S 0391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION AI'PLICATIONIPFRMIT PLUMBING_MECHANICAL S 0391
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APP(- DONSURMITTALDAO!
CO
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NE: N
NIC C(yNh
'IXOtt
ARCHIFEC'UIENGINEF:H: LIC NO: A7�if ( ❑
7 �O ❑ AA
Consultant Fees Paid by Applicant(Initial) BLDG E F,Cf PLUMBfa[(II
❑ ❑ NeIA/-`ll
LICENSED CONTRACTOR'S(DECLARATION QTY ELECTRIC P17RMIT PEE JOB DESCRIPTION
I hercby affirm Ihd I am licen.md under Provisions.f Chnpmr Y(amnnencing
O D O with 5tttion]q)01 nl Division t.rte Businc'a
III bessions CWT'and my licensc is RESIDENTIAL
CO2 in full force and a PERMIT ISSUANCE
❑SFDWh C]KITCHEN REMODEI.
QU(J License Lic.p APPLIANCES-RESIDENAL ❑ADDITION ❑P[UMBING RE"I'll
1 v1-i66 Dme�Commcmr ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATIO PANELS MODIFICATION
ZCI underxtnnd my plans shall he used as public records I]P'IO2gd AMPS INTERIOR CUMNEY REPAIR
F 4„F„0 Licenced Pnd'e,sinnal 2aL11XX1AMPS IMI'NUVEh1ENl' E]SWIMMING POOLS
�
�f; DWNER-BUILDER DECLARATION OVER 1000 AMPS
E]HSI H REMODEUREPAIR C]UI?MOLI'I'ION
C C Q 1 hereby aRrm that 1 am exempt from the Contractors License law for the ElLUBER
C 6 U following rcesun.(Section 7031.5.Businessland Professions Code:Any city or county !QTY. PL!UMB1NGPERMlT
ELECTRICAL
t+)3 LL to which requires a prrnil m cousvua,alter.improve,demolish.or min r any 4m,mre
IC�C� prion.ire issuance.also moors theapplicant for such permit te file a signedoatenmmLCIRCUFUMISC.
� } that he is licensed po,nam to Rm provision%of the Common's License Law(Chapter v J7_7
MMERCIAL:
Iy�jCgp (commencing wish Section70Nft of Division 3of life Business and Prof,,,inns Gnle)nr METER OR POLE INS'T. N13W BLDGIADDITION [I DEMOLITION
Ibm he Is each,thercrmnt and the bast,boom alleged uamnptiun.Any violation nr
W m Section 9031.5 by any applicnnl fnrapernil alb O,the applicant to milt I iY ofPOWER DEVICES THNAN'f ❑1'UOD Sh;RVICIi
t more than five hundred dollar.($500). IMPROVI?MENT
_s, ❑ Las owner nOhc property.or my employers with wages a,their sole compensation, ING POOL ELECTRIC OTHER
F. will d.the wok,and the stmcwrtis not immmdcd nr alicrtJ for sok(Sec.7044.BusinessIR-SW'ITCIIES-FIXTURES
m and Professions Cde:The Colnmclnrs License Law dos not apply nt an casco of
13- pmpery who builds or improves thereon,and whit does such work himself or through NEWESIDENTIAL,T;LECIR S
his own employees,provided that such improvements am not intended of oncred for ET.
sale.IL however,the huildine or impmvnnent is sold within oneyear ofcomplaion,the
er-budder win have the nnNennfprovmg molot997
PW caT AI,: X99O 1,as nwmer til Ihe po,coy,am exdaskely contracting with reamed conn......munmn Ihe project(Sec.]two.Business and Professions Csdc:)The Contractors Li-
selawd.e,..,apply to an owner ofproPerty who builds ser improves themon.and PLUMBINGPERMIT whoconvictsforsuchpnrjectswithacommands)licensed pucalantto the Contractors
License law. ,tl&PCfor lM1is'rtasmITISSUANCEO IamexemptunderSec. -GRAIN&VENT-WATER ILA) VALUATION
Owner nam
• WORKHOOnder COM of ,jury
ru DECLARATION RACK FLOW PROTEGE DEVICE V
I heresy arlirn under cally ifi,ur Penury ones(me following dedaru,Cu
I❑ (have and will mainWina Certifica¢ol Consent to self-inure for Wader's Cnnspcn- DRAINS-FLOOR.ROOT,AREA.GOND. STORIES TVI'Ii CONS]'RI1C'I'ION
,firm.¢s provided for by Section 37M of the Labor Cede,for the pe formana,of the
for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compcnsnon Insurance,as u,.imd by Seems, STEh1-I INCA OUTLETS APN
3]oOofthelabrn Cabc,mOhc aof the work for whichGAS-[A.SY
this permit is issued. OCC.GROUP
My W.rk von In anon c r and Policy numlrcw'ssD.L/ GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy lacy 111177��((ll!!
