S 1469 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY,OF CUPERTINO BUD.DING-ELECTRICAL PE IT NO. p
RUINING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1469
4I BUILDING PROJECT IDENTIFICATION i
1 BUILDING ADDRESS / SANITARY NO. AYPLICA'1'ION SUBMITTAL HATE.
i i
OWNER'S AM': PHONE: CONTE f0 SNA [ .IC NO:
NIC CONTROL#
00
ARCHITECTBNGINEER: LIC NII: ,l ADDRP S- ❑
ar
CONTACT: PiON17: -BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLUEELECT' PLUMB MUCH
1:3 ElL.ICENSEDCONTRACTOe'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm the licensed am Iicensunder provisions of Chapter 9(commencing OB .$CRI PTION
WON with Section 7000)of Division 3 ofthe Boniness and Professions Axle,and my license is RESIDENTIAL:
II--SOCto full force and elfat. PERMIT ISSUANCE
y.B1F ❑SFDWI. [I KITCHEN REMODEL
aUzr, License Class Lic.# APPLIANC1iS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE:
yQ W Date-Clmlmclm
Flia�y ARCHITECTS DECLARATION . ❑MUEH-UNIT' ❑STRUCTURAL.
ANELS
Z y Z 1 undersmnd my plans shall be used as Public records � '� MODIFICATION
UPT0200AMPS • �rV ❑INTERIOR C]CHIMNEY REPAIR
FyF 4O1 Licensed Professional 201-1000AMPS IMPROVEMENT [)SWIMMING POOLS
ayf,� OWNER BUILDER DECLARATION
OVER IBIBAMI'S ❑BAT IiMODEI/REPAIR ❑DEM ITION
egg, I hereby affirm that 1 am exempt from the Conlon,Co License Law for the
X 6 V following moos. imnoiu1 7031.5.Business and Professions Coda:Any city ur county SIGNS ELECTRICAL Ill"R
Y7 LL O[-y which requires n peal to quires the
Nler,improve.demolish. file
repair any swemreOf
ffnn.;7}
that
he Els inn sed p alsoant to he Ibe upplicum the such Comocrntinn f to n signet sl "1'/MISC.
;!I} that he is licensed pursuant to provisions of the ConmactoI"License Law lCftO (commencing with gemion]BIX1 ofDivininnJnfthe Business ant Prnfessionsors 'h O POLE INST. COMMENCIAL'
that he is exempt threfrom and the baziz for the alleged exemption.Any vinnr ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant to a civil. ,ol ' [-1 TENANT ❑FOOD SERVICE
z6nor more thin five hundred dollars(55(01.
IMPROVEMENT
01,as owner mine pmpeny.or my employees with wages as their sole compensation. SWIMMING POOL[ELECTRIC
will do the work,and mr,Imem.is not Emended aoff and foT sale(Sc,.704UL Business ❑OTHER
LL] and RofeWom.Calc:The Contractor's I.Immse law does tai apply 1^an owner of OUTLETS-SWI9'CHES-FIXTURES
C property who builds or improves thereon,unit who does such work himself or through
his own employees,provided that such nufmvements arc not intended or offered for NEW RESIDI?Nl'IAL ELECTR SQ Ff.
.]a.If,howevenlhe Wildiitim impmvemem ismld ambiance yearofcompldion.the SQ.IT.FLOOR AREA LSQ.f-f.
owncola Elder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1,m owner op
f the mpaty.am exclusively contracting with licensed count la TOTAL.
construct the pmjal(See.7044.Business aid Professions Codwe.)Lae Connector's Lt.
se Law down nt apply m an awnerolIt parry who baddsor improves thereon,and QTY. RING PERMIT FEE
who conwms for such projects with a conlrocmrts)licensed pursuantlo the Contractors
License Law. _ PERMI ISSUANC.
