S 1021 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C[TY OF CUPERTINO BUILDING-ELECTRICAL. - I'ERMI'I'Nfl.
BUILDING DIVISION APPLICATION/1'RRMIT r1.uMBmc-MEcxpmcAl. S 1021
IIUILDING PROJECT IDENTIFICATION
B RING RESS: t - SANITARY NO, APPLICA'I'I(1N SUIIMI'ITAL DATE
oig�rv�,l - l3 8 ro ria
O 'S NAME: ;1 1 -'O.^ C ORSNA ass �- LIC NO:
U I • NIC CON'fNOl.p
AR HITECDENGINEER: LIC NO: ) SS' Cz f' 5. ❑
CONTACT; PHONE: l BUILDING PERMIT INFO
❑ Consultant Fels Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
0 29-4f1S° ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATIONQTY ELECTRIC PERMIT FEE
I hereby affirm,hat I em licensed under pnrvininne of Chapter 9(commencing JOB DESCRIPTION
CWZ with Section 70(ap of Division 3 ofthe Business and Pm(essions Cede,and my license is RFSID NTIAL:
WOO w PERMIT ISSUANCE.
Fly in full force rode t. ❑SFDWh ❑KITCHEN RIiMODIiI.
IU1("] License _ Lic.N Pew pPPL1ANCRS-RESIDENTIAL ❑ADDITION [I PLUMBING RF.-PIPE:
F Z 41 Date Contractor (Y(.S
na6c. ❑MULTI-DNIT El STRUCTURAL
FOrn ARCHITECTS DECLARATION PANELS
rn Z I tomearand my plmx shall be.1 m public recoNx MODIFICATION
OZ4`- UPTO2OIAMPS E3 INTERIOR ❑CHIMNEY R17PAIR
P41-Hi Licensed Professional 201-IIMAMPS IMPROVEMENT SWIMMING POOIS
g.dx OWNER-BUILDER DECLARATION OVER 1003AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
1 hereby affimt that 1 am exempt teem she Contmmofx License Law for the
xax O y U following....(Sation 7031.5,Business and Profeaxim,Code:Any city or county SIGNS ELECTRICAL
0 4 ❑OTHER
W 3F' which requires a permit to melowl.almq improve,demolish,or repair my nown. - -�
prim to in issuance,also requires the applicant for such perminn file a signed statement SPECIAL CIRCUIT/MISC. f
� } Nat he is licensed
pursuant to the provisions or she Comracmrs License Low(Chapter 9
�IYM (commencing with Section 7000)of Division 3 ofthe Business and Professions Cede)or TEMP.METER OR POLE INSL COMMERCIAL:
a y c
that he is exempt therefrom it the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC m_4.
Section 7031.5 by any applicant for a pcmi
r ,suhjects the applicant in a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SIiRVICE
F-2} not mote than five hundred dollars S500) IMPROVEMENT
C ❑ 1.ssowner o(the property.nr my employees with wages as,hcir axle compensation, SWIMMING POOL ELECTRIC din Y
will do Be work,end the anim
uctme is not enm n
ded06md for sole(Sec.714,Business OTHER
and Professions Code:The Coal...mfs License Low dons net apply to an owner of OUTLETS-SWITCHES-FIXTURES /
property who builds to imprnves,herem.and who does such work himself or through
his own employees,provided that such impiewriu ms art not intended or offered for NEW RESIDENTIAL ELECTR SQ I-N.
sale.If,however.the building or improvement issoW within one year nfcompletion,the $Q.FI'.FLOOR AREA IR.
