S 1511 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PEgIT NO. 1511
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APP LICATIONSUBMUTAL DATE
'�-���L LAN DY 1--'� • �
O :R'S NAME: �1PHONE: "FIAC IR'S NAME: LIC NO:
1✓_I y' Q�II ` 1�" N/C MNTROL#
+AKCHGFCT/ENGINEER: LIC NO: ADDS: 1�0
❑
CONTACT: PH BUILDING Z BUILDING PERMIT INFO
�� V ❑ Consultant Fees Paid by Applicant(Initial) B DG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED Cdunder'FACTORS DECLARATION
of CON QTY ELECTRIC PERMIT FEE
1 hereby(form mm 1,3 eased under ndi'moaa m Chapter 9(conlmpose is JOB DESCRIPTION
W apO with Section'lUW)nf Division3-[the Business and Professions Crcic,and my hcenae is RESIDENTIAL
!!-- in full fora tmd epce ../� PERMIT ISSUANCE
aUV Licen.e Chts U_I—Lia# ❑$FDWL [I KITCHEN REMODEL
rF�ul Date Iu-//�• Q�S�Comrvdu APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLAR ON PANELS Ll MULTI-UNIT El STRUCTURAL
O Z y Zz I understand my plan,shall be used(s public a rzds M D CTUR L
:f UP TO 200 AMPS
LL01 ON
Licensed Professional ❑INTERIOR HIMNEY REPAIR
201-10011 AMPS IMPROVEMENT
OWNER-exemptdrom the ommetaRATION ❑SWIMMING POOLS
6 1 Hereby v[tirm That 1 ten exempt Bore the Commemr'v License Law for the OVER IMOAMPS El BATH RP.MODELBEPAIR ❑DEMOLITION
W 3 Vim.F following reason,(Section 70315,Business and Professions Gde:Any city nr wmnly SIGNS ELECTRICAI. ❑OTHER
F O md which requires a permit to vmstrrrr,alter,improve,demolish,or repair any structure
y y...l
prior to its issuance,also requires[tic applicant for such permit o file a signed statement SPECIAL CIRCUI'UMISC.
Y malbeislicenmdpursuanfmthcprovisionsol''the Contractors License Law(Chapmr9
W (commencing with Sectim,7000)of Division 3 afthe Business and Parmaelorc CWe)or TEMP.METER OR POLE INST. COMMERCIAL
a.y M that he is exempt therefrom and the basis for the alleged exemption.Any violation of -
4X1 Series 90315 by any applicant lar a permit subieds the hear Io o civil ❑NEW BLDG/ADDITION ❑DEMOLITION
y p pp penalty of POWER DEVICES ❑TENANT
y
not more than five hundred dollars y employees
El FOOD SERVICE
5p ❑Lothe owner k,the pmpeny,ar myyemntended crumpled
for sth wages as ale
044.Business
SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the.vtrewreis not intended proffered for svle(Sec.9044.Business ❑OTHER
W� ti and Professions Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES RES
property who builds or improves thereon,and who does such work himself or through
his own emplayees,provided that such improvements am not intended nr offered for NEW RESIDENTIAL ELE 'QFC
sale.If,however.the building or improvement is said within one year ofcompletion,the SFT FLOOR AREA S/SQ.FT.
m er-brader will have the burden of pmving that he did not build or improve for pur- /
Ease of sole). in
❑ 1,net Be p of 0e Seeproperty,.B exclusively contracting with licensed cnnlelix,to
construct Thep jeer(Sec.9044,Bueinoss and Profevsipns Code)The Cnnwnpr's Li-
extra,
i-c se Law does not ch plr man owner swithaofpmperty who
esedpds rs improves thereonContractors
QTY. PLUMBING PERMIT FEF.�.�Uh
who corrects for su(hp feels with aepntmemr(e)Ileensed punuantmma Cpmreclnrs V
ti
License Law. PERMIT ISSUANCE
❑ 1 am exempt anner see _,B&P e far has reaxan
ALTER-DRAIN&VENT-WATER(fes) \
Owner Date _� LUATION'
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE 'LIDO
I hereby affirm under penalty Mpegury one of the following declarations:
❑ Ihnve and will m(imam a Certificate of Consent to self-insure far Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND.
