S 1392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pe IT NO
BUILDING DIVISION APPLICATION(PERMIT PLUMBING-MECHANICAL 1392
BUILDING PROJECT IDENPIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
ik 'a I o wt -� C
OWNER'S NAME: rrl�I� PHO=E'. CONT CI'012'S NpMF� ` I LTC NO:
11ft A4 LP- 3 SIC CONTRDLN
ARCHITECf/E (NEER. ^LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EV PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provision,of Chapter 9(commencing JOB DESCRIPTION
Opwith Section](11X1)of Division 3 of the Business and Profnxsions Cade,and my license isRESIDENTIAL
P[RMIT ISSUANCE
C
Ed= a full force and effect. WL ❑KITCHEN REMODEL
aUU License Class LI0.N
IJme ContractorAPPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F zz tai
m¢a ❑MULTI-UNIT ❑STRUCTURAL.
F 7 N ARCHITECT'S DECLARATION PANELS
1 understand my plans shall he used as public records n/� MODIFICATION
OZ�� UP T0200 AMPS i/r11 INTERIOR ❑CHIMNEY REPAIR
F.N., M Licensed Professional 201-IOMAMPS IMPROVEMENT []SWIMMING POOLS
-� OWNER-BIIILDER DECLARATION OVER 1700 AMPS
❑BATH REMODEUREPAIR ❑DEMOLITION
yf�G 1 hereby affirm that i oro exempt from be Corrosion
Cc License Law for the
k O w U I reason.(Section t I L5,Business and Professions Code:An I count ❑OTHP.R
indicant, Y ci y os Y SIGNS eLCC'CRICAL --
W a W y which inquires n permit re conswm,eller,improve,demolish,or repair any stroctum
F�Oa that hoslits cