S 0610 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BUILDING-ELECTRICAL 1, 11 rvD
BUILDING OF
DIVISION APPLICATION/1'ERMIT PLUMIUNG.MECHANICAL J O O
'BUILDIN(:1'NOJH:CI'IDF.NTIFICA'I'ION n
SANITARY NO. APPLICATION SUBMITI'AI.DA'(I
nuua c ss: I �-r
OW KE. PHONONNE: CO gCfON'g NA :: w LIC NO �k"
!p7 /C V /C CONTNOLM
• ARC( I'1'IiCf/ENGINEER: LIC NO: D � ��
KESS. s , A�/ El
CON PHONE: 7 BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) LDa ELECT PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION QTY EI-ECFRICPERMIT ( FEE JOB DESCRIPTION
I heathy affirm that 1 am licensed under provisions of Chapter 9(mmnameing
naZ with Section]000)ofDivi+nnJol the Business and lh -'nnsCW nd ylicensoi, RESIDENTIAL
W O p PERMIT ISSUANCE
F W� in full force and effect. 0 0 SFDWI. ❑KITCHEN REMODEL
�UU I.iansc Clu. I,ic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PI'li
F ZRd Dow Cnntmmnr
m6y ❑MULTI-UNIT' OSTRUCTURAI.
ARCHITF.^T'S DHC =1- cw
MODIFICA'T'ION
zp7J- 1 nJeannd my Pl. . hall UPT0200AMI'S -
OZ is sEl INTERIOR 0CHIMNEY REPAIR
F, W Licensed Prolessional 201-HXNIAMPS PROVEMEN'I' L]SWIMMING POOLS
4sy ; NEN-RUILDI. DECLARATION OVER!"AMPS 'fH REMOUEI/REPAIR [ DEMOLITION
fr Mt 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
sLx a U following manor.(Section 7031.5,Business and Professions CWe:Any city orcounly SIGNS ELECTRICAL. ❑OTHER
W 3 LL H which requires a permit to construct,alter,improve,demolish,or repair any structure
on prior,,its issuance,also requires theapplicant for such pereniuo file asignedswtament SPECIAL CIRCUIT/MISC.
Fr y that he is licensed Panna mine pro,dims mine Comments. Genu Ww lChaptcr9
W�C�O (commencing with Section Di vision Sof the Business nnJ F4ofessi m CWeys,
TIME, MMIt OR POLE INST.
O.p,m q that he i.,exempt therefrom and the hasis for the alleged cxemptioa.Any vinlminn of N BLDG/ADDITION El DEMOLITION
fI%1' 4y Section 70315 by anyapplicum forupennit,thpas tacin,diwnt to a civil penuhy ofHVICEti T A T 0FOOD SERVICE
Z
not inorc than Bve hundred Aollarx(ES,IIp, ��-•IMPROVEMENT
pO I,ns owner of ohm pmpeny,ar my employee,wish wages as their sole mmpcnxntinn, G P(lfl1,IB.IiCTRIC
FG'f will An tint work.and the slmnuro is nnl hucnJCA nr offenSIfimwtle(Ser.2W4,Busincis
OTHER
a and Prnficonons Code:The Comruaom's License Low does non apply 1..an owner of -SWITCHES-pI%TURES
property who builds or improves thereon,and who does such work himself or thmngh
his own employees,provided that such improvements um not intended or o0'eted forDENTIAL 11LFCTR SQ FT.
sale.If,hmvever-the building or improvement is soldfhfn one year of completion,the SQ.IT.FLOOR AREA VSQ.FL
wnerfwildt,will have the burden of pooling that he did set build or improve for par-
pmeofsaleJ. TOTAL: ,
.0 I,re owner of the pmpeny,in,cschoively comracting with licensed nmtracmw to A h
contact the pones,(Sec.]014,Rosiness and Professions Cade:)The Contractor's Li- - P r g�
terse Law does not apply to an owner of pmpeny who builds or improves the reon,aad QTY PLUMBING PERMIT pF-E
use
La .forsuch projectswinbumm�mctnd,)licenxd pursuannothe Contmnnr's �/ �� QP�
License Law.
