S 1377 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEgIT NO.
]BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 1377
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: i SANITARY NO. APPLICATION SUBMITTAL.DATE
14r4141
LO
OWNER'S AME: PHONE: CONTRAC 'S NAME: - LIC NO:
Y, }In A (y N/C CONTROI,p
A Pont 4zu.-4445S i
ARCHITECT/ENGINEER LIC NO A�)DRP- .SSS I lr 1. 1 C �1 ❑
CONTACT: _, PHONE I BUILDING PERMIT INFO
I �'�_^/ S ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Y..n Cfto6 Rr
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 here y offlor that I ren licensed under previsions of Chapter 9(commercial; - JOB DESCRIPTION
Oa'Z with Section 9(100)of Division 3 eflhe Business and Professions Code,and my license's
11100 PERMI'I'ISSUANCE RESIDENTIAL:
FIy in full forcennd;[fy9Q ❑SPDWL [I KITCHEN REMODEL
�UV License Class Lich LIANCES-RESIDENTIAL. El ADDITION Ll PLUMBING RE-PIPE
PZ;Z Date amo-acmr
ARCHITECTS DECLAR '1 N ❑MULTI-UNIT ❑STRUCTURAL
F 0 m PANELS
z Vnz7 tun ersu dmy plans shall beusod aspnbllerecor.s .Mf]�IFICATION
OZ'-, UP TO 200 AMPS C1 INTERIOR HIMNEY REPAIR
Licensed Professional 201-IODOAMPS IMPROVEMENT CjSWIMMING POOLS
•] OWNER-BUILDER DECLARATION OVER IfN10 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLH'[ON
st 1 hereby afOma that I am exempt from the Contri License Law for the
1113 O y U following reason.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W rF which reyulres a permit I.construct,alter,impreve,dmnoliah,m repair any nmetnre
F�o�ne� prior to its issuance,also requires the applicant for such permit to file asigrod shoement SPECIAL CIRCUIT/MISC.
ggggyy that her,hoposedpurauanuo the pmvislovof the Cis scmr's License Law(Chupmr9
^GC) mm
(mcreing with Section 70Wgaf Division 3ofthe Business and Professions Cobb)., TEMP.ME'T'ER OR POLE.INST COMMERCIAL:
611 Ra e that he is exempt therefrom and the basis far the alleged exemption.Any viable.of - El NEW BLDG/ADDHHON ❑DEMOLITION
W Section 7031.1 by any applicant for a permitsubjects the applicant to a civil penally of POWER DEVICES
�`� not more than five hundred dollars($500) ❑TENANT [I FOOD SERVICE
��Y OTHER IMPROVEMENT
yd ❑Lo as,
the pm peny, remyemntended with wages compensation, SWIMMING ELECTRIC
�'py Q will do Ne and the he Cmu parcms not Livens orOffered sci r ancient
apply to 114,Business ❑OTHER
�•m and Pianissimi,Codc The Centmemr'a License w Law dopa not apply s if owner of OUTLA"fS-SWITCHES-FIXTURES
property who builds is Improves mor i and eche doss such,into himself Ihmugh
has own employees,provided tbm such improvements am not intended or offerul for NEW RESIDENTIAL CLECB SQ PT.
,vole.If,howeverthe Initiation improvement is sold within one year of completion,the
ner-builder will have the burden of proving that he did not build or improve far poo
REM VW ETET
pose of eine)
❑ 1,as owner of the properly,am exclusively cartoon,wish licensed co meemas to TOTAL: p�'j
,ngmet the protect(See.9M4,Business and Professions Code.')lazed
L} 'MMR 8 1998
cen.ve law does not apply h.an owner ofpreperly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who wmraes for such Impacts with sentiments)licensed pursuant to the Contractors
License Law, PERMIT ISSUANCE BYE
Owner Date
L]I am exempt under Sec. ,B&P C to,his reason
ALTER-DRAIN&VENT-W ER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT. ICG I Zpo a •��
have
and w atfionll mai codtain a Cenal,y of perlary eso t ofdv elf-impre for tiedamtions:
� Q lhavc... din maintain Sc Certificate of Con Label elf insure.. Worker's Camper- DRAINS-BOOR,RO R. ND. STORIES TYPE CONS'1'ftUCT10N
work
rkfas provided for.. Sermon 37IHI ofthe Labor Cade,for the performance ul'the
work for which this permit is issued. FIXTURES-PER TRAP
37 1 have and will maintain Workers Cance offs w Insurance,which required by Section
My orke Labor Cnde,fon Insurncecancer and Poork for number are
permit is iswed, GAS-F,A.SYSTEM-1 INCA S OCC.CROUP APN
My Workers Compensation Insurance canter and Polley number vre:
Carrico: Paltry Na: GAS-EA.SYSTEM-OVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE IN'1'ERCE
COMPENSATION INSURANCE. BUILDING DIVISION FLC_S
(Tlakwollon need not hccompleted lf,heporrad is for one hundreddollar,S 100) GREASETRAP
or IessJ PLANCHECK PEE
Terrify that in the performance note work for which Navp nit isi �J,Lball SEWER-SANITARY-STORM EA.200F1'.
not employ any pmsn anymanp r' a� eb ,ibjectl f Wod r Camper- ENERGY FEE
Z Marion Laws of Califs Date WATER HEAT ER WIVENTELECPR
0 O Applicant - GRADING FEB
NOTICE TO APP NT'.If making is enlf a of Esemption,you should WATER SYSTEM/IREATING SOILS FEE
a become subject m the Works I C u pereand t pros Minns of the Lahar Cnde,you must
fonhwi,h comply with.meh pm c as no permit shall be deemed revoked. WATER SERVICE
Q
CONSereis a'IONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Date ReceiplI
1 hereby arfn i that m,i is a..it(Sac.30 lending agency for the performance of
O the work for wNch this permit is irsuud ISee.309],Civ.C)
Lender's Name TOTAL'
U Lender's Address TOTAL:
0. BUILDING PF:.
I cenify that I have read this epplicn,ion and stns that the above tambourines is �
I) vamncet.l.greaa,stormily bida.11ehy and county ordinances aptitude lawsrelmiegm QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U{L
mild......nor iumind hereby outhnnze repreeenm,ives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
ishilines,judgments,costs and expenses which may in anyway more against said City ALTER OR ADD TO SUCH,
in onsequence of the granting of Chit permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'CIO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER FLOOD CFM) CONSTRUCTION TAX
Signomre of Applicate/Contmemr Dam EXHAUST HOOD OVMUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Willow applicant or future handingrect,adutue or handle hazardous moped.1 HEATING UNIT(TO 100,000 BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,acr the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU)
❑YesNo
� VENTILATION FAN(SINGLE.RF,SID) PAID pate Receipt p
Will the applicant or future building occupant use equipment or devices which
mit hawrdaus air contearmams as defined by d.Bay Are.Air Quality Management BOILER-COMP(3HP OR 100,01111 BTU) TOTAL:
Dastnnp
❑Yes 71 No BOILER-COMP(OVER 100,1810 BTU)
I have read the hicaWoov mttedals requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health Safely Code,Stan...25505,25533 and 25534.1 undemmnd that if Ne NEW RESIDENTIAL.MECH. SQ.FT.
bulldln of currently have r appon,that s any resprosa ity m notify he ore pant OO
of the ants, ad,mus,edma is, of nlfe O u
OVliiarpmhmn,c tr
gent Hit TOTAL: ISSUED B'4 ^-- f ' O
OFFICE