S 0620 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD.mNC-ELEcrRlcnh 1 F}y�flT NO. 0620
BUILDING DIVISION APPLICATION/PERMIT PLUMNG-MECHANICALPFT
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
3 1411,1 ek q yr 4-m
OWNER'S NAME: y/ PHONE: p CONTRACTOR'S NAME: �Q&JW_S LIC NO:
B�yCr�•� e� ^/1/•T �• 01'X P� -T i, N/C CONTROL
ARCHITECHENGINEER: G_ `L LIC NO:YI ADDRESS: - ❑
11-(2 z 5".f to C A f�i/e
CONTACT: ./ PHONE: BUILDING PERMIT INFO
�U+jy I "� S "� ' �,_ G ❑ Consultant Fees Paid by Applicant(Initial) BLD2 ELECT PLUMB M[c
LICENSED CONTRACTOR'S DECLARATION QTY. ELP.CTI2IC PERMIT FEE
I hereby art,,.mat I an licensedan
der provision,or Chapter 9(commencing JOB DESCRIPTION
RESIDENTIAL
with Section](X1111 of Division 3 of the Business erd 1'mfeasiona Cade,end my licenre is
FIB in full force and effect. �g PERMIT ISSUANCE ❑SFDWL C3 KITCHEN REMODEL
Jul"y}[
[ License Clns _ Liap Gr ppPIJANCES-RESIDENTIAL. [I ADDITION [I PLUMBING RE-PIPE]]
N6 LL Dalc r.'nnlmcn)r
p.7'/+
ARCHITECTPANELS S DECLARATION [IMULTI-UNIT ❑STRUCTURAL
Z O-Z 1 understand my plans shall he usrd ox puM1lic rccOrJa MODIFICATION
OZ—p UI'T02W AMPS El INTERIOR ❑CHIMNEY REPAIR
1=4�JY�ra Licensed Professional - 201-Irm AMT'S I PROVP,MENT SWIMMING POOLS
g a OWNER-BUILDER mDECLARATION - OVER 1000AMP$ i REMODELI +PAIR ❑DEMOLITION
0 I hereby aRrm that 1 em exempt from the Cammemra f:AnyLicense Lew for the
0 6 U following reason.(Seaton]o L&Business and Professions CMe:Any city ns countyre SIGNS ELECTRICAL OTHER
tole F aj O il: ~ which requires a permit re convect titan improve,demolish, file
repair any ttmcturc
prior to its issuance,also requires the applicant for such perosino fileasigned statement SPECIAL CIRCUIT/MISC.
} thathe is licensed pursuant to the provisions ofthe Continuum's License Low(Chapm,9
-s'
(commencing with genion]lMX1)of OivisionJnfthe tlusiness end PnrfessinnsCMe)lir TEMP.METER ORPOLE INST. COMMERCIAL:
L pr a C mat he is exempt therefrom sad the basis for the alleged exemption.Any shuman of NEW BLDG/ADDITION ❑DEMOLITION
Section 71131,5 by any applicant for a Perot subjects the applicant o a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
not more than five hundred doll.,,lS50hf 1 ROVEMENT
Dl,ax owner of the property,nr myempinyees with w�gesntheirsnle compensation, SWIMMING POOL ELECTRIC
O will do the work,and the someone is not intended mothered forwle(Sec.70,14.Business HF.R
6 a m end Profession Code:The Contractor'.,License Law doe.,not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property In builds or improves there..,and who dues such work himwlf or through .•
his awn emplayese,provided that such improvement,arc not intended or offered for NEW RESIDENTIAL.ELECTS SQ
sale.If,however,the buildingorimprovemem is cold within one year ofcomplmion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have me burden of proving that he did not build or improve for put-
,so of sain.).