S/SQ.
caner-builder will have the burden of proving that he did not build or improve for put.
pose of sale.). TOTAL:
❑1,as owner of the p )Ivmy am exclusively contruning with licensed contractors to
construct the project(Sec.7014,Business and Prnlcsainns CIA.:)The Contractor's Li- -
riseLaw does not apply toair owner of property who builds or improves thenen.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with o amntetons)licensed pursuant In the Conmactor's
License Low. PERMIT ISSUANCE p
C Ism exempt under Sec. ,B&P C lire this--""I M
ALTER-DRAIN&VENT-WATER(EA) VALUATION
In
Owner Data 1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEOCT
Iherebyatherounder Cenolty lc perjuryencofthe fnllowing Workertlno
❑Ihave andwillmaintaina Certificate ofConsent to
Labor
Code.cure for
erformaceopthe pRAINS-FLOOR,ROOF,AREA.CONU, yT yp1i CONS'T'RUCTION
worka provided far by Section 37M of the Luhnr Cale,for the performance of the STYNICS
work for which thin permit is issued. FIXTURIiS-I'BR TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code,for the perfotmunce ofthe work for which this pem,it'is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCCGROUP AI'N
My Worker' pytgvptation lnmmnce carrier and Policy nuZn-1--305t-1GAS-EA.SYSTEM-OVER 4(EA)
Cartier; Yt I F+ —Policy Na:
CERTIFICATE OF EXEMPTION FROM WOR KERS' OREAS'UINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This scOtmaneed nm he completed ifthe permit is for(Inc hundred dollars lS IM) GR' AP
or less) PLANCHECK FEE
I cerify,on in the perfonnmceo0he work for which,his permit is issued,l shall EWER ANITARY-STORM EA,200 FT.
not employ any person in any manner so as to become subject m the Workers'Compen. ENERGY FEE
2, sation lows of California.Date WATER HEATER WNENT/ELECfR
zO - GRADING FEEApplicant
h NOTICE TO APPLICANT:IL after taking this Cmificma of Exemp,i...you should WATER S YSTEMOURBATINC
? become subjecno the Workers Cempensatinn provision of the labor Cale,you mus, SOILS FEE
{ta Ir forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTIONLENDINGlending agency
NEW RESIDENTIAL PI-14B. SQ.FT. PAID
LJ for
this .it them
issue (See.30 len ding agency funhe perfnnantt of Dam N
W the work for which this permit is issued(See.JIN)7,Civ,C.)
O U Tinders Name OTAL.
III LendelI Address TOTAL:
y I entity that 1 have read this application anJ antro that the shove informminn is BUILDING Flili
fA C.I.I agreemcooply with allcity and county ordinances and state laws relating'a QTY. MECHANICAL PERMIT FEE SEISMIC FF,E
U z building construction.and hereby amhoriu representatives of this city to enter upon the
r above mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep ham,less,he City of Cupertino against
liabilities.judgments,costs and expenses which may in my way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this panni,.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IJANDLINGUNITTO 10,000CF1,I) MECHANICAL FEE
SOURCE REGULATIONS.
b I (1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
antra nfApplicanVContractor Date 1 RXHAUSTHOOD(W/DUCT) HOUSING MITIGATION ME
HAZARDOUS MATRIVALI DISCLOSURE
Will the applicant or future building orcupatn store or handle haamdous material HEATING UNIT(TO 100,000 BTU)
us deft by the Capers..Municipal Cale,Chapter 9.12,..it the Health and Safety
Cada Seclim 25532(a)7 HEATING UNIT(OVER HIf1."BTU)
❑Yes 0N VENTILATION PAN[SINGLE RFSID) PAID
Date R.Oci,tN
Will the.it llcmt m future building occupant the ti use co Air Qu er Mona which
149 ami,hamrdnus air conmmin.nls as defined by,he Bay Area Ah Quality Management BOILER-COMP(3RP OR IW,IMITI BTI) 'IfaTAI.:
Di,,mel ROILER-COMP(OVER IOg000 BTU)
❑Yn El No
I have mad the hueunlnus mmerialx rmluiremcnts,miler Chupmrfig5 nllhe ddb AIR CONDITION17R ISSUANCE DATE
forme Health&Safmy Cada,Sectinns25505,25593 and 25534.1 nndecstnnd that it(be NEW RESIDENTIAL.MECH. SQ.FT.
building does not c...emly have.Ienunh lhm it is my responsih'dlly In notify llm eecupirm
of the requirements which muni he mat prim to issomcc of a Cenifieum"I Occupancy. IFEE]
Owner or authofred agent Dane TOTAL: ISSUED BY:
is
OFFICE,- �. _- —_Lv^