S 1238 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, Pfiff NO. 1238
I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1 2 3 8
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRI ' /� _ SANITARY NO. APPLICATION SUBMITTAL DATE
OWNE ' /f,.,�N /'-,"* 'I tNH: C(l C'fOR'S NA ?: LIC NO: .
n,r/ N NIC CON'IRUL4
ARCHI F /ENC>JNP:R y� /iC NOc ADDRESS: ❑
CONTAC. (T/ .JJ',t' ,PHONE: ,Xy[- BUILDING PERMIT INFO
-0 -3 ❑ Consultant Fees Pail by Applicant(Initial) BLiKi/ ELECT PLUMB 1:1
LICENSED CONTRACTOR'S DECLARATION (I/ QTY ELECTRIC PERMIT FEE LIr�I/ Ilr��
I hereby affirm that I am licensed under pmviaions of Chapter 9(emmmenoias JOB DESCRIPTION
{Q{�00 wim Seclion'I000)nf Divi.rinnJ nflhe Business and Yrofensians Cale,and mylicense is O RESIDENTIAL;
NTIAL;
FW- In full farce and effect. PERMIT ISSUANCE r ❑SFDWL ❑KITCHEN REMODEL
TUU License Class Lic.X APPLIANCES-RISIDIiN LAI. ❑ADDITION ❑PLUMBINGRE-PIPE
E W Dare Contractor
lin 4 ❑MULTI-UNIT []STRUCTURALARCHITECTS DECLARATION
F 7 lin PANELS MODIFICATIONZ p H Z 1 undersand my plans shell be stud as public records
OZ=p UYT0200 AMPS [I INTERIOR El CHIMNEY REPAIR
F ia�~ts Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
r¢� OWNER-BUILDER DECLARATION OVER I(XNIAMPS ❑BATH REMODEUREPAIR El DEMOLITION
yy+4' Q 1 hereby affirm that I am exempt from the Cnntmaha's License Law for the
pe 4 V following reason.15ution 71131.5,Husinco and Padessions Code:Any city ar,munty SIGNS ELECTRICAL. ❑OTHER
LLLL1l a 4 which requires a Permit to construct,alter,improve,dnrnnlish,or repair any structure
prior,.its I....nce,also requires theupplicanl forsuchpenmh to file anignedstamnmnt SPECIAL CIRCUIT/MISC.
9;!(} that he is licensed pursuant to the provisions of to Contractors License Law(Chapter H
W . .commencingwitge,tion]INX))of Division 3 of to Business and Professions Cade)or 'TEMP.METER OR 1431.E I NST.
c.4 cy Ihm he is exempt Iherefmm vad the basis for to alleged exemption.Any violation of ❑N- BCUG/ADDITION ❑DEMOLITION
XMN
Section 7031.5 by any applicantfor a remain subjects the applicant to a civil penalty of POWER DEVICES ENANT E3 FOOD SERVICE
W t more than five hundred dollars($500), IMPROVEMENT
��QElLns owneraf the lin n.mrm em 1.ees with wa cs ur teirssde cons tion,
C t standard
y y p y g pctna SWIMMING POOL ELECTRIC ❑OTHER
call Jn rd work,and the she C n is r not intended omiw do furor apply 1. a Business
6 � and I'nrfexsiom Cade:The Cnnvunm's License Taw Jtps nm apply to an owner of OUTLETS-SWI'TCIIES-FIXTURES
.. pagcny who builds of improves tercsm,and who does such work munwif or through
bis own employees,provided that such improvements are na Imm�ded m.Bared fur NEW RESIOENTIAI.ELECfR SQ FT
sale.i4 however,the huildingor immoverrom isscld within one yum.famnpla, "the SQ.17E FLOOR AREA SISQ.PT
ownerhudder will have the human of paving that he did nor build or improve far par-
pow of sale.).