E]I,as owner of the property,am exclusively contracting with licensed contractors 10 TOTAL: A- � D
onstruct the project(Sec.](144,Business and Prefe winds CMcJ The Commerce,Li-
cence Law does not apply to an owner of pmpryi who builds murance,Iacocca, ad QTY, PLUMBING PERMIT FEE �71�
who contracts for such projects with a connections)licensed moment to the Contractors
License law. PERMITISSUANCE SEP 22 POD
❑limexemptunder Sec. w
,B&PCformiamon
Owner Date ALTER-DRAIN&VENT-WATER(EA) p�_VA��J/1JJJ.}W���7 N
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT DEVICE `fry '
I hereby affirm under penalty of perjury one of the following declaration: �J �/
❑I have and will maintain a Certificate MConsenuo self-insnre for Worker's Compete. DRAINS-FLUOR.ROOF,AREA.COND.
STORES TYPE CONSTRUCTION
motion,as provided for by Section 37M of the Labor Code,for the performance of me
work for which this permit is issued. FIXTURES-PER TRAP
P11hare and will maintain Workers Compensation Insurance,as required by Section
37M of the LaMar Cut l'or the performance ofthe work for which this permit is iswem GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP AI'N
My Worker', pcnsation Insurance carrier and Policy Lyr
S� a¢
Cartier. iL'rE 'GT 1✓O Policy No.: 1!'y;%- GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ORFASEANDUSI'RL WASTE INTERCEPTOR BUILDING DIVISION PE13g
(This section need not W completed Balm permit is foronehundreddollaND W) GRFASET'RAP
nr less) PIANCHECK FEE
I certify that in the isaforrande,ofthe work Tor which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FL
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
saline Lawsof California.Date WATER HEATER WNIWD/ELrCI'R
z Applicant k GRADING ME
NOTICE TO APPLICANT:If,after making this Ccirfle t.of Exemption,you should WATER SYSTEMORRATING
abecome subject to the Workers Compen.,mion provisions of the Labor Code,you must SOILS TEF.
LkI
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RP.SIDENTIAI.PCMB. SQ.Cr. PAID Date Receipt#
thereby amthi that them is ed See.30lending agencyfimhe performance of
W p+ the work for which this permit is issue)(Sec.309],Co.CJ
F' Lender's Name - TOTAL:
{U Lender's Address TOTAL:
1 certify that I have read this application and state mat the eMve infnrmmion is BUILDING FEE
'y cored l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
LIZ building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify mid keep harmless the City of Cupertino against ELECTRIC FEE
li.hilities,judgments,costs and expenses which may in any way acinic against said City ALTER OR ADD TO MECH.
in consequence afthe granting of this permit PLUMBING ITE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0X10 CTM)
SOURCE REGULATIONS, MECHANICAL.FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of AtiplicenlContmmor Dam FXIIAUS'r HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thcepplicant or future Wilding occupant stare m handle b...ahms mammil HEATING UNIT(10 100.000 BTU)
as defused by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CMe,Section 25532(a)'! HEATING UNIT(OVIIR I00,00011TU)
❑Yea -1 No VENHLATION PAN ISINGLE RESID) PAID
Dare Receipt X
Will the applicant or future Wilding mention use equipment or devices which
emit hrmrdou.s air contaminants as definM by the Bay Area Air Quality Management BOILER-COMP OHP OR I10,000 BTU)
TOTAL.:
Dlsmct2 BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nu -
-
Ihave real the h.nlninue mmetiulsrcyuirctmnu under Chapter 6.95 of the Call. CONDITIONER li- - ISSUANCE DATE
forma Health&Safety CMe,Sections 25505,25533 anA 25534.1 understand that it the NEW RESIDENTIAL MECH. SQ,FT.
builddoes nm currently have tenant,that it is my responsibility to notify the occupant
,if virtmcnts which most be tact prior to issuemce'if.Cmilicale of Occupancy.
—2 Z
Ow or euthorizcd egem Date TOTAL.: ISSUEDBY:
lose
OFFICE'