S 1083 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
JI-DING
TY OF CUPERTINO � BUILDING-ELECTRICAL PERMITNO.
CAL
UII.DING DIVISION APPLICATION/PE.RNIIT PING P oncirRDENTIFICA S 1083
BUILDING 1'RDIRCT IDENTIFICATION- -- t. SANITARY NO APPLICATION SUBMITTAL UAL
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O` PHONE: CflNi'@�fZR A fi;� �{�C ( �j NIC CON'IAOLpJ\JCI161 IL —/ j� yU ) 0: LIC ADI)$1]gS: l IF Y trop,, C v11V1b ❑ V c N,R
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CONTACT. - PHONI!: - BUILDING PHRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I ELECT PLUMB MECH
LICENSED CONRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE mak,l��x
I hcrchy off ria that turn licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with
Section eDivision 3nfNe business and Pnduninns Code,mutiny lunsc is SIUFNTIAL
00 PHRMITISSUANCIP
aW� in force and affect.
❑SFDWL ❑KITCHEN REMODEL.
dU�j License Class Lic'N APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
F•Ta W Dam Common,
"i a ❑h1ULTI-UNIT ❑STRUCTURAL
ZO ARCHITECT'S DECLARATION PANELS
I undersmnd my plans shall be nsM us public renals MODIFICATION
OZ � 111"102(10 AMPS - El INTERIOR ❑CIUMNEY REPAIR
h HF-41 Licensed Professional 2II.1000AMPS IMPROVEMENT SWIMMING POOLS
$.•JJ OWNER-BUILDER DECLARATION
any'0.i4 OVER1000AMPS _ ❑BATH RF:h10UF.IlItEPAl1 CMOLITION
L ICU 1 hcrchy.(Senn nt 1 I. exempt from Ilse Cssoum,.o e:A nye law Lor the
''a�((�6V following rumn.ISectinn]Ol LS.Business end l'rafexsionz Calc:Any clly nreounly SIGNS ELECTRICAL
4131L f"' which requires a pemtit as c mntvm,alter,improve,demolish,or repair any swclare
0proplo loioarance,aL,.rei lheapplichm for such permiunlileasigncd sommem SPECIAL CIRCUI I/MISC. . .
f N ,hut he is licensed prominent mthepmvisionsofthe Contractors License lax'lChapter9
� CSO (cnnuaeneing with Section]IXofNpDivision 3afthe Business and l'mfesxinns Csxle)er 'IP.MP.METHRORPOLEINST. COMMERCIAL:
d c that he is exempt therefrom and the basis for the alleged exemption.Any via:nion of ❑NEW BLDG/ADDITION ElDEMO[.T ON
=lei Section 7031.5 by any applicant for a permit subjects the applicant mucivil pena0y of POWER DI3VICCS C3 TENANT ❑FOOD SERVICE
.F+ not are than rive hundred dollars($50d, IMPROVEMENT
SSD ❑ Las pones flhe property,army entpinyea,;with wages asnhch sole compensation; SWIMMING POOL ELECTRIC
will do the work,and theswmure is not intended or offered f a,,da(Sec.]044,Business ❑OTHER
W-' and Promosions Code:The Cantmemr's License law does nm apply In an owner of OUTLETS—SWITCHLS—IIXT PS
6 a.. pmpeny who hailds or improves thereon,and who does such work himsell or through - - -
his own employees,president that such improvements am no,annotator idmod for NEW REMDENTIAL ELECTR SQ FT.
sale.IL however,the laideingnrimpmvement is sold within one year of completion,the SQ.17.FLOOR AREA $/SQ.1--r
ner-builder will how.the burden nlproving that he did nm build or improve for par.
K.. 'If N PA
AL.
