemtil ix issue)(See 309],CIv.C)
C) Lenders NameTOTAL:
WLenders Address TOTAL:
As 1 certify that I have read This application and into Chet the above 1^I'ora anion is BUILDING PEE
Cir to correct.l agree to comply with all city and co^my ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z. building conslmation,and hereby authorize representatives ofthis city to e^lerupnn the SEISMIC PEE
above-mentioned property for rope lion purposes. PERMIT ISSUANCE
(We)agrcc In save indemnify and keep hornless TheCity of Cnpenim,againsT ELECTRIC PEE
Iiahililies.judgments,costs and expenses which may in any way acerae against said City ATTER OR ADD TO MF.CH.
consequencein of the granting of this permit. PLUMBINq), A
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'P AIR HANDLING UNIT(T010,W0CPM)
SOURCE REGIILAI'10 �`�� MECHANICAL FEE
�.na�r�/n� eshr AIR HANDLING UNIT(OVER IB,WB CFM) CO rI�N X r
Signa enf Applicam/Cont for I Data EXHAUST HOOD(W/DUCT) HW$ING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appliront whom building^reupunm smm or handle nvnrdresmateriul HP.A'TI NO UNIT(TO 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Safety - "-
Cade,Section 25532(x)? HEATING UNIT(OVER I W,Op BTU)
L]Yes ®Nn
VENTILATION PAN(SINGLE RESID) PAID '
Date Receipt#
Will the it cmrlorimum building occupant use.Air Qunrdeviceswhich BOILER-COMP(3HP OR 10)•000 BTU)
tit htiznrdous air camaminunu us defraud by the Pay Area Air Quality Management TOTAL:
❑Yes ❑No BOILER-COMPfOVP.R 10).00)BTU)
AIR CONUI'IIONES
I havHealth
&Sathe fe,,Coardon coon,11 1,1151 an under ,1 uner 6 derstand
d IThe Cali- $SUA D�'E
mine Hudth&Salcry Cndq Sections 25505,25533 and 25534.1 understand the if the NEW RESIDENTIAL SUCH. SQ.FT. �,� G r/�_/
buildingd urn Trendy hmeomnam.Ihnl it is myresponsibility(notify the occnpom
fl t haus met prior to issuance of a Cutl)M •nf y
ac .
� ✓ 'I t�
LV
ri or omnon<al age TOTAL: ISSUED BY: —
OFFICE