B 0105 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]full DING-ELECTRICAL PER ND qq CC
BUILDING DIVISION APPLICATION(PERMIT PLUN;BING-MECHANICAL SOOOI '&0105
BUILDING PROJECT IDE,\ri TCATIO\
IBUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL.DAI
2B r
OW :S NAME: I / / PHONE: C RACTOR:S NAM°. LIC O'.
IY/ /cV� O NIC CONTROLN
CH ITEUUENGINEHR: LIC NO: ADDRIS� �� ❑
CONTACT: PHONE: BUILDING)OffRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MSCI
LICIiN51iU CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMiT FEE
1 earehy entree tem 1 ata licensed under pmmamm of chapter 9(a,nlmcuumg JOB DESCRIPTION
BZW �msechou9(kl(BNI)ivisi i3onhe Buslnesxaed mf1_exionFCodr,and my ucmueia R TDENTIAI.:
W O p PERMIT ISSUANCH
b+Wcz indult encu and eR .gA SFDWL ❑KITCHEN REMODEL
GUU Ilam YJJ Conuaclor APPLIANCES-RFSIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FSH !-IIITECTSDECL ATION PANELS [I MULTI-UNIT []STRUCTURAL
mZ I stantl shall be used a. licrc MODIFICATION
p Oy�� s UPT02g1ANPs CINIHIMOR CCHIMNEYREPAIR
F..W Turemod 201-19MAMPS IMPROVEMENTSWIMMING POOLS
OWNER-BUILDER DECLARATION C
CY' .4 OVER Ig0ANIPS C BATH REMODEUREPAIR El DEMOLITION
9 d I hereby alGrin that I um exempt from the Contractor',Licence Co.for tee
k0.x 06 U following reason.(Section 7031.5.Business and Profession Gxlc Any city nr county SIGNS ELEC'T'RICAL C OTHER /.
til 3 W y which aromas a permit m construct,alma improve,demolish,or repair any structure (C..
,�OQ, prior m in issuance,also requires the applicant bswch Permit file a signed statement SPECIAL CIRCUIT/MISC.
le } that he is licensed pursue.,the provisions of the Com acences Licenm U.(Chapter 9
W COO (commencing with Section 9(001 nl Division the Business and Professions TEMP.METER OR POLE INST. ER IAL:
daoC Ila,he is exempt chercfmm and 0e heads for are alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
se m W Section 9031.5 by any applicant for a peters subjects the applicant to a civil Penalty of POWER DEVICES
[]TENANTWim TENANT CFWDSF.RVICE
SQnote an than Five hundred dollars($500). IMPROVEMENT
0Las owner ofthe prolony.or my employees with wages as their colo compensation, SWIMMING POOL ELECTRIC
N will do the work,and the structure is not intended or offered for sAe(Sec.70, Busincav ❑OTHER
CCW13wand Prdussdnn Cndc'.true CummLicense clure eenee Law does napply to nn owner of OUTLETS-SWITCHES-FIXTURES
"'Tarty who build,or improves Ihclam,and who dues such work himself or thruogh
his own employees.provided that such improvements arc not intended or ofRred for NEW RES IDENTLAL ELECTR SQ PT.
sale.If.however.the building or improvement s add within one ycarofcompletion.the SQ.Er.FLOOR AREA V$Q.FT.
owner-builder will have the burden of proving that he did not build or improve for Pur-
prt of avid.).
❑1.as owner of the pmpeny,am exclusively commeting with licensed contractors to TOTAL:
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
censeLawaxssolupplym�mownero[progeny who nuJd.or impmvcs thereon,and QTY. PLUM BING PERMIT FEE
who contracts for such projects with a conernnor(s)licensed pursuant to the Contractor's
Licene Law. PERMIT ISSUANCE
l me exempt under Sec. ,B&PC for this memo
ALTER-DRAIN&VENT-WATER(BA)
Data VALUATION
WORKER:SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one rf tine Muer,ing decLvationa:
Oki havcand will maintain a Cenificate ofConsem in insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.
