31003 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'FINO BUILDING-ELECTRICAL PERMIT NO. 1
BUILDING DIVISION APPLICATION/PERMIT PLUMING.MECHANICAL 3'1 O O 3
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRBSS9: m SANITARY NU. APPLICA'TON SUBMITTAL DATE
OWNERI�UI� %LILE� PHsSf_ CONTR 'fOR'SNA �CN�.
a NIC CONTROL,
}RCHITECf/ENGINEHR; LIC NO, ADDRESS ❑
8 / /_0/54 ff Cts
CONTACT: PHONE: BUILDING PERMIT INFO
/' ✓ CJ0, /k l�+- q / F-1ConsultantFees Paid by Applicant(Initial) BLDG IiLECT PLUMB MECII
LICENSED CONT RAC I OR'S DECLARAnON QTY. ELEC'T'RIC PERMIT FEE
I hereby affirm tbm I am licensed uvwom orome
nder prof Chapter 9 tmncing JOB DESCRIPTION
WOZ
WOO) with Sortion](XXBof Divi,km3oOhe Husine.aand ltafnsiom Cafe,ondmy license is RESIDENTIAL:
PERMIT ISSUANCE FLL
in full fame and cftcclp �{ ❑SFDWI. ❑KITCHEN RF.MODEI.
C U F License Class u L�3 Lic.M '
F- U APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
yea Date Ly�1�j ten? C.ca
/'! �s
p.bN ARCHITECT'S IHiCLARA'TI(IN PANELS ❑MULTbUNIT ❑S'TRUCTURAL
Z p m Z1 understand ray plans,hull be u,d as public immst, MODIFICATION
OZ HQ UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
t:LL Licenced Poifconevil 2111-1110AMPS IMPROVEMENT
�yE; OWNER-BUILDER DECLARATION OVER 1000 AMPS [:1 BATH RLMODF.1/ EPAIR [I DEMOLITION
aeC Q I hereby affirm that I am exempt from the Contractors License Use for Ne
a' 1 U followingn.(Section]W L5,13usinesx unit Professions Code:An cit t ❑OTHER All �/.'/1»
uwsn Y Y we county SIGNS ELFiCTRICAh
3 LL h when requires n e.also
re eanss fire tater.improve.deermit t m repair sig any tttunent NFbt/ G//NOOst/S
,F]6p poor it)its issuance,also requires rte applicant for such permitmRleasigawiCatammt SPECIAL CIRCUIT/MISC. —
z'�yQE thm hecticinnsedpursiit)n7 h)Provisions.fiche Contractorsnd Poil,ou(CCude)9
that he is exempts oreffo d and th D asisf r me al Business and Professions Gado)Or TFiMP.METER OR POLE INS'1'. COMMERCIAL:
a W c C
that m i,exempt therefrom and the basis for the allege)exemption.Any l Penalty of El NEW BLDG/ADDITION [I DEMOLITION
knLL Scclinn]03 LS by any applicam fora permit wM1jecu the applicam,oacivil pcnahy of POWER DEVICES
W^m not mora than Five hundred dollars 651H11� ❑TENANT El FOOD SERVVE
F=6 Les owner of the norm In ccs with wa es as their tale rnm tion. SWIMMING POOL ELECTRIC IMPROVIiNEjJT-
❑ pnope ct Y of in Y 6 Pens i KJ�,IMI�CJt.✓L/
will do,hewon%andab The urers oLieccdn Law
sowsred not apply to an.Business ❑OTHER
{mil m and Profusion Care:The sthereContractors Liccns who
saes not apply s if owner of OUTLETS-SWITCYIP.S-FlXTURES
his opropany who mild,p improves thereon,and who rtes wch work himself or through
his awn emplo5'eo,pmvidd Nat ouch impmvemenu am not mandator offered for NEW RESIDENTIAL IiLECI'R SQ FT.
sale.If,however the building or improvement i,sold within one year ofcnmpletion,the SQ,FDJ'L&jP9 5/SQ.FT.
