S 0235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. 01� C
BUILDING PROJECT IDENTIFICATION L J
BUILDING ADDRESS:
Dbr' cf � � o SANITARY NO, APPLICATION SUBMITTAL.DATE
U a (L . ..''1
OWNER'S NAME PHONE: CO G
RACTOR'S NAME: LIC NO:
NIC CO,YTROLp
ARCHRELTIENOINL•ER: LIC NO: ADDRESS: �Y ❑
CONTACT: PHONY.: BUILDING PERMIT INFO
/a ..K G �7 #,- `^ ❑ Consultant Emit Paid by Applicant(Initial) NLD ELECT' PLUMB MECH
fdt ter 40
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under previsions of Chapter 9 Rmmmencing JOB DESCRIPTION
�0ZO with S.�ion 9(NIO)nf Divisi.n3.f the Businessand Professions Csde.std mylicense is RESIDENTIAL:
in full force ands ct. PERMIT ISSUANCE
<FVZ�j Licenu Class "' Lic.M y VCy m 16 ❑SPDWI, ❑PLUMBs.N REMODEL
NdG Damyt�e�� Contra sr .^IL"" 4 4 1 APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMfi ING NE-PIPE
ARCHITECTS DECLARA"ireTION
a� PANELS ❑MULTI-UNIT El STRUCTURAL
O Z C I un Blond my pleall;aW as p��`y ODIFICATION
1/ UP T0200 AMPS
F-4�W Uccn Pmfessmmal �— ❑INTERIOR 'HIMNEY REPAIR
`Y ....l1 201-I"AMPS IMPROVEMENT S MMING POOLS
,_l OWNER-BUILDER DECLARATION
yy CC 6 I hereby oRml that 1 am exempt from the Contractor's License Law for the OVER INITAMPS ❑HATH REMODEIIREPAI ❑DE'MOLITION
bd 3,V following reason,(Section]031 5,Business and Pm exsion.s Cudie Any city or co.uly SIGNS ELECTRICAL ❑OTHER
YY17 n,I- which requires a parmil to construct,alter,improve,demolish,or repair any swcmrc
prior to its issuance, requires the applicant for such pemot to file a signed SPECIAL CIRCUIT/MISC.
w.7J B^
wommethat he slicensed Sectioturadminn.theprovisiomn3oftscaftle,ContraeBusinssa Li anselxw(Cho1for
Cyt ii. Icat he is sem ith Sationg,argue
f basisf rth theegend exemptand Proon.A.,ost Cale)of TEMP.METER OR POLE INSI'. -o-MMERCIAL,
d L=eC that he is exempt Therefrom and the Iwsis for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 byany applicant fora Permit suNeau, he...he.....a civil peohy of POWER DIiVICES
LL! rn not some than fee hundred delta.($500). TENANT ❑FWD SERVICE
C ❑I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
will do the work,and the structure m 04
Ls not intended offered for sole(Sec.94,Business ❑OTHER
Land Professions Code:The Cenitacmrs Licence Use does not apply to an owner.r OUTLE'CS-SWITCHES-FIXTURES r
.-, property who builds.r improves thereon,and who dues such work him+elf or through
his own employees,provided that such improvements art ma intended.r offered for NEW RESIDENTIAL ELECTR SQ FT.
saw.If,howeve.the buildings improvement is sold within one yem.fcampletim the SQ.FT.FL, RAREA LSQ.FT.
owner-builder will have the burden of proving that he did notbuild or improve for Aur N
pose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed commcmrs to TOTAL: ANS �a
consumed the project(See 7044,Business and Prnfasio^a Codc:)'Dte Contmdor'I I-
cense Law docs n.l apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who common for such projects with a contradons)licensed pursuant to the Conwetor'.s
License Law. PERMIT ISSUANCE
❑1 an exempt under Sec. ,B&P C for this reason
Owner [)aidALTER-DRAIN&VENT-WATER(EA) TION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICH
I hereby uflirm under penalty of perjury one of the following declarations:
l have and will maintains Cenificam of Consent toself-maxum for Workers Compere DRAINS-FLOOR.ROOF,AREA,GOND.
said...as provided for by Sciatica 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work far which this permit is issued. ENTITIES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37Mofthe Labor Code,for Performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Worke's n lnyxrunee cartrry3g((and Policy y^�c
Carier:� O'M�.�OPolwy N..: �r O a GAS-EA,SYSTEM-OVER 4 MA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASPIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(iFEF'_S
bis aalionmad not becompletW iflhe parmt is Tonins hu^drWd.11anOloip BUILDING DIVISIONGRFA$ETRAP
or less.) PLANCIIECK FEE
Icenify paraminanymnnero as to become
for subject to
the Wisiss'Com,n. SEWER-SANITARY-STORM EA.2110 FT.
not employ any parson ^any manner au m I.bceome subject to the Workers'Compere ENERGY FEE
Z Applicant
ant COlifsmia.Data
z � A locate � WATER IIIiATIiN WIVEMI'/ELEC1'N
PP GRADING TEE
fA NOTICE TOAPPLICANT If.after making thisCertificateof FLmor Cod you should WATER SYSTEM/TREATING
Wbecome subject m the Workers Compensation Provisions hal of the Labor Cede,you nun SOILS IFF,
� forthwith comply with such provisions nr this permit shall he JcemW revoked. WATER SERVICE
0. 0
i z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Thereby affirm that there is o construction lending agency for the performance of Date Receipt#
14. e� the work for which this permit is issued(Sec,3091,Civ.C.)
Q {kILender's Name TOTAL:
Lender's Address TOTAL:
gy Icenify that 1 have read thin application and sum that the above information is - BUILDING FEE
N ewome.I agra to comply with all city and county ordinances and slam laws relating to QTY. MECHANICAL PERMIT FEE
V z building construction.and hereby eathmize representatives of this city t.enter.ponthe SEISMIC FEF.
ubove-mentioned property for inspection purposes.
(We)agree to care,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEF
hidtlilies,judgments,cwtsand expenses which may many way acme against said City ALTER OR ADDTO MECH.
in consequence of the gmating of this permit. PLUMBING FEE
'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature Of ApplicandCuntmcter Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hmardons national HEATING UNIT ITO I00,000 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 HEATING UNIT(OVER 1000n)BTU)
F]yea 7 N VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or fnum building eus
escapism e equipment or or devices which Dam Receipt 4
emit hauN.us air contaminants as defined by the Bay Area Air Quality Management BOILER-COME LEE OR 100,000 BTU)
District? TOTAL:
❑Yes No BOILER-COME(OVER 100,003 BTU)
I have read the Initiatives moderiils requirements under Chapter 6,95 of the Cali- AIRCONDITIONER ISSUANCE DATE
times Health&Safety Code,Salome 25505,25533 and 25534.I understandthat if the NEW RESIDENTIAL MECH. SQ.Ey
building it.not ntly have a wren,that it is my respomihiligm^aily the ace,bt
.fthe or which um hoe met Pat.it e.fricartifcate nf0ectiparay.
Owner o mhonzc agent Date TMALP ISSUED BY:
OFFICE