S 1252 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'CRICAL PEISIT NO. 1252
BUILnING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL: J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
7 y"7
OWNER'S NAME: ' PHONE: CONTRACTOR'S NAME LIC NO:
/ 1 N/C CONTROL#
�RCHITECT/ENGINEER: LIC NO: AD FSS: �/ ❑
` CONTACT: - PHONE: BUILDING PERMIT INFO
6 �e�,�Q- 377 76ia- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
VV ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEF.
I hereby affirm that I am licensed under provisions of Chapter 9 branumbroing - JOB DESCRIPTION
FMW OW whh Section9o00)of Division 3 oath,Huxinessand P..essionsC de,and my license is RESIDENTIAL:
n full decd and elfecl. Qr PERMIT ISSUANCE.
CW� n Ca9 / ❑SFDWL El KITCHEN REMODEL
aUU License ClnssLic. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
N Q a Ddte R�=_ Cnnbd art%
ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
F D m PANELS
Z O to 7a 1 understand my plans shall be used as public records MODI ATION
O Z IIP TO 200 AMPS
0Z [_1 INTERIOR MNEY REPAIR
uQ Licensed Prnfissional 201-1000AMPS IMPROVEMENT ❑S IMMINGPOOLS
C <14 OWNER-HUILDER DECLARATION OVER 1000 AMPS L1 BATH REMODEL/REPAIR El DEMOLITION
1 hereby aBirm that 1 am exempt from the Contractor's License Law for the
O6 U following reason.(Section 9031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W O^ wInch occurs,a permil to au stract.ober.Improve.demolish or repair day ame and
a1 prior to its issuance,also requires the applicant for such permino file a signed statement SPECIAL CIRCUITIMISC.
Nthatheielleemedpursudnuo the pmvlsbnsnf the Cauldrons,license Law,(Chapter 9
(commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0.y M rG that he is exempt therefrom and the basis for the alleged exemption.Any violamn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W'"rn Sectinn 90315 by any applicain for a permit whjectstheipincant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Gnot more than five hundred dollars S500). IMPROVEMENT
01,as owner of the propeny,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
WW will do the work,and the svucmre is not intended or offered for sale(Sce,7M4,Business ❑OTHER
mand Pmfessiom Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
A'
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENT[A].ELECTR SQ FT
sale.If.however,the building or improvement is sold within one yearofcompletion.the SQ.IT.FLOOR AREA �� r® $/SQ.FT.
enbuilder will have the burden of proving Oct he did not build or improve for par- WAR
C
pose of sale.). WA 6
❑1,as owner of the pupeng am exclusively contracting with licensed ctmtracuns to TOTAL.
- construct the pr jest(Sec 9044,Business and Professions Code.)The Contractor's Li- CII Y uI• Lou G11 hlJ
cense Law does not apply to an owner of property who builds at improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmelcou licensed pursuant o the Catamount's
License Law. PERMIT ISSUANCE
E] I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER CA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE /l�7 iC'oa
I hereby alarm under pernu
m ly of pery one of the following doolaratians:
❑IhoveandwillmaintainaCenificnteof Consennnself-insurefnr Worker's Contpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided far by Sectinn 3900 of the lush...Code,for the performnden of the
VICarwhich this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Stores
3700 ofthe Labor Code,for the perfemmtce effort work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 DID LETS OCC.GROUP APN
My Wnrk,�45,,[[�YC�enpensminnlnsurana carrier and Policy terminator
Conic CJs(/��_.. Policy Nu. GAS GAS-EA.SYS'fEM-OVER 4(P.A)
F.RTIFICATF.OF EXEMPTION FRO WORSE S'
COMP17NSATION INSURANCE. GREASE/INDUS'LRLWASTF.INTERCEPTOR
(Phis section need net be completed if rhepetmit Is Torose hundred dullors(SLIM)) BUILDING DIVISION HER
err less.) GREASETRAP PLANCHECK FEE
I amany that In meperformanceofthework fiewh'eh this permit isiowod,l shall SEWER-SANITARY-STORM EA,2011 FT.
not employ any person in any md la anner so as to become whitethe Workers'Comped- ENERGY FIE
Z notion Laws of Cal Forms.Date WATER HEATER WNEN'VELECTR
70 Q Applicant GRADING FEE
(n NOTICE TO APPLICANT:If,after making this Cennf^cate of Bx himajon,you should WATER SYSTEMOREATING
c"t become suhEal to the Worker's Compensation Ichni s of the Labor Cede,yen mus SOILS FEE
WH forNwirh comply with such provisions or this permit shall Mdeemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
L) O l hereby affirm shat there is a construction lending agency lot the performance of me Receipt#
the work far whieb iv.this permit is issued(See.3099,CC.)
U Lender's m
Nac TOTAL:
O V Lender's Address TO'LAU -
aI army thin I have read this application had state that the abase information is BUILDING FEE
h correct.1 agree to comply with all city and county eminences and state laws mooting 10 QTY. MECHANICAL PERMIT FEE
Q z building constriction,and hereby authorize representatives ofthis city to anter upon the SEISMIC FEE
above-mentioned property lot inspection purposes. PERMIT ISSUANCE
(We)agree to save.indemnify and keep had deac the City of Cupenino against ELECTRIC PEE
liabilities.judgments,costs and expenses which may in way accrue agaidstsaid City AL'T'ER OR ADD TO MECIL
in eonsrgoence of the grainingpermit.of this PLUMBING PGE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON[I(TO 111,0111 CFM) MECHANICAL PEE
SOURCE REGULNGONS.
'L S. d
45�, 11 15,-G�t7 AIR HANDLING ON[-[(OVER 10,(x)0 CFM) CONSTRUCTION TAX
Sigmifideof Aplth... ecur Data EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PEG
H ZARDOUS MATERIALS DISCLOSURE
Will yteCupenwrfmuni building occupantsstore 912,handle the
and Safety HEATING UNIT(q'010),OW ITU)
as defined io the Cupertino Municipal Cnde,Chapter 9.12,and the Health and Sd[ery
Cade,Section 25532(e)'t HEATING UNIT(OVER 1(10,1X111BTU)
❑Yes El No PAID
VENTILATION PAN(SINGLEREBID) Dute Receipt#
t Will the applicant or future building occupant use equipment or devices which
emit buzardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
Uisrietl
❑Yea [-I No BOILER-COMP(OVER IBOOM B'IV)
Ihmerrad the hezvrdous mumriels mquimmenrs under Chuprer 6.95 of the Cnlr AIRCONDITIONER ISSUANCE DATE
Paris Health to Safety Cede,Sections 25505,25533 add 1!534 1 codestand that if the NEW RESIDENTIAL MECIL SQ.Fh
building does not currently have a tenant that it is my mawrmihilily,,notify the decupanr
ofNerequirements which must be mortar 1,i..unuceofa Cunifirme of Cooperate,
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE