S 0879 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-FJLRC'I'RI CA{. PERMIT NO
IIUIL.UINGUIVISION APPLICATION/1IFRMI'I' rLu,'amnr.".$IbLunNlcAh S o0'7A
NUILDING PROJECT IDEN'1'IF'll'ATION OO II ..77
SANI'T'ARY NO. AI'1'LICAFION SUBMI I'1'At,DAI'13
MING AIIIlRESS:
Ub,,.� Psi; w.A I2r�-�t
S N E: YIIONI3: CONTRACTOR'S NAME: LIC NO: N/C J/J��(�.f�CON'1'ItI
e ` ' Lh ❑ Vv /
111 AR 1"rp .1GZ"ER: LIC NU: ADDRESS:
h
CONTACT: PHONF,: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOT)DESCRIPTION
I hereby affirm that i um licensed under provision.or Chapter 9(commencing
QpZ with Sectionl0finuf Uivisien Jnrme B.,naysand Professinns G,Je.and my licemseis PERMIT ISSUANCE RESIDENTIAL;
cc0In lull force unit effect. ❑SFDWL ❑KITCHEN REMODEL"
U Llccme Class Lica APPLIANCE'S-RIiSIDENTIAL ❑ADDITION ❑PLUMBING RI7.111P3
NZaµa1 ])are Contractor ❑MUCrI-UNfr ❑STRUCTURAL
C ARCHITECTS DECLARATION PANELS MODIFICATION
~HZ I understand my plansshall he used as public records UPT0200AMPS
z C)s3 IiR10R ❑CHIMNEY REPAIR
hzFpj Liccmcd Pafir,, mI 2II-IhB1IAMPS I ROVI3MEN'F DSWIMMING POOLS
s1 f'� OWNER-BUILDER DECLARATION OVER 030AMPS
El BATH RF.MODEIJRF,1'AIR ❑D13MGLITIGN
2:0 C C Q 1 hereby affirm that 1 am exempt from the Curconu is License Law for the ❑OTHER
x31 U ho ovo re.....(Seem ]IRIS,Idmimx,and Pryfcaeion,Codc:Any dtyor county SIGNS ELECTRICAL.
W LL N which rryuires a permit In comfort,alter,improve,demolish.or repair any xwcturc
� pr ort t I.n I me,the applicantf hpc ilt file -b daatemcnt SPECIAL CIRCUI'VMISC.
� T mal licensed pursuant l theprovisions Oh c I Idsl 1 IChapRrl COMMERCIAL
H.C (commencingwthSctin 7")of Division t flh BusinessadP f::ons C-dc)or TEMP.METER OR POLE INST.
H.
N ❑OF IOLLHON
I.,ca that he is exempt th,mfrnm and the hast.,for the alleged exemption.Any violation of
x^m Section 70315 by any applicant I a Permit sobjeas the applicam roe civil penally of POWER DEVICES TNEW HLDG/ADDITIOEN ❑FOOD SERVICE
not more olurtbivecp
hundred dollars 0500)- YEMENI'
F=Q voxnerropcnY.nr mY employees with wages us theirzole comlmnatinn, SWIMMING POOL ELECTRIC THER
F willdothework.and lheetrndurc is nm intended or olfercd Brr,alc(Ser.70i4,Bmincss OUTI 1?I:S-SWI'T'CHES-FI%'Il1RE5
W 3 m and Professinns Colic:The Convenor's License Law docs not apply to an owner of
property who huildx or imp ovc.thereon,and who dims such work himself or through NEW RESIDENTIAL ELECTR SQ Ff.
his own employee.,provided that such improvements am not intended or-ObreJ Tor SQ,17 PI,OU AIi IIA $/SQ.FI�
side.If,howcvcr,thc building-r improvement iesuld within e one yeti of completion.the _ w
wnerbuilder will have the burden of proving that he did am bond,),intpmve lot Pur- ^ r 1
po, ofsaG
le.).
❑1,as owner of the popcny,all,exelmively contracting will,li,c.,d cmnracmrx in
construct the project(Sec.7014,Business and Prnfalsions Come:),he Cialool or'a Li- FEE
ase Law docs not applym unowr,,ur pnc
gny who build,martmwe,them-n,and QTY, PLUMBING PERMIT
who amtrau furarch projects with a intimations)licensed pmsrant In the Contractor"
Lice—Law. PERMIT ISSUANCE
slam exempt and tic. .I1&P C for this rcamn
ALTER-DRAIN,@ VENT-WATER IFA) VALUA I ON
fz Urate
• xner K; pl3NSA'rtON DECIARA'IION BACK FLOW PROfECB DEVICE
it under penaltyat penury oneof the ollowingdcdear m: I
[These
err will manminr Cenificatc of Consenuosvll-inxum for Worker's Compcn- DRAINS-FLOOR.ROOF,ARE A,CON]) S'I'OR]US TYPE CONS I'RUC'1'[ON
saint,as provided lot by Section 3IIX)of the labor Calc,lin the performance of the FIX'IORES-PER'IRAI'
work fur which this permit is issued.