saran, -prse, fnr by gation l9W of the Lunn C1xle,for the performance of the STORIES TYPE CONSTRUCfIC
which this Iwmtit is ismed. FIXTURES-PER TRAP
w 1 have and will nminmin Worker's Compemmion Insurance.as required by Section
19100of the lab or Code.fort he performance of the work for which this permit in issue. GAS-EA,SYtiTLM-I INC.40U'I'IJ 1'S
My Work pJt�y'"It dPolicyn OCC.GROUP APE
Carrier.ut )ZO lV//% : Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CER HFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
(This section teal not be completed time permit is furan hundred dollar,(SI W) BUILDING DIVISION FEES
or less) GREASE TRAP
YLANCHBCK FEE
1seedy thin in the any
office workfurwhichthis the Weis issued,lshall
not employ an,person in un mhemmc tub est In the Workers'Campcm SEWER-SANI'T'ARY-STORM EA 2010 PI'.
y manneno as j ENERGY FEE
OZ Aline Laws of Cafifornin.Dote WATER I[EA)ER WNENT/ELECTR
Z co Applicant GRADING PEE
y SOL[CF. API)the Workers
IL after making this provisions
o of Lxcmptio d you should WATER SYS'1'IiM?RLATING
hculme subject u1 the Workds Come,or this
provisions of IM1e Labor Cade,you moat SUITS FEE
�
forthwith comply with such provi.anna or this permit shallMJttmed revoked. WATER SERVICE
a0
= z CONSTRUCTION LENDING AGENCY NEW RESIUEMIAL PLMB. SQ.FT. PAID
G Ihereby ichthis.em isacofSar.3r,lending agency for the perfoemance of Dole to
V. r. the work for whichthixpermit is issued(Sec.J099,Co.C.)
WLander's Name TOTAL:
Lerdcr's Address TOTAL:
Cat 1 certify near I have rend this application and state lad tile above Information is BUILDING FEE
m comet.I agree a,comply with all city and county ordinances and state law%rclaingu' QTY. MECHANICAL PERMIT FEE U Z building construction.and hereby authorize representative%of this city to enter upon the SEISMIC FEE f
uMn'e=menlioned pmpcny
for inspection phave as.
ELIS
Jose)agree to save,indemnify and keep harmless the City of Cupertino against L PERMIT ISSUANCE CDOC
FEE
liabilities,judgments.costs and<spen.n which may in any way accrue against said City ALTER OR ADDTO b1ECH.
in asequence of the granting of this permit. PLUMMNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINI AIRHANDLING UNIT(TO IB.B(I(ICFMI
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTItUC'fION'IAX
Signature of Applicant/Contmen), Dam EXHAUST I IOOD(W/DUCT)
HA%ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will peaPpbcnnl or far..Wildingoecupantaore urbandle hamNouvmmerial �. HEATING ON]'f G0100,000 BTU)
as defined by the Cohen,..Munici 1 Code.Chapter 9.12,and the Health and Safety
Cade.Section 25532(a)9 HEATING UNIT(OVER 100.000 BTU)
❑Yes o
VENTILATION I'AN(SINGLE RESID) PAID --
Will thea Beam nr!aline ildin t use c Dane Receipt a
pp glecupan equipment or devicm which BOILER-COMP i
mil hvallouv air conwminants' dcflne0 by the Hay Area Air Queli[y Management 6111'OR 10NI,0O RTU)
Uistrin? BOILER-COMP(OVIR lopot10 RTU) TOT .
❑Yes Nn y
I have read the hvallou rielceeapri is un der Chapter 6.95 of IM1e Calm AIR CONDITION12R ISSUANCE DATE
Gonia Health&Safety 1 ons 8505.2553. arW 25534.1 understand dot if the NEW RLSIDF.NTIAL MECH. sl).FT.
buildingdeean servantrdec ite apon,ifilaytonutifyWoccupant 7 _
of tint re mend win' m.st le mat n ���eee555���of a Cenifcae of Qcupan /
6./Sts S�
Owner or authorized agent Dalc I. ISSUED BY:
OFFICE /