B 0421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT rvo. 'n
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. �popy 0�
BUILDINGPROJECT IDENTIFICATION DI/VVl
BUILDING ADDRESS: � SANI1'AItY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'. N/C �COCC #�
A. S' YO -$3b . L I C4 C. 2
HI CI'/ENGINEER: LIC NO: AU RF,SS: ❑
► to I C' 212 .9 ArljosE fA f
CONTACT: �I �PPHqHONE: BUILDING PERMIT INFO
*03 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELkCT P UMR MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby handed 1 am Eumm under pnoialona of Chapter 9 procurement, JOB DESCRIPTION
AaZ Ih Seellon 711W)ofllivirion3ofthe Rosiness and Professions Gds,vry mylieense i. RESIDENTIAL:
WOO wt ( PERMIT ISSUANCE
Fly_ n full force and effect. �� ❑SFDWI. El KITCHEN REMODEL
�UULicence Cla,.c I Lim, j�
v Zgj APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Sam ` Commcmr ❑MULTI-UNIT ❑STRUCTURAL
(„gym ARCHITECPS DECLARATION (, pgNELS
I understand my P].s,hall be used as polide cemds MODIFICATION
zpmm-K UPT0200AMPS C1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-IOMAMPS IMPROVEMENT C]SWIMMING POOLS
+�C•4 OWNER-BUILDER DECLARATION OVER IOW AMPS 0 BATH REMODELIREPAIR 0 DEMOLITION
C W I hereby affirm that i am exempt from the Comradm's License Law for the
d U fellowing reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
F O y which requires a permit in construcr,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the appliwnl for such permit to file a signed statement SPECIAL CIRCUFEMISC.
l jt that he is licensed pursuant to the provisions ofthe Convvetofn License Law(Chapter 9
(commencing with Section 700noOncklon 3 of tee Business and Profesaiun.c Code)., TEMP.METER OR POLE INST. COMMERCIAL'
IY ly py that he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [IDEMOLITION
Section 9031.5 by any applicant for apefird suhJsaul the applicanun aeivil penaltyof POWER DEVICES OTENAN9' ❑FOOD SERVICE
HWZ not more than five hundred dollars($500).a0 IMPROVEMENT❑1.asowncrofthe propertpormy employees with wages as their solecnmpensa me, SWIMMING POOL FLEFrRIC
will do the work,and the structum is nm intended omfiered far sale(Sea.7044,Business OTHER
m and Professions Code:The Contractor's License Law does not early to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself a through
his own employees,provided Josiah Improvernenta ate nrl intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale 11,however,the M1uilJing nrimprovement is sold within,neyear afwmPlelioq the SQ.PI'.FLOOR AREA $ISQ.Ff.
cr-bullder will have the burden of proving that he did not build or improve for pur- d /
ado.frale.). �--. LIVINy LQQ 7��oS
❑I,as owner of the pmpery,vIn exclusively mntmcting whh Ileensed cmntmcmrs Io
ormWclthe pngect(Sec.7044,Business and Pmfcesions Codc)'I'our Comm-I,I...i- -L'Z$S
cause Law does not apply to an owner ofpropeny who bunds or improves thereon.and QTY. PLUMBING PER FEE 11
who contracts for such pryeck with a conhammr(s)licenced pursuant o the Contractor's
License Law. PERM I'p ISSUANCE
1 am exempt umdet Sec. ,R&P C for Ihis reason
ALTER
FLOW PROTECT D A) }yhl1AT10N�FO
owners Date C(JY/JVr(J
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DF.VICF.
I hereby a1Rnm under penally of perjury one of Or foliowing declarations:
I have and will maintain a Cenifieate ofConsinto self insure for Workers Cmaren- DRAINS-FLOOR,ROOF.AREA, ND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3900of the Lubar Cade,for the performance of the
work for which this pemtit is issued. FIXTURES-PER TRAP
1 have and will mainmin Workefs Compensation Insurance,as required by Section
391]0 of the Labor Code,for tee perfotmnncenf the wohforw i'h is te,is,red. GAS-BA.SYSTEM-1 INC 40UT.. OCC.GROUP APN r
My Wor����/nnnI.��svrence evnierut. Policy nu re: GAS-P.A.SYSTEM-OVER4(P,A)
Currier. —+4 PolicyNn.: ttp 1 A'so-vtoo
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE 9 BUILDING IVISIONFEES
(This section need not be completed ifthe permit is Income hundre dm1Z$100) OREASBTRAP
' nr less) PLANCHECK FEE Q� �
I certify that in the performance rfthc work for which this Peron is issued,l shall SEWER-SANITARY-STORM P.A.200 FE p�e
not employ any person in any manner so as to become subject to the Workers Comment- ENERGY FEE O
O •z action Laws.f Califemia.Data WATER HEATER WNENI/ELHCTR GRADING FEE
Applicant
G y NOTICE TO APPLICANT:If,afier ,making this Ca ilicate of Exemption,yon should WATER SYS'I'EMTREATING
F becmmesuNecl Io the Worker's Cam non f the Labor Cade, I SOILS FEE
I psora prmiit Thal a You mar
forthwith comply with such provisions or permit shall be deemed,evoked. WATER SERVICP.
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAI
I herehy affirm llmuhem isnmrowetion lending agency tonna perfannancen( m Receipt (—
C.) � the work for which this remain is issued(Sec.3097,Civ.CJ
0 F^ harder,Name TOTAL:
W lender.,Address TOTAL.
1 certify that I have read this application and state Iha1 the movie,informBUILDING FEE
information is 0
Fr to correct.I agree to comply with all city and county ordinances and state laws relating to QT . MECHANICAL PERMIT FEE
U Z buildingcoustnlcLinn.and hereby authorize mpreserativesmunschyle cincture.the SEISMIC FEE
above-mendoned property for inspection purposes PERMIT ISSUANCEELP.CTRIC F 7, S"
(We)agree to save,indemnify and keep harmless the City of Cupertino against
limiliums.judgmems.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH, (�
I. musculature of the granting oflhis permit. PLUMBI E s-+
APPLICANT UNDERST D. AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) —f
SOURCE RF.0 Q MUCH 1 .FEE [
Jn/I �7 AIR HANDLING UNIT(OVER Ig000CPM) CONSTRII 1IONTAX
Signature ,veil oak r V Date EXHAUST HOOD(W/DUC'1) HWSI 1MITIGAT[ON FEE. 2
HAZARDOUS MATERIALS DISCLOSURE
WilHheapalicam er fmmre huliding occupant more nrhandlc hazvrdeus material HEATING UNIT(TO l0o00I BTU)
as defined by the Cupertino Municipal Colo,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)9 HEATING UNIT(OVER 100,000 BTU) is
❑Yes E-]No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the it contaminants
inant a building by the Bnt y Ase rea
Air Qualitment or y
deviceswhichBOILER-COME(.3HPOR 100,000 BTU)
emil,hrzardoos�pir mnmminan[s as defined by the Ray Area Air Quality Management T
Distiict9 / e
' E]Yd, [:1 No BOILER-COMP(OVER IlN1,W0 BTU)
Ghave read the locations materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
[omia eollh&Safety Code Sections 25505,2,1533 and 25534.1 understand Nat Bond NEW RESIDENTIAL MECH. SQ.Fl(
building does nomurently eatenant.that it is my responsibility to notify the occupant C
of the d,mo 1st etprionn issuwee ofa Cenificme'If Or- an
Owner or out oris Date TOTAL: ISSUED BY:
OFFICE