❑1am exempt under Sec. ,B A,P C for this mason
ALTER-DRAIN&VONT -AT (13A7 P A U ION
Owner Dane
blow WOEKERIS COMPENSATION DECLARATION BACK FLOW PR(Tf .DEVI
1 hereby afnmh under penalty nF perjury one of the following dedamtions: APO q Man
IhnvemdwiWnuimtnina Gerd Ocalc ul Consmv mself-insnrc lbr Worker's Compen- DRAINS-FLOOR,ROOT, ,CO S O ECONS'I' ON
lion,as provided for by Section 37I0nl'We Labor Code.for the pvr[ormanee of the
work for which thin permit is issued. FUTURES-PER'I'RAP CITY-U
+'YGtI ITV
❑I have and will maintain Worker's Compensation Inmmnce.as required by Section V V
3]Wofthe Labor ala.fonmisalkrmunco-oflhexvrk for,shichlhisperarko issued. GAS-EA.SYSTEM-IINC.401TI'LITS OCC.GROUP PN
Wry Work �' hst a mer and Policy number ore:
Carrier. I'ultcy No.: GAS-EA.SYSTEM-OVER 4(EA) �a
CERTIFICATE OF EXEMPTION FROMWORKERS' GRHASEIINUUSTRL WAST Ii IiHCE:ITOR `
COMPHNSAI'ION INSURANCE BUILPIMGDM SOITIS
(This sectioa need not be compl arcs d the permit in footle hundred dollars(111#1 -
or less.) GREASE TRAP PLANCHECK FEEL"
leamy that in theperformmcmfthe work for whichlhis permit in issued,Is ban SEWER-SANITA -STORM EA.200 IT.
not employ any pcmm in my manner m as to become subject to the Workers'Compcn- ENERGY PEE
z sato.Laws of California.Data WATER HEA . WNENT/ELECTR
Applicant ,- GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER ST17MC CREATING SOILS IT
[+ bcmam subject ,,the Workers Cmnpensmioo provisions of the Lubar Cade,you out `
Ll1 G forthwith hvmply vilhomh provisions aphis permit shall be dancd revoked. W ,R SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY NEW RFSIUHMI'IAI.Pf.MB. SQ,FT. PAID Dam Receipt N
U 0 I hreby alBnn In, is construction lending agency for Inc performance of
f•' the wort:for which this permit is issued sucJ(Sec.3097.Civ.C.) "TOTAL:
B" Lenders Name
U Lenders Address TOTAL:
QWi I cattily that I have read ON uppllanion and atom that the above information is BUILDING FEE
L4) correct.I agree to comply with all city and county ordinances and Mate laws relating to QTY MECHANICAL PERMIT FEF.
U building consmhction.and hereby amhmire representatives of this city to enter upon the SEISMIC FEE
,drove-mentioned property for inspection par son. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hmmless the City of Cupertino against
luddlities.judgments,costs and expenses which may in my way narrow against said City ALTER OR ADDTO MECH.
PLUMBING FEEin consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(170 I0,000 CFM) MECHANICAL FEE
SCERT ' .AnON . I,
AIR HANDLING UNIT(OVER 10,000C CONST RUC I'ION TAX
Signature n Appman9CmjomIm Data EXHAUST HOOD ONMUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupmr store or handle hmnNous material HEATING UNIT(TO Ban VI
as defined by the Captain Municipal Cale,Chapter 9.12,and the Health and Safety
Caic,Seeman 25532(m? ❑No HEATING UNIT(OV I00Jn)BTU)
❑Yes VENI'ILAT10>46(SINGLE RESID) PAID Date Rearipla
Will the applicant or furore building occupant use equipment nr devices which
harardousaircontaminmisasdfin
eedhydre Bay Area Air Quality Management BOILS COMP(3HP OR IW,INN)ITN)
'tWTOTAL:
mel? ER-COMP(OVER IW,00013TU)
❑Yes ON.
(have read the hazardous mmeduLs requirements under Chapter 6.95 of the Call- ALR CONDITIONER IS IANCF.DA
Tarots Health A Sufcry QNIe,Sections 255115,25533 and 25511 undersmnd Ihnn if the NEW RESIDENTIAL MECH. SQ.ET.
building does nal currently have tenant.but It Is my responsibility m notify the occupml
of the requirements which must be mel prior to issuance of a Cenilicam of Occupancy.
Owner m atummired agent Data TOTAL: ISSUED BY:
OFFICE