sada(,as provided for by Section 3200 of the Leon,Code,fpr IM10 anumaraare of'he STORIES TYPE CONSTRUCTION
work for which this p,air is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compens:nion Insurance,as required by Section
3700 of LaborCode.far the performance otube work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC CROUP APN
My Wr
orkerls Compensation Insunce carrier and Policy number are:
Carrier: Policy Nn: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI.WAS TE INTERCEPTOR
IT his.aectioa need not be completed ifihe permil is for one hundred dollars(S I W) BUILDING_DIVISION FEES
nr lest.) GREASETRAP PLANCHECK FEE '
I certify that in the perinnnance of the work for which this pe mil is issuW,Ishvll
not maplayanyperon in any manse a b'wlln mines Camper-en- SEWER-SANITARY-STORM EA.200 PT.
Minn Lnws ofC Date M ' P ENERGY FEE
Z O A licam WATER HBATER W/VENT/ELELTR
PP GRADING FF.P.
to NOTICE E0 P ICANT f,after ung ms C ¢ale of �xemp ma.you should WATER Sys mMIfREATING
been subj Ito the Worker's Compensulion provivinns oftho LabnrCode,you must SOILS FEE
FLl ry
forthwith c.+mplywith mch pmviainm or this permit shall he demnWrevoked. WATERSERVICE
Jfv
Zoo) Z 0. Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMD SQ.Er PAID
I hereby affirm that there is a construction lending agency for the performance of Date
P the work for which this permit Is issuod(See.3097,Civ.CJ pt#
Lender's Name OTAL:
LUkI l dri Address TOTAL:
L1s 1 certify that I have read this application and state that the above informal.....IvBUILDING PEE
it 0 correct.I agree to comply with all city and county oNimances and slam laws relating to QTY MECHANICAL PERMIT FEE
C) 4 building construction,and hereby authorize representatives of this city to emeruponthe SEISMIC FEE
above-mentioned prepeny For inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Caperton against ELECTRIC FEE
iniiiliti dving.ffluRerangatthisseswhlch mayinany way accrue against said City ALTER OR ADD'TO MECH.
ns quem oRhe gmntlng oRhis permit. PLUMBING FBF,
APP1 ' NT UNDERSTAND NDW COMPLY WITH ALL ON-PO T AIR HANDLING UNIT(TO IO,WOCPM)
SOU REGULATIONS. I MECHANICAL FE
�/' AIR HANDLING UNIT(OVER 0,00000D CONSTRUCIO TAX
atum Applic J adtmcmr r m EXHAUST HOOD(W/DUCD HOUSING MITI . ON FEE
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building rcensor store or handle hazardous material HEATING UNIT(TO 00.W0 BTU)
as defined by the Cupertino Municipal C..de,Chapter 9.12,and the Health and Safety
Code,Se vino 23532(u)1 HEATING UNl'T(OVER 100,000 RTU)
L-]Yes No
VENTILATION FAN(SINGLE RESID) _ PAID DateReipt#
Will the applienm or future building oceupam use eyuipmem or devices which BOILER (3HP OR I(N1,0(0 BTU)
cmll M1umus -
rdoair inmann m n,as defined by the pay Are.Air Dumbly Management TOTAL:
Crone,?
El Yea ON. BOILER-COMP(OVER 100,000 BTU)
I have mad the hazardous materials AIR CONDITIONER _ ISSUANCED TE
requirements 25533 an under Chapter ndar of the if the
fomia gdoesHealth&$curry Coda,a Sections 25hat i is my and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.FT
buildingdoesnotc whit currently met
isre pnneihrtifitonotifytheocupum
of the requimmcnN which meet be met prioret met pripnoissuance of a Certificate u f Oc upu acy,
Owner or authnnzed agent Date 'fOI'AL: ISSUED BY:
OFFICE