S 1233 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDmG-ELECTRICAL. POSIT NO /�
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MECHANICAL J 1233
BUILDING PROJECT IIIEN'TIFICATION J. V�!
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
vnaR
04-. �_� �V
O ,k'S NAME: P / C ACkO�'LS_NA LIC ,...L..,
�y,f { N/C CONTROL#
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• ARCHITECT/ENGINEER: LI NO: ]DRESS: •l I V ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 nereby amrtn mat I am reenaca ander prnviaioms of chapter 9(.ommem.i.g JOB DESCRIPTION
Wap with Seml.n 9fNX0 of Divlslon3of the Bnsin.esand Pndessiom C.de,and my liwnsels FERMI F ISSUANCE RESIDENTIAL'
�F,F in fullforce anile�f(s�t•� � ❑SFDWL ❑KITCHEN REMODEL
UZV License lass�p�—Lic.N APPLIANCES-RESIDENTIAL.
ti64 Date=s--'= --Commcmr ❑ADDITION El PLUMBING RE-PIPE
F.Dw ARCHITEC IS DE CL A ION ❑MULTI-UNIT E:1 STRUCTURAL
z O n z L undersand my plum shall fictiewdia,mid,lic records PANELS
MODIFICATION
0 y,b,], L¢ensed Pmfeseional UP T02IX)AMPS El INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT SWIMMING FOOLS
1P.'...�II OWNER-BUILDERexempDECLARATION
W C�6 I hereby nfEms thw I am exempt from the Contractors License Law for the OVER IBfN)AMPS ❑BATH REMODP.IAREPAIR 0 DEMOLITION
iC 34 U following reason.(Seetirn 9031.5,Bostonsa vnd Pmfeesions Code:Any city or county SIGNS ELECTRICAL _ ❑OTHER
O0 which retluires v permit to construct,alter.improve,demolish,.r repair any stmewre
�H rid] prior to is issuance.a]...id,mce,mviopplicam foronla permit,,filen signed a..temenlSPACIAL CIRCUIT/01St.. ��
G� 14
that he is licensed Fontenot.the povisiors,if the Cennuctnrx License Law(Cbepmr9
00 (commencing with Section]000)of Divisinn3ofind Business and Professions Code).r TEMP.METER OR POLE INST. COMMERCIAL:
4 y p eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
iYCI 4y Stairs 7031.5 by anynppllcvm it,,it wroit xpbuxt, he a,dicanm a civil penalty of POWER DEVICES
not More than Eve hundred dollars E300). El TENANT ❑FOOD SERVICE
SpFl T,as owner ofew property,or my employees with wages as their.sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
E.. will do the work,and the structure is not intended or offered for sule(Sec.9044,Eupnea; ❑OTHER
3 ae and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWI'I CHIS-FIXTURES
property who builds or improves thereon,and who des s such work himself or through
his own employees,provided that such impmvemen¢are not intended or offered for NEW RESIDENTIAL ELECTR Sol IV
sale.IL however,the building or improvement is sold within one year ontappEtion.the SQ.FR FLOOR AREA $/SQ.UU..
crEnalder will have the burden of proving that he did not build or improve for par-
,a.nr sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors In TOTAL:(0/
ondruct the p feel(Sec.]044,Business and Professions Code:)The Contractor's Li- v
se Law does mol apply man.,,,at of proper who builds or hoprovo;thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a eonu nouns)licensed Panamint to the Compactor's
License Law. PERMIT ISSUANCE
❑I amexemptu.der Sec. ,B&PC forlhisresom
Uproar DoneALTER-DRAIN&VENT=WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hereby offimt under penally of p,jO,one of the following recursions;
❑ I have and will mainminaCertifcmeol'C.nsenl m self-insure throw kci,Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES '1'YPG CONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
have and will mountain Workers Compensation Insurance,as required by Section
3 of the Labor Code,for performance ofthe work for which this permitis Issued GAS-EA.SYS'IEM-I INC.40UTLETSC -,ROUP APN
My Wor Com .utionlnsu�yp(��vrierand Poli. EA.SYSTEM Grtrier: llT. PolicyN.S � 6''S�N GAS- (BA)
CEGPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ORGSUINDU$TRL WASTE INTERCEPTOR L LNG DIVISION FEES
(This section need not Na completed irthe permit is for one hundred dollars($100) GREASE.TRAP
or less) PLANCHECK FEE
I certify that in the Performance.f%ework for which this permit is issued,Lshall SEWER-SANITARY-STORM EA.200 fH'. �/
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z an..Law,of Cul forma.Data WATER HEATER W/VF,NT/F.hECfR
Z 2 Applicata GRADING FEE
y NOTICE TO APPLICANT:If,after making thh Cerifeme of Exemption,you should WATER SYSTEM17PREATING
04 become subject to We Workers Compemnli.n provisions of the Labor Code,you mad SOILS FEF.
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ.FT. PAID
UO Thereby affirm thin inuconstruction leading agency for the performance of Dole Receipt
V. Fthe work for which this permit is issued(Sec.3f199.Civ.C.)
Leader's Name p
WLenderss's AddreTOTAL: 3 8O
I� 1 certify that I have read this applmatma and state that the above information is BUILDING FEE
f-+ fad correct,1 agree to comply with all city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEP.
above-lowhomed property Incorporation puT,,ses
(We)agree to save,lndemniry and keep hasmlmsthe City of Catoctin.against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,posts and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
to onsec omice.f the gramid,of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,000 CFM)
SOU CP EOULA[IONS. ) MECHANICAL FP.P.
�/792 AIR HANDLING UNIT(OVER 10.(KKI CPM) CONSTRUCTION TAX
Si al re.fA1dcm Commcmr Date EXHAUST HOOD(W/DUCl) HOUSING MITIGATION PEE
HAZARDOUS MATER A DISCLOSUI E
Will the applicuram furore building ors panlm.reorhans ehazardonsmaterad HEATING UNI T(TO 1 MORE BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Codq Section 25532(x)'! HEATING UNIT(OVER 100,000 BTU)
F]Vic; E]No - PAID
VENTILATION PAN(SINGLE R251 D) Date Receipt#
Will the applicant m future building occupant use equipmetn.r devices which BQILBR-COMP(3HP OR IBO,WO BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management �' T09'AL:
District,
E]Yea EIN. BOILER-COMP(OVER 100,1E0 BTU)
I have read the tendrilous materials teyu
ialirem ¢enunder Chapter 6.95 of AIR CONDITIONER 16,
the Cali- SEANCE DATE
moria Health&Safety Code,Sections 255(15,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FP. r 7$
building does not urrently have a tenant,that it is my responsibility to notify the occupant
of the reyuiremems which most be at pnor in issuance of.Cmbfi,amof Occupancy.
Owner nrauthoracd agent Data TOTAL: ISSUED BY:
OFFICE