S 0315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BuiTHING.ELECTRICAL PI MIT NO.
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING.ME: HANICAL 0315
BUILDING PROJECT IDENTIFICATION'
SANITARY NO. APPLICATION SOILMI'I DU.DATI
BUILDING AUIJRLSS:
OWNER'S NA' PIIDNE CONTRACTORS NAME: LIC NO:
NIC COhTRUI.M
�A . I1iNGINEER: IC NO: ADORES ❑
CONTACT: PDONE0T3 .Y71 BUILDING PERMIT INFO
❑
Consultant Fces Paid by Applicant(Initial) BLDG ;LEc'r PLu n MI CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Nat I am licensed under pro,fsi.m of Chapmr 9(commencing
WpZ with Swtinn"I(Mp)af Divmsion 3.fthc HusinczvnJ P'nfcs,i.ns Colc.andmrlicenmi, RFSID NTIAL:
CPI_ in lull fomcvndc t G/ PERMIT'ISSUANCE QSPDWI. ❑KIT CHEN REMODEL
cc_, I,iccnst Closx C�1.icN AYI'hIANCIiS_RESNEN'1'IAh ❑ADDITION DPLUMBINGRF PIPE
tF�W Date Contrucmr ❑MULTI-UNIT ❑STRUC'ILRN.
ARCHITECTS DECLARATION
PANELS
f— MODIFICATION Z 1 understand my plans shall be used as public owned,OZ�� UPT0200AMPS ❑INTIiRIOR ❑CHIMNI:Y REPAIR
F 4tw Liwnsed Pmficoionol 201-100IAMPS IMPROVEMENT E)SWBMMINGPGOI.S
6 .� OWNER-BUILDER DECLARA'T'ION
OVER IIXXIAMPS ❑BA)'H kFy(iFIF 'P IRM l
C Q' I hereby alBnn that I am exempt from the Contrucmr s Livcnse Lax'for the kr[
G O y U Wl ecu (Scot..7031.5,Business unci Prof,wo,Cole:Any city or cot I, SIGNS ELECTRICAI. ❑(YTIIh;R � w
[+x13 W which requires a parent m eonxuur,alter,improve,demolish,or repair any structure
F 4'Oy prior In its issuance.also reaches the applicant for such fiction to rile a.cigned.mmmem SPECIAL Cl RCUIT/MISC.
S Y that he is licensed pursuant to the provisions of the Contractors,license Co.(Chapter 9 COMMERCIAL
: '
�yp0 (commencing with Section of Division 3 of the Business.and Professions Colc)or TEMP.METER OR POLE INS'r. 01
P.a oC Nm he is exempt therefrom and the hast,for the alleged exemption.Any vialrion of ❑NEW BLDG/ADDITION ❑DEMOLI'T'ION
W^N Section 7031.5 by any rMlicam for a permit subjects the applicant to a civil penalty of POWER DEVICES [I TENANT FOOD SERVICE
nm more than rive hundred dollars 13500. IMPROVEMENT
ODI,cruse...of Ncpngxnyormy anployws with wvgcs use theirmlecompcnmdon, SWIMMING POOL ELECTRIC
Yf o
will do the work,unci the snadure is mu mtended ornffcmd lin sale Sec.A".Bm'incs ❑O'TI{I?k
L3 w and Hofes,inrn Code:ThrContrctirtx License Law dons not apply m en owner of OU)'L1?IN—SWITCHES—FIX'IURCS
property who NmId.or improv e,thereon,and who does such work himself.,thomgh NEW RGS IDIiNTIAL ELECIR
his own employees,provided thin such imp,nvcencros art no,intended or offered for SAFT.FLOOR AREA ASQ.17..