owner-builder will have the burden afproving that he did not build or Improve for par-
prove of salejl
E] 1.us owner of the propcny.am exclusively contracting with licensed amusctom la TOTAL: r GB 27
onstruci the project(Sec.](W4.nosiness and P-m%sious Cadc)The ContraelnI rr a Li RECD
actra Lawlor,not apply to on owncrofpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whocontracts for wchprojects with actomeri fs)licensed pursuant athe Continuities iiiis License Law. PERMIT ISSUANCE CITY Ur Wf E /N I IND
❑1 am exempt under Sec. .B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PRO'1'L'CI'.DEVICE
1 hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Cenilicam of Covent to self-insure for Worker,Campers- DRAINS-FLOOR,ROOF.AREA.COND, STORIES TYPECONSTRUCTION
anion.es provided far by Section 3)W of the Labor Cuba,for the parfurnuence of the
ork far which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compression Insurance,as rest by Section
PW in the Labor Cale,lin the performance of the work for whim this permit is imocd. GAS-EA.SYSTEM.I INC.4 OUTLETS (ICC.GROUP APN
My Workers Camg ,io Insu�trce c!rand Policy number are:
Carical 12ff %Y Fr/11z,1AoImy Na,: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OP EXEMPT ION FROM WORKERS' GRCASE%INWSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IEES
(This section need not N completed ifthe permit is foronchundecddolled,PHWI GREASETRAP
or lcvs.l PLANCHL'CK FEL'
I certify that in the performance fthe work lin which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any Permanner sees in any mannse es to become,subject the Worker:Camper- ENERGY IEE
O Z ,union Love al California.Data WATER HEATER W/VENT'/ELECIR GRADING FEE
Z 0 Applicant
tr .N.. NOTICE TO APPLICANP.If,after making this Cmefic use of Exemption,You should WATER SYSTEM/1'REATING
F > SOILS FE
become subject to the Worker's Compensation provisions of the Labor Code,you must E
forthwith comply with such provisions onhi,permit shall be deemed revoked. WAI'EN SERVICE
aQ
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID ON Recalls Of
UQ IMmhy ulirm Int there iso consmtnion lending agency for the perfamnnceof
the work for whim tris permit is issued(Sec.309].Civ.CJ
C) P:
Lcndds Name��A`�%D TOTAL:
r {j Lender's Address T )
y 1 cenily that 1 have read this application and state that the above information is BUILDING FE
F' V) O..ct.l agree,.comply with all cityand county ndinances moisture lows reining to QTY MECHANICAL PERMIT FEE
V Z building construction,find hereby umharlm representatives of this city to enter upon the SEISMIC fE
anuve-oentioned Progeny for inspection 1.1ocs. PERMIT ISSUANCE
(We)age m rewvc.indemnify and keep harmless the City of Cipmom-gains, ELECTRIC 'CE
Iiabilior,,judgmems.costs and expenses which any in any way acrueamim,said City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBI GtEF.
APPLICANT UNDERST AND WII LY WITH ALI.NON-POINT AIR HANDLING UNIT(TO I0.000 CFM)
h i S MF,CHr ICAL FET:
SOURCE]::U
AIR HANDLING UNIT(OVER 10,06)CPM) CON 'RUCTION 9'AX
Signature. enal moccur
ale / EXHAUST HOOD(WMUCT) HOU ING MITIGATION FEE
HAZARDOUg MATIi A DISCLOSURE
Will the applicant or future building opammore or handle hamNous mammal I I HATING UNIT(To 110).WB B'TUI
as defined by the Cupertino Municipal Calc.Chapter 9.12,and Ne Health and Safety
Code,Section 25592(a)? HRATING UNIT(OVER I W.BtlB BTU)
❑Ycs �No
VENTILATION FAN(SINGLE RESID) PAID D e Receipt
Will the applicant or boort building damparm.,a egnipar.t or devices which
ami,numerous air conerninants as defined by,he 13a1 Arca Air Qu lily libus'ement BOILER-COMP(3HPOR M(NKI BTU) TO L
District? BOILER-COMP(OVER 101,0015 BTU)
❑Ye,
I have madthe Wm msmannalsmyuire uuMer Chaptcr695ofthe CAi- AIR CONDITICONDITIONERIS JANCE DATE
Retain Health&Safely Cede,Sections 25585,25533 sal 25534.1 undcrsund that If the NEW RESIDENTIAL MECH, SQ.ET.
building dceu not curently havcu tan,,,hm i,isnry res msinitym nobly the occupant
of Ne requimmidn whit be tan Prion.' Certificate of Occupancy.
Owner or autho' Use TOTAI.: ISSUED BY:
OFFICE