S 1314 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PFSIT NO. 1314
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL \V
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
20210 Lynton Ct . -2-6-
—2G- Q
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
"ARCHITECVENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Michael' J. Alton 490-5655 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
LICENSCu CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 on licensed under provisions of Chapter 9(comencedng JOB DESCRIPTION
AaZ wim Section 9000).(Division3.1 the Business and Pmfessions Gide,and my Beenseis RESIDENTIAL,
F in full force and cBem. PERMIT ISSUANCE
C4 UzF' License Class 1-,, 513296 ❑ADWL El KITCHEN RF-PIPI.
m6L `=� APPLIANCES-RF.SIDF.NTIAL [I ADDITION El PLUMBING RF.-PIPE
F 4 W Dnle CTs DECLARATION
ARCHITECTS DECLARATION ❑MUL'fl-UNIT ❑STRUM URAL
F PANELS
2 1 understand my pions shall be used as public records MODIFICATION
py CA.Q UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
1�=-W Llcial Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
E+� OWNER-BUILDER DECLARATION OVER 1000 AMPS El PATH REMODEVREPAIR El DEMOLITION
C vr I hereby affirm mal I am exempt from the Commcmr's License Law for the
3 G FU+ following meson.(Section 70313.Business and Professions Code:Any city,,county SIGNS ELECTRICAL ❑OTHER
W p y
which helf.ines a"'am, t t alter.hou,noxf,dennolisic,uncIati,say etmnurc
1"'^ pito t t '. vis y th ppllc t[ hp iu fl -6 datum Wont SPECIAL CIRCUIT/MISC. v
des,han,fancied ptar tt tl of11Carolina, License L (Chapter9
�pCboommation, lh Section 9000)ofD"ste 3 idnee Ito ss andPrf is Code)cr TEMP METER OR POLE INST. COMMERCIAL:
d 6 m yv that he i.e.exempt therefrom and the basic for 0m alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tZSection 9091.5 by any upf icam Ia pm
In, ermnhjecls mapp
e h up,In a civil penal,,of POWER DEVICES
W^y ❑TENANT ❑FOOD SERVICE
not mom then five hundred grope donors y amp. IMPROVEMENT
�' � ❑ Lothewoowner k,the property,structure
intended with wages for sale
compensation, SWIMMING POOL ELECTRIC
(. will dothesants ands he Comisnn',Unease Lias riddo Rt rot applySee 7044,Business []OTHER
and ernfeshe b Code:The Contrthera License Law doer not apply himself owner of OUTLETS—SWITCHES—FIXTURES
propeny who oyeIdses,or impreves thereon,and who nts a such work tid(i ff through
his own employees,provided that such improvements are not intended e offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.ll',however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
w
nnerhmlder will have the burden of praying that he did not build or improve for par-
now of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the proton(Sec.9044,Business and Professions Cade:)The Contractor
,Li-
nty Law does not apply to an owner of property who builds or impr,vea thereon,and QTY. PLUMBING PE IT FEE
who contracts for such pmleaa with a enntractor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑I am exempt under Seo. B&P C for reason
Owner Date ALTER—DRAIN&VENT—W FTO VALUATION
WORKER'S COMPENSA'T'ION DECLARATION NACK FLOW PROTECT.D G
01 7
' IM1crcby affirm under penalty of perjury one of the following declomilons:
Ihave and will mainmina Certificate of Conserv to sell-insure lar Worker's Cnmpen- DRAINS—FLOOR,ROOF,ARB�gfsflfy STORIES TYPE CONSTRUCHON
tion,as provided for by Section 37M of the Labor Cad.,for the performance of the
Iwar n
r which this permit is issued. FIXTURES—PER TRAP
haveand will maintain Worker's ante athe wrkforwhiathis perm by Section
3]110.f the Labor Code,fonhepufinmance of the work for which this permit is issued GAS—EA.SYS'TEM-I INC.4OUTLETS OCC,GROUP APN
sGtmpcnsCompensation Insurance n ld, ptB )% S
Carrie,: � NA \ � %, % GAS—EA.SYS TEM-OVER 4(EA)
CRT bry*fON FROM WORKERS
COMPENSATION INSURANCE GREASE/INDUSTRI,WASTE INTERCEPTOR
BUILDING DIVISION FRES
(This section need not It,completed ifthe permit is for one hundred dollars(81 W)
CREASE TRAP.,less) PLANCHECK FEE
I certify that in the perforionee ofthe work forwhich this permit is issued,)shut SEWER—SANITARY—STORM EA.200 FT.
not empl,y any person in any manner so astobecome subject to the Wvrkerc'Compen- ENERGY FEE
,Z eaten Laws of California.Date WATER HEATER W/VEN'VE,LECIR
��jj O Applicant ` GRADING FEE
q .~N. NOTICE PO APPLICANT:If,after making this Ceirete of Exemption,yno should WATER SYSTEM[IREATING SOILS FEE
fti become subject t.the Workers Compensation provisions of the Labor Code,you must
{a✓:1 forthwith comply with such provisions c rthis permit shall be deemed revoked. WATER SERVICE
n, Q
UC) CONSTRUCOONLCNDINGACENCY NEW RF.SIDENTTALPLMB. SQ,FL PAID pate Rc i
1 hereby affirm thvuhere is a construction lending agency for the performance of
L) r. the work for which this permit is issued(Sec.3099,Civ.CJ
Lender's Name T AL:
O V LenJcr'.c Address TOTAL
131 BUILDING FEF.
[r 1 certify that I have read thirty and
ni c un and clam ces the.beta information is
h r reit.1 agree ct comply with all city and.numy ordinances and emm Taws relating a QTY. MECHANICAL PERMIT PEE
U Z building construction,and hereby authodee represenmmves of this city mentor upon the SEISMIC FEE
alone-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEP.
hadhilitics,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in ,ny.ence of the granmit
um,of this per . PLUMBING FEE
se
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNI I'(TO I0,IMXI CFM) MECHANICAL FE
SOURC E, zNS
4 —Aix.
ix -C? y AIR HANDLING UNIT(OVER 10,I)DO CFM) CONSTRUC'1'IONTA
Si n t enf App manl/Commclor �'�•] trixp TDateO EXHAUS'LHOOD(W/DUCT] HOUSING MITIGATIO FEC
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllcamm future building wer,artmoreor handle haeardous material AHEAUNGUNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Sermon 25532(v)'! HEATING UNIT(OVER 100,M)RTU)
El Yea ❑No VENTILATION FAN(SINGLE RESIfd PAID
Date Receipt#
Will he applicam or future building Nydantuseea AhrQnt.tdMana which BOILER—COMP(JHPOR 100,OfN1 BTU)'
emit hazardous air conmminams ac reflood by the Bay Aren Air Quality Management[ TOTAL:
Dtstrict1 Yes ❑No BOILER—COMP(OVER 100.00NI BTU)
❑
1 have reed the htzard.,materials remarcrnents under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT. 2/ -9
building doe n t,much eutenant,mat it is my rcsponsituddym notify the oecupmn `^J
at _ met Pouna,issuance o' Ceni,(cut of vpa y. p .
am o Ized agent - Date TAI, ISSUED BY:
OFFICE