S 0498 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL IT NO, O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 9`.7
498
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
O R'S NAME: P CONTRACTOR'S NAM(?: LIC NO:
NIC CONTROL x
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
bA1C Nib 331 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
iSk ❑ ❑ ❑
LICENSED ONTRACPOR'S DECLARATION QTY ELECTRIC PERMIT FEE
MWZI hereby aRrm the,I am IicusW under parrebb o of Chapter 9(commencing JOB DESCRIPTION
wo, with Section 10001MDivision 3oflhe Businessland Pofeselma Ccde,and.1 house is RESIDENTIAL:
WOO PERMIT ISSUANCE;
!- "� infullforce.Class dcRcct. ❑SFDWL ❑KITCHEN REMODEL
�U Date Class _ Contract
APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
W Date Cammcmr
ARCHITEC'S DECLARATION PANELS "' _ ❑MULT6UNIT ❑STRUM URAL
1 understand my plus shall be used as public retools MODII7CATION
ZOZ-,O UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-�I:ul Licensed Professional 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER IODIIAMI'S ❑BATH RE DF.IJRF, F.MO06 1W LITI N
yy tga� 1 hereby affirm that I am exempt from the Contmerors License Law for the
pe O6 U following maven.(Section 7031.5,Business and Professions Cole:Any city or county SIGNS ELECTRICAL. ❑OTHER
LLLL1l O�j which requires a permit to construct,alter,improve,demolish,or repair any structure
m prior to its issuance,also requires the applicant formch permit to rile a signed statement SPECIAL CIRCA I'T/MISC.
Y that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9
<£ (commencin COMMERCIAL:
g with Serono and of Division the
theessution.Any vi Code) TEMP.METER OR POLE(NST.
d q e C that i is exempt therefrom end Nc basis far the ce,Ilalleged exemption.Any violation of ❑NEW BLDG/ADDITION CI DEMOLITION
it LL. Sectio///]W LS by any epplicam fore permit subjats the epplicam wacivil penehy of POWER DEVICEti [I TENANT -❑FOOD SI?RVICE
Y nal p(re Nu Bve hundred dollars($50% IMPROVEMENT
6 �1 ownar ofthe pmpeny,or my employees with wages as their sale compensation,. SWIMMINGPIXIL ELECTRI
5p will do the wmk,and the saunme isnotOtendedoroffered for sate(See 7044,Business ❑OTHER
send Professions Core:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-PIXTU
property who holds or improves thereon,and who does such work himself or through
his own employees,provided that such impovemems are not intended or offered fm NHW RESIDENTIAL EI.
sale
.l howese¢Nohuikbr'or improvement is sold within one year ofcompletion,the SQ.PC FLOOR AREA $/SQ.FT.
builder will have the burden of posing that he did not build or improve for pur.
of sate.). PAID
ow 1,as ow lar of Nc properly,am eadu,ivelY cnmrvctin8 with licensed contr4cmrs m TA ,
ttmstmn Ne pmj ss and Professions CaleO The Cnnuacrar's Li - -
censeLawd nt apply-__nwam properlywha bvildi or imprbvcs the...sed QTY. PLUMBING PERMIT 'E 'SEP 18
who eon IsG rlwts with ueo Nnemr(s)licrosed pursuant to the Contractor's
Licen, a PERMIT ISSUANCE'. 7�
❑1 toexempt under .B&P C for Nis mason rj'TM
ALTER-DRAIN&VENT-WATER IEA)
O lar Doe
ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LOP
I hereby aRr under penalty of perjury one of the following declarations:
❑Lhasa and will lnainaCenificateof Cansenttoself-insurefor Worker's Compen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
tion,as provided for by Section 370 of the Labor Code,for the psrfnmmnce of the
'nr which this permit is issued. FIXTURES-PER TRAP
(affil have and will maintain Worker's Compensation Insurance,as rc,uircd by Section
3700.fNelnMr Code,,jj.r robe perfotmatlpe o(Ne work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OIITLETs OCC.GROUP APN
My Wr sGrmp a7Mn su anis Policy number am: GAS-EA.SYSTI?M-OVER 4(EA)
Cartier a��'csss y No.:
ILCFiY'Cf :OF EXEMIT
IN' PROM WORKERS' GREASMNDUSTRL WASTEINTERCEPfOR
PFVn!'f OMPENSAGON INSURANCE IUILDIN (VISION IT S
(This metica.milnm be completed iDhepum,is forma hundreddollars(Elan) GREASETRAP
or Icss) PLANCHECK THE
I certify that in the perfrmmeroflhe work for which this permit is issued,)shall SEWER-SANITARY-STORM F.A.200 Ff..
Out employ any person in any manner so as to become subject to the Workers'Compen- ENERGY PEI?
z sun.Laws of California.Date WATER HEATER WNI?NT/ELECIR
2 Applicut I GRADING F
N NOTICE TO APPLICANL If. for making this Certificate of Exemption,you should WATER SYSTI?MURF.ATING SOILS
become subjecnn the Workers Compensation provisions of the Labor Code,you must
Lkatl �+ forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
V Iherehy uffinn Nenhere iseconswclinn lending agencyfnr theperfmmanceof am Receipt
ps the work for which this Permit is issued(Sec.3191.Cih,C.)
O(.1Lenders Name
Luders Address TOTAL:
0.1 I cavity that I have read Nis application and seem that the above information is B .
y cancer.I agree m comply with all cityvnd runty ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V 7 building conmremirn,and hereby authorize representatives ofthis city teemerupon dueSF.1. IC IEE
shove-mentioned property for flawed perryvscs, PERMIT ISSUANCE
(We)agree and keep harmless the Chy of Cupertino against P.I, CTNIC F'
livbilities' rid expert which may in any way name ugainn raid City ALTER OR AUU TO MECH.
r,IC
I' MUING F. a
AUNDF.RSTA S AND ICI.COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM(GULATIONS M ItANICAL FLiIi
9_16_w- AIR HANDLING UNIT(OVER to,11 )CFM) co .TRUCTIONTAX
Signature o vdUCom
mmer Date EXHAUST HOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSUREIIOUSI MIl'ICATION PEE
Will the app'cant or future building Occupant score or handle haradnus material HEATING UNIT(10 100,000 BTU)
as definal by the Cupertino Munlcop Crude,Chapter 9.12,and the Health and Safety
Code.Section 235: x77 HEATING UNIT(OVER 100.000 BTU)
[I Yet VENTILATION PAN SINGLE RESID) PAID
Dat Receipt x
LWill the applicant orinfuture bui a by'the B use equipment Of devices which
t hazardous air contaminants od nW hy'Ne Bey Area Air Quality Management BOILER-COMP(3HP OR 100,0011 NTD) TOTAL:
Disaicl2 BOILER-COMP(OVER 100,"BTU)
❑Yes
1RWctw to us materials rcquiren¢nts under Chapter 6,95 oftbe Cali- AIR CONDITIONRR ISSUANCE DATE
f m Saba,Gone, rations 25505,25533 mad 25534.1 undersmrd Nat if the NEW RESIDENTIAL MECH. SQ.FT.
U mgdas no urrentlYh eamwm,Nm it is mY reapnnsihilitymnaifY Ncompvnt
of them{bireme ,whit ust be met'iano i's uanceof aC ileac lOcsw>f
rived agent Date Torn).: ISSUED BY:
OFFICE