L us nwatt of the opined,am exclusively enamoring with licensed comes, ram •._
on low,the project(Sec.Late,Busl ness and Prnfesslnns Code:)Me Conuacnry Li- - - '•V V
cense Law dues nm apply,.an nwaensf property who builds an improvcstheremn,and QTY PLUMBINGPERMIT FEE I•v '�
who contracts for such projects with a nsmm<un(s)licensed pursuant m the Commcmrs rypp
License Law. PliµMl i'ISSUANCI] /1
❑Lam,semptundcr Sec. .N&PCforlhis reason , UF`'
-• AUTER—DRAIN&VENT—WATT! (E TION
01 4 �_D' 0—
= 2.1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm tinder penalty of perjury one done following declarations:
I have and will maintain,Cmil,rRof Consent w,elf.!mure lbr Worker's CcPan- S'IORIE5 'TY CONSTROC['I01
sat!on,as provided for by Section 3](111 of the Lader Code,fir the performance of the
work for which this permit is issued I'IXTURES—PER TRAP
❑I love and will muimsm Worker's Compc.siann Insurance,os required by Section
3700 efthe labor Code fortepedormance ofine work for which this permit in issued. GAS—P.A.SY.STEM-I INC.4 OUTLETS OCC.GROUP- APN
My Worker's Compensation Insurance carrier nod Policy number ore:
Carrier: Polley No.: I GAS—BA.SYSTEM-OV HR 4(FLA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI%INDUSTRL WAS'TF.INTT:RCEI'1'OR
COMPENSATION INSURANCE .G DIVISION PEFS
(Thissectinn neMeNbecompletediflhep,mon is farad hundred dollars(Shi GREASETRAP
erless.) PLA HP 'FEF. �w
I ccnify that in lh,perfoorane.fthework foTwh0dis permit is ien,ad,[,hall SEWER—SANITARY—S'IORM IIA.201 FT.
not employ any pennn in aymanner ,,as¢,lammaenah)ecnnlhu WnrAcrs'Cnnnpen- B iNOY FILE
,Z, satin.laws of Califamia.Data WATER BEATER WNENT/ELECTR
Applicant + GRA G FF.
NOT ICE TO APPLICANT:IL idler making this Ceniricae,of ExempOmh you should WATER SYSTEM/IREA1'ING
a ^ became subject loan,Workers Compensation pmvisianbor s of the laGNe,you must SOILS FGE
LTI G forthwith cnmply Is hit Inch p nsmons.,,his pe.it shall bo dunned revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDEM IAL PLMH. SQ,FT PAID
L) 0 I hereby affirm that there is a comwction lending agency for the Nrfonn,nce of Date Recei'a#
the work for whie t DCrgnil ssrnsuM(Sea,90 ] iv.CJ r
1••u Lenders fume n` xP 9 TOTAL:
QW Lenders Address TOTAL:
0. 1 ccnify that 1 have read this ap,heminn aced nmm Nal the above informmiun ie BUILDING +IiG
r�. (A correct.I agree to comply with all city andcnunty,ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
huiWinginawructlon,and hereby amhorim repreventieves oflhilcitym enter upon the - -- SEISMIC PT:
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indmarm
infernally and keep harmless he City of Cupertino against ELECTRIC hEE
liabil'ities,juJgmcros,cnmsiam experi which may in any way name against said City AITER OR ADD 9'0 MECH.
PLUMBING PGE
in cnt requence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALT.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE RE UL.AI S
/-, �� /�apAIR HANDLING U
�1 UNIT(OVER 10.0011 CFM) CONSTRUCT ION TAX
SngnrIma aTpphcmaUCnnnacon Date 1 EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or whore Nodding occupant store or handle hmasdous nnaerial IMATING UNIT IT 11X),0!1(1 BTU)
as defined by the Caper ino Municipal Code.Chapter 9.12,and the IIcahn and Surety
Ctdc,Station 255321¢)4 I IHA'I'INC,UNIT'(OVER I(H)0001ITU) -
❑Yes ❑No VENTILATION PAN ISI NGLE RIS BY, PAID ID
Dam RcceiptX
Will the applicant or Ramo,building occupant use equipment nr devices which
I301LER—COMP(3HP OR IOQINp RTU)
emit hazallous air contaminants as defined by the Bay Arca Air Quality Management '1'U 1_
Dinnict4
❑Yes FIN. BOILER—COM['(OVER 100,001 BTU)
Ihavc rend the Weardnus mateims neduareulns under Chapter 6,95 of tiro Cali- AIR CONDITIONER ISSUANCED
Esmin Health&Safely Cale.Secnions 25505,25533 and 25534.1 tadevater What if the NEW RESIDENTIAL MFCH. SQ,lei'.
building dues in,eamently have a near,that a is my nifasmibild,to nrnify the oocupunt
of the requirements which mint be met From to issuance in a Ceniticate of Occupancy. \�/�J�
iud
Ovan,ratialla agent Date TOTAL: ISSUED BY: ��
OFFICE