CITH ISCATE OF FXEMFI'ION(:NOM WORKERS' GREASIVINDUSTRI.WASTE INTHRCEVTOR
COMPENSATION INSURANCE BUILDING[)]VISION FEES
(Thissunlon need not hccempleted if,hc fiction isformchundreddollum 8INd GREASE'I RAP PLANCHECK FEE
or less.)
Loy any that in the a,..am,su r, work far v.'hicbmis Permit iser,'Cilshall SEWIiN-SANITARY-STORM EA.2(X1 FT. ENERGY FEIi
no employ any pcmnn in any manner xn as m M<ome subject m,he W.dcr:Coml'en-
Z union U.,of Califnmia.Date WATER I IEAFER WIVI:NTBB,ECTR GRADING PEI,
zC) Applicant
y NOTICE 11)APPLICAN I':If,after making this Certified,of Exemption,you.should WATER SYSTEM/TREATING SOILS FEE
became subject to the Worker,Colf,rac Lien provisions of the I alma Code,you muss
{at1 G limhwilh comply with such Pmvi,iuu,c,(his permit short be deemed revoked. WA OR SF,RV ICE
Q PAID
CO.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.14. Dale 'ciplk
UQI hemby affirm dranherc is a construction lendingageney for the Performance of
V. Ihe wad for which this permit is issued(Sec.3(03],Cie C.) TOTAL:
O 1” Lender's Nome TOTAL:
U Lenders Address BUILDINGFEE
L 1 certify that 1 have read this application and some sen the abuse iafornmimm is
IA core LI agrecm"Imply'I'll all city and county ordinances and stem laws relating in QTY. MECHANICAL PERMIT PEE SEISMIC IPE
U 4 building comou,nom.and hereby aori am,,m,cuold1r1 nr this city III calla Too the
abovemero
utioned property Far inspection parposes. 1112 it M I'I'I SSUANCE U ELECTRIC ITH
(We).,me to save,IndemnHy and keep harmless he City of C.,mmn against
liabilities,jm,rdap ,mots and capenss which may in any way accom aemm,wid City AISERORADDTOMECH. PLUMBING FEE
in consequence of he granting of this permit. .(N
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO 10.000 CFM) MECHANICAL FEE GCS
SOURCE REGULATIONS.
AIN HANDLING UNIT(OVER 10,000 CFM) CONS'I'RUCI'ION TAX
Signature in Appllcnd/Comme., Date EXHAUST HOOD(WIDUCT) I HOUSING MITIGATION FEE
IIAZARDOUS MAIPRIALS DISCLOSURE O
Will the applicant or future building occupant store or handle M1ay.Mous material 111?ATING UNIT('TO IIXLlXX11iTU) L
as defined by the Cupertino Monte fide.Chapter 9.12,and the Hcuhh and Safety HEATING UNIT(OVER 100.000 BTU)
Code,Section 2PAID
55J2(up sg/
❑Yes Nu VENTILATION FAN(SINGLE RESID)
Dam umeim x
Will the applicant or future building'ecupant use equipment or devices which BOILER-COMP COUP OR UXI.000 BTU)
mil hamNou,a air nmtamim; as red by the Bay Arca Air Quality Management TOTAL:/a
•District^. BOILER-COME(OVER I(Most 131 U)
❑Yes Na
AIR CONDI]TONER ISSUANCIi DATE
I have rtad the M1 ode.Se nonstick5,2533 arequirements under Chapter h95 of Ihe Cali- /
L,mia Health n Salcey Cale.e 8 Lena 25505,2s my and 25534.1 understand audit'the
mat if the NEN'HISIDE:JTIAI,h1ECI1, SQ.FT
building does not currently M1avca¢wm.that itnmy rtxrymsibiliry mmnify the oecupan, !/
of w mquitemcnm which must be met prior to ismance of a Certificate of(kcupdeY.
Owner or amhoriced.%cant Dare T(YfAI•: ISSUED I3 Y: � �_ ' O
OFFICE