PERM]T ISSUANCE Q�s 1
] Ino exempt under Sec. ,B&ITC for Obis rcusnn '
ALTER-TRAIN&VHN'I'-WATER(EA) LU/- - VAI-
UA
Owner ! Dane /,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE V OI�IIs,J
thereby affirm under Penalty of perjury one of the following dedawtions: �
•�ve and will maintain a Certificae of Consent to self-insure for Workces Compen- DRAINS-FLOOR,ROOF,AREA.COND. S'I ORAS 'TYPE CONSTRUCf101
anion,as provided for by Section 3900 of the Who,CWe,(m the performance of the
kf hich this permit is issued. FIXTURES-ITER TRAP
and will maintain Worker's Compensation Insurance,as retuned by Section w]00 nfthe Labor CWe,for,be perf/�gnance ofthe weak for which this pe.it is issued GAS-EA.SYSTEM-I INC A OUTLETS OCC.GROUP APN
Myrier: r`Ty' rY'soc;R11<ranJ Policy r�t)(11�rcf. a q7 GAS-EA.SYSTEM"OVER4 HI)
Cornier. y u•!!//YY//// Policyolic f.,��/ 7 J 1- L�.
CERTIFICATFi OP EXEMPTION FROM WORKERS' GREASIDINDUS9'RI,WAS'1'E_INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section nad nm,he cninplewd if,halerrot i+for me hnnd'Wdnllam($I INIJ 'OREASE'I'NAP
or Iess.) PLANCHECK IEI3
ccnify0atin the rf enftb"Zkforw ahthi• er lwisissued,(,hull SEWER-SANITARY-S'T'ORM EA.21X1 IL
not employ any pers in ty ,sn o fO been I - Wnrkecd Compen- ENERGY FEE
Z satin,Lows of CalWATER HEATER W/VENI'/fiLECfR GRADING FEE
Z O Applicant
NOTICE TO At ' CANT. hafle,maki g Nis Certificate of Exemption,you should WATER SYSTF-M/IREATINC
become subject m the Work
Worker's Compensation provisions d the Isbm CWou e,yma', fPAI
FEE
LaLI forthwith Ourply with such provision,.,,his permifshall W deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAI,('LMB. SQ.PT D c Receipt p
� 'Z I hemhy affirm that there is a convmdinn lending agency for the"formmtev of
U the work in,which this permit is mowd(Sec.9099,Civ.C.1 "
QV LcnAcr's Name -
LSJ
TOTAL:
Lender's Address
I cendy that 1 have read this application and state that the above infnnnntion is BUILDING FCIi
fa/) correct.1 agree to comply with all city and county ordinances and sem laws relining to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorise representatives of this city to enter upon the SEISMIC FTE
., abswe-mentioned property for inspection pmEaro,. I PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cupenma against ELECTRIC FF.
hill Cn
liabilities,judgments,costs and capenu hich twyin any way acerae against said City ALTER OR ADD TO M ECH. PLUMBING S
in SInscyoena of egwmi (this ,0.
AI'PLICANq'U e f WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,11(10 CFM) MFCHAN .AL ITE
SOURCIi RCC I
AIR HANDLING UNIT(OVER Ifk(NN)CFM) CONST crEN'FAX
n:nnr Appllev ontrnc, r Aum EXHAUST HOOD(W/DI1Cq HOPS G MITIGA'HON FEE
HAZARDOUS MA'I'13KIAI S DISCLOSURE
Will the opplieanrnr future building occupant store or handle hmamloux material HEATING ONIT('[0 IDLOtN)BTU) _
u,ddined by the Cupertino Munici al G • hapter 9.12.and the Health anti Safety HEATING UNIT(UVEB IIXLINIO PTU)
Code Seen 25532(a11
O Yes ;01VENTILATION PAN(SINGLE RESID) PAID ate eceiptN
Will the applicant nr future building..,atuse equipment or device,which BOILER-COMP(3HP OR 100,0(111 BTU)
•emit l uzmdous air mntaminenu as defined by the Bay Area Air Quality Management TOTAL:
D,,me,P - BOILER-COMP(OVHR ItN."BTU)
D Yea ONn
I have read the hazmdmoneariul.ure,duenrms under Chapterfi95ofthe Cali. AIR CONDITIONER ISSUANCE DATE
Ibmiu thnith&Safety Cotte,Sections 255115,255)3 and 25534.I understand(bun it the NEW RESIDENT IAL MECI I. SQ.FE
huilding does out curtenty have u tmrmC that It k my re,achil'ny to miry the«<,gvnt
of the mquirements which must M met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE