S 1890 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO.
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL 1890
BUILDING ADDRESSBUILDING PROJECT IDENTIFICATION
: SANITARY NO. APPLICATION SUBMITTAL DATE
��� 1'HO
OWNER'S NAME: PHONE: C//O(]�N'TTRA-CT/OR'S NAME`, LIC NO:
t.p� J i'le's —70 N/C CONTROL#
ARa HKJUCT/ENGINEER: LIC NO: ADDRESS: ❑
S?o 1t. c f, q s1 a _
CONTACT: Irs"P : - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ' ELECIis DMB MB H
. ELECTRIC PERMIT FEE '❑ ❑
I hereby affirm that I am licensed under pmvisinns of Chapter 9(commencing
LICENSED CONTRACTOR'S DECLARATION QTYJOB DESCRIPTION
Woe, with Sec0on9f100)OfDivision3Ofthe Business and Professions Code,and my license is RESIDENTIAL•
Fad= In full force and elieqq{{ 7?C, PERMIT ISSUANCE
aUUl� Liccree Class T-"110 Liv.# OSFDWI. O KITCHEN REMODEL.
NQyDater-�I7. __ComwvF APPLIANCES-RESIDENTIAL.
p.prn ARCHITECT'S DEC LA RATION ❑ADDITION El PLUMBING L PIPE
z0a,Z l catamount my plaroxhill be used as public reamis PANELS ❑MULTI-UNIT ❑STRUCTURAL.
UI'TO 200 AMPS MODIFICATION
F.reJ,(aQil Lmensed Pmfvsnonal 1:1 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
0.' < 1 hereby affirm that 1 um exempt Co.,the Contractor's License Law for the OVER 100()AMPS ❑BATH REMODEUR PAIR 0 DEMOLITION
a following reason.(Section 9031.5,Business and Profexsions Code Any city or roumy SIGNS ELECTRICAL OOTHER
which q a Permt .t t her p d lish p y mmence
FNO prior t also q e.thapplicantf hpeair, M g dsmtement SPECIAL CIRCUIT/MISC.
2 pr
'but hers,licensed prsv t to the p n.of the Contractors LL (Chapter9
W d (commencing with Section fU Sin 3 fah Bu.' ss dP 1.s1 na Cwlc)or
❑1 t,0 g TEMP.ME'TGR OR POLE INST. COMMERCIAL-
that he is exempt therefrom and the basis for the alleged oxempnt to Any violation of ❑NEW BLDG/AUDITION 0 DEMOLITION
W..h not core than by any
undredapplicant ollars apermit subjects thO applicant toacivil penalty of POWER DEVICES
C not more than five hundred dollars($500). OTENANT OFOOD SERVICE
'G 001,as owralmf thepmpeny,nr myemployecs with wages es thenhade compensation, SWIMMING POOL > RIC IMPROVEMENT
X will do he work,and the str ,i
ucmreis no, moD'erul formle(Sec.TAT4.Business 00THER
wand Professions Code:The Commoners License Law does not apply tar an owner of OU LLETS-SWIT T11TURES
,,open win builds m impmvos theann,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELGC7ER(�)
Q FT
sale.If,however,the building or improvement is sold within One year Ofemmpletimidua SQ.FI'.FLOOR AREA $/SQ.Fp.
owner under will have the burden of parsing that he did not build m improve for pur-
pose of sale.).
❑ 1,as owner or the property,am exclusively contracting with licensed contractors to C
construct the project(Sec.9!144,Business and Professions Code:)no Contractors Li- '
se Law does not apply to an owner of property who builds or improves thenen,and QTY. PLUMBING FEE
Abu contracts for such projects with a contmnegs)licensed pursuant to the Contra mils
License Law. sit
-
OlamexemptunderSer. ,B&PCfmffiw easm PERMIT ISSUANCE. �/ALTER-DRAIN&VENT-
Owner pate - (rr '-61LUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CAj
1 hereby affirm under penalty of perjury one of the following declarations: //P(,
❑ I have and will maintain o Complain of Cousenno self-insure for Workups Compen- DRAINS-FLOOR,ROOF,AREA CONU. STORIES TYPE CONSTRUCTION satimn,as provided for by Section 3900 or the Labor Code for the Performance or the
rk for which this lariat is issued IXT
FURES-PER TRAP
S-1 have and will maintain Worker's Compensation Insurance,as required by Strict
3900 of the Labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WmkeJfs Qom nsamon Osumi cecarrier and Policy num
¢er rc,� ,
Cacti co ! Policy No:A/ 3f1N�___e.�l���_ GAS-EA.SYSTEM-OVER 4IEA)
CERTIFICATE OF EXE ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This section hoed not be anrepmmdinnelernitin Intone hundred dollars(alta) -
BUILDING DIVISION FTE,S
mr less) GREASG TRAP PLANCHECK FEE
Loy any that in the perany ormance mannero theas
havormk for whlch ice,to Perthe Wokt is es'Carer- SEWER-SANITARY-STORM EA.200 FT.
not employ any person In any manner so as m become subjecue the Workers'Carper- ENERGY FEE
0, z satiety ant California.Date WATER HEM ER W/VENT/ELF.CTR
77
NOTIAppliCE
ant GRADING FEE
r7 ti NOTICE TO APPLICANT:If,otter making this Ceaificatc of Exemption,you should WATER SYSTEM/TREATING
a7 become subject m the Worker's Compensation pmvisinns of the Labor Code,you..,at SOILS FEE
W forthwith comply with such previsions or this permit shall be deemed invoked. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
I hereby affrin that here is a constriction lending agency for the performance of Date Receipt#
the work fee which(his D m ,is Issued(See 3097,Civ.C.)
U Lender's Name TA L.
�
Low
kI Leader's Address'y W I certify that 1 have mind this application and state that the above information is ` BUILDING FEE
n.t h cooled.i agree to comply wins all rity and county ordinances and nom Inw..clatops, QTY- MECHANICAL PERMIT FEE
building construction,and hereby authorize representatives of this city to enter open the SEISMIC FEE
above-mentioned property for inspection purrynes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC PEE
liobilums,judgment`.crusts snit amensea whlchmay in any waywereeagainn,id City ALTERORADDTOMECIL
In cuneegaence of the granting of this permit. PLUMBING FEE it
APPLICANT UNDERSTANDS ANU COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(1(1 CFM)
SODRC ^ 5A MECHANICAL FF
_) "51
) " AIR HANDLING UNIT(OVER III,IXIOCFM) CONSTRUCT 101 TAX
Signature ofApplicartEmomctor Data G EXHAUST HOOD(W/DUCI) HOUSING MI IGAI]ON FEE
'HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant once or handle hrardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chaptu 9.12,and the Heahh and Safety
Code,Section 25532(a)9 HEATING UNIT(OVER 100,000 B'TO)
❑Yes ON.
VENTILATION FAN(SINGLE RESID) PAID
Will the or oor nt Or is a,building occupant use equipment or devices which
Dam Re«apt#
emit hazardous air contuminams as defined by the Be,Acca Air Quality Management BOILER-COMP(THE OR I00,IX00 BTU)
District? TOTAL:
❑Yes ON. BOILER-COMP(OVER 100,070 BTU) �Lj IL
1 have read the hozardous materialsISSUA CE DATE
regairemems under Chapter 6.95 of the Call- AIR CONDITIONER� T
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 undemmad that if the NEW RESIDENTIAL MECH. SQ.Fn
building docs not currently have a tenant,that It is my responsibility to notify the occupant
of the requirements which man be mat prior m issuance of a Ccdplicate of Occupancy.
Owner Or oumarized agent Data TOTAL: ISSUED BY:
OFFICE