❑h as owner of the property.am exclusively contracting wit licensed contractors to TOTAL:
consumer me pajecl(Sec.7004,Business and Pafcssi...Caxi In.Conuam.rs Li-
cerulaw d.os rot apply to an owner of),.party who huibu.r improves[hereon.add QTY, PLUMBING PERMIT FEE
who contracts for such Projects with a commcmr(s)licensed personal to the Contractor's
License Law. PERMIT ISSUANCE'
❑ lint examp mah,Sec, ,B&PCfim Ihi,massm -
ALTER-DRAIN&V17N'I'-WATER(EA) VALUAI[ON '
• Owner 1 Date
IO
WORKER'S ader,rCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 SDO
1 handwaffirmanter ,penalty mperjuryoneofthefollowing derkno's or /
❑ IM1ave and will maintain ation 37M of Consent Code,far the Wumna Compen- DRAINS-FLWN,ROOP.AREA,COND. STORIES '1'YPIi CONSTRDCDON
wtiom,as hick this
fur by Section 3]00 of the Labor Code,fur the Perfarmance.f to
work for which tis Faunal is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Instance, h required by Section11
J]INl of the Labor Qmlq for the performuntx of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.40UTLF.TS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy annular are:
Currier: Policy No,: GAS-EA.SYSTEM-OVER 4(EA) u
CERTIFICAI 12 OF EXEMPTION FROM WORKERS' GREASPJINDU53'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need net b;completed if me permit is for one hundred dollars ISI(p) GREASETRAP
art less.) PLANCHECK FEE
I terrify mal inrhe P:Aommnwmfine work for vehi,M1this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner s,as to become subject to the Workers'Compen- ENERGY FEE
O z smion Laws of California.Duce WATER HEATER W/VCNT/ELF.CTR
Applicant GR LNG FEE
GCs lip NOTICE TO APPLICANT':If,after making this Ctraftme of Exemption,yon should WATER SYSTEM/fRi?APING SOILS ITT:
beards,eahject to the Worker's Compensation provisions of Its,labor Code,you must s
Lakl Q lium itheomPly withsuch pawkions.nhispcand,hal Mdecmed revoked. WR'I'ER SERVICE
CL CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET
� � 1� Dal
Receipt X
V 0 (hereby affirm lhanherc is ucovwcd.n lending agency for the performance of at510
V. F' tlhe work
Name far
which tis permit is isvmJ(Sec.399],Civ.C.) vJs� TOTAL:
U landers Address TOTAL: ,
1 certify that 1 hove rtad this application and sate that the above information is JBUILDING FEE;
rA cores.I agree to comply with all city and county ordinances and state laws carries to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize repressmanvesof this city[center uprome SEISMIC FEF,
above-mentioned Faunally lin inspection purposes.
(We)agree to cam
ve,indemnify and keep hunnlesx e(:ity of Cupetmo ugainst PERMIT ISSUANCE ELL'CTRIC LTH
hithililies,judgments,noes and exp,uses which may in any way accrue against wid City ALTER ORADDro MECH.
consequencein of me gaming at[his permit. - PLUMBING 113E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 30.000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of AppllcanVContmetor Data 17XHALJST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant"',vor handle hazardous material H EATI NO UNIT(10101,001 BTU)
as defined by the Cupertino Muca,,al Code,Chaplin 9.12,and the Heath and Safe,,
Code,Section 25532(a)? nF®TING UNIT(OVER motsNI In
El Yes 0 N VENTILATION PAN(SINGLE RESID) PAID
Date Receipt Y
(I
IWill to applicant or future holding oacupmtt use equipment or devices which
emithara .o,aircontamiranteasdefimedbytbe Ray Area Air Quality Mmm91meor BUILER-COMPI3HPOR 1010.0ID13TID Tec,
Dindct? BOILER-COMP(OVER 100,000 BTU)
t_ ❑Yes ON. '
I have read the hazardous materials requirements under Chapter 1.95 of the Cull- AIR CONDITIONER ISSUANCE:DATE
Rance Health&Safety Cale,Sections 25505,2.5533 and 25534.1 t ],.and that if th, NI?W RESIDEN'HAL Ml:Cll, SQ.FI'. Z—
building does not annually have u meant.that it is my resrymdhillty to notify the tccomal _1
of the ramicannams which must be met prior to isuanc of uCnificare of Creature, n
Ownerminitodzed age,. Dam TOTAL: ISSUED
OFFICE