I have and .If maintain Workers Compensation Insurance,as required by Section
3700 of the Lah,rCWe,bathe performance oOM1c work lar which this permit is issued. GAS-EA.SY$'I'13M-I INCA Ol1T1.ET5� D OCC CROUP APN
My Worker's Compensation Insurance calmer and Policy number are: GAS-EA.SYSTEM-OVER 4(EA)
Caricr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERSGREASEIINDUSTRL WASTE 1 IP BUILDING DIVISION FEES
COMPENSATION INSURANCE
(Thisxectioinced nm becompinNifthe Permit is foronehmaireddollars($100) GREASETRAP PLANCHECK FEE
or Ico.)
Toy an,that..the cedormncenr Ncwmklin,abraq this the W isissued,
'CmrSyn- SOWER-SANITARY-STUB .NX)F - ENERGY P1313
not employ any peraono'any manner In va ser become xubjeet m the Workers'C-ml'eo-
Z vlion laws of California.Date N'ATI3R HI3AT13R WIVI3NTftiLEC'1'It GRADING IgHi
ZO Applicant
rq NOTICE TO APPLICANT:IL after making this C'emticate of Exempm-m,you shnulJ WAI'13R SYSO3MiTREATING SOILS FEE
ati become subject rat the Worker's Compensation provisions of the labor Codc,you must
lLl mail.ith comply with such prraymonn or this pernnt shall be dccmcd mvaw.,L WATER SERVICE
OPAID
]z CONSIRUCHON LENDING AGENCY NEW RESIDENTIALPLMB. SQ —Dale14. Rccciptp
Iherebyeffinnlhauharelsaronsamain.lcndingagcncy Tonle perfnnnatecof
V O
the work for which Nix Isatin is issued(Sec.3000.Civ.C.) TOTAL
QH Lenders Name
r W Lenders Addm,, BUILDING FEE
I comfy thre
at I have ad Im,application arta state that the above micur ion m
G
rn correct.I agreeto comply with all city and county ordinances and state laws mining to QTY MECHANICAL PERMIT FEE SEISMIC Ftiii
U building co."nuvaon,and hereby an hmiac rcpresentalives al this citymremcr upon the
nNrve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PCE
(We)agree m ams.indemnify and kap harmlcxs the City,,[Criterion-r8ainn
Iiabildies.judgmena,cu..as and expenses which may in any way accrue against said City ALTER OR ADD TO MECII, PLUMBING FEI3
mxegrencc of the gmming or this permit.
4C,ahr,
PLICANT UND STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'('1010,000 CFM) MECHANICAL FEE
IJRCI RE'U 1 ` :7
AIR HANDLING UNIT(OVIiR I(L(XX)CPMI CONS'1'RUCI'ION TAX
gna o dcimmemr Eric EXHAUST HOLD(WIDUCO HOUSING MITIGATION FIT
�aHAEARDOUS NIAT17RIALS DISCLOSURE
I m,pplmanOmrutumhnlldingantpant M-re.rh:mdlalnnard-nam;mairl HEATING UNIT(IT)It%h1Xg)BTU)
def y the Cupertino Municipal Crde.CM1ap¢r 1.12.and the Hwllh and Safety HEATING UNIT(OVER IIXL(AMI BTU)
Section 255321)^ 1'AIU
❑Yea ❑No VENTILATION FAN(SINGLE RESID) Dam Rccciptp
Will the opplicunt or Faure building cecupem or equipment or Acvices which BOILER-COMP 1911P OR 100.00011IL)
•emit h rermut air con ioniums as defined by the Bay Arta Air Quality Management T(l'rA L:
s
Bistro'? BOILER-COMPtDVER 100j)(X)BI'U)
❑Yes ❑No
AIR CONDITIONER ISSUANCE DATE
have mad the hnuNous ..ro 215 mgriremcnu unde,2553 1 tang rsta 0l the Cali
omnia 11 cahn ou Safety Calc eati ate 25585,2554)and 25534.1 node Land the if he NEW NIiSIDENTIAI.MECH. $U.FT
building Jcexnrn currently hat'eetenantthat it i,my re,pmaihility to moldy the cecupnnl
of the requirvnems which const R met prior to issuance of a C'enificate of Occupancy. 0
flwn authnri�ngcm
DoleISSUED❑Y: SM
OFFICE