svle.If.however.the buildingoriing-outem isaid widimueywnfcon,letion.the Ipxl D
,-builder will have the burden of proving that he did not build or improve fill pur-
1 pose of sale.). TOTAL:
L us owner ol'ihe prnpcny,am exduxivcly cohou,jo,with Iiecn,cd contrvrms en Drill^[
con tmeL the pmjcct(Sec.700 1.Business and Profcxsinns Club:)The Comonlor's I.i UG Rril
•
cense Law docs not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT PEE R[{/
whocomracts for such pmjcct with a comr etorp)licensed pummat to the Contractor, Cir
LicenLaw. PERMIT ISSUANCE
se Uf "UrdsI ANO
❑1 am exempt amts,Sec. .B&P C for this mama
ALTIiR—DRAIN&VENT—WATER IPA) VALUATION
Owner Duce
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(YfECT.DEVICE
• Iherehy allirntnoJee penalty ofperp,one of the following declarations:
❑ I have and will maintain a Cenificmc of Consent to self-insum for Worker s Compcm DRAINS—R.00R,ROOP,ARIiA,C(IND, STORIES TYPE CONSTRUCT,
satin,as provided for by Section 301)of the Labor Cole,for the performance of the
k for which Nis permit is iszueJ. FI%TURES—I'[R t'kAP
I have anti will maintain Workers Conticnsation Inmrnw,us required by Swoon
Xlnf the LtM,rQNe.fnr the perinnnuncc of the work far which this permit iv ix,ued GAS—IiA.SYS'TEM-I INC.q(Il1TLFT5 DEC.GROUP APN
My Wnrkc Coiq mxotian '•terrier snit Policy. M1c
y nsnnmo Y ,(� t
Cnrricr:fl./ �.g L1'olicy No.^�ly�/�w� GAS-1?A.SYSTEM-OVHft 411iA1
CIiRTIFICATE( 'F.XIiMITION FROM WORKIiRS' GREASIIINDUSTRL WAS'Oi IN'I IiHC[ITOft
' COMPIiNSA'TION INSURANCE BUILDING DIVISION PENS
(This section aced not lc<nmplatcJ iftbc permit is l.r nnc bundred Jolla.(511X11 GREASC'TRAP PLANCHECK FEE
or lard
I ccnifY ohm in the performanec of the walk(.,which this permit is izsued.l shall SF,WEk—SANITARY—STORM IiA.?(XI FT. ENERGY THE
not employ any pennn in any manner,n as m Meatus subject m the WorAen'G,mpcm
Q z ration Laws ill Culilinnia.Dam WATIik HEAT Iik WNEN'I'/IiLELTN GRADING FEE
7 O A,Bit.
m
G NITI'ICE'DO APPLICANT:If,a0er making this Cenilicam of Exemption,you should WATER SYS'I'EMOETATINC, SOILS FN
aFw ? become a.bjc,,to the workers Comlcns pion provisions of the Labors Code,you must
fonhwiNcomPly wish,mch provisions or this permit shall be deemed invoked. WATERSERVICE
7 (]z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALYLMB. SQ.Ft. PAID Date Rcaiptp
UQ I forwhihthi Nm thereisawnslmetl3097.Cing Creasy for Ncperformanceof
W Nc sand:for which this Permit is Issued(See 3097.Cil CJ TO'IAI.:
O F" lander',Name TOTAL:
r LU61 Lender's Address EMECHANICAL
FEE
1 I unify that 1 have real this application and ante that he move information is
F' tAt evolect.I.,me to comply with all city and county ordinances and slaw lawn relating to QTY. MECHANICAL PERMIT FEE EE
U z building construction.and hereby authorim rcpresentmives of this city m enter upon the
three mentioned prnpcny for hiri,m ino pmlcus. PERMIT ISSUANCE: FEE
(We)agree m save,indemnity and keep harmless the C'ny of Cupertino inguina
lianilitics,judgment.cost and expenses which may in any wxyacemeageina,ed City ALTER OR ADD TO MECH. FEE
in consequence ill the granting of this per nit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TIO 111.10X1 CFM) FEE
SOIArtCE R[GOA,TIONS. y
V"^'- AIR HANDLING UNIT(OVER If"CPM) CONS'rRULT10N TAX
Signawre of ApplicenV omrnps
Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HA.ARIZII MATI3RIALS DISCLOSURE.
Will the upplicamor fume bondingoccupant stare or handle mi,milous mammal BEATING UNIT(TO 1000m BTU)
es defined by the Cupertino Mnnkipal Code,Chapter 9,12,and he Hcallh unit Safety HEATING UNIT(OVER I(XAIXXI B'I'U)
Cow.Section 25532(a)'!
E3 Yes No VENTILATION PAN(SINGLE RFSID) PAID
Dam Rccci,h#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP OTIP OR 11X1.11(1 BTU)
WOomit hmNnus air contaminants as Jcfned M1y the Bay Area Air Quality Management TOTAL:
District? BOILER—COME(OVER 100,10OBTU)
[:I YO, 0N /
NR CONEA I DINER ISSUANCE'DATE
1 have read the hazardous
Se tionmaterials 5,2553 cat.under255. 1 and rsta of the it the
Bmtia HwIN&Safety Code Sermons 25505,2s my s sho iii 1 to understand that if the NEW ftl!SIDIiNTIAL MECH. SQ.17.
l currently have amwnAthat.is my Cirtifcate of
the wcurym
n( e r yuimncnt which must M tact,cion.issuance of a Canirwra.race ancY.
U 'n rxuthn rrla n Date TOTAL: ISSUED 13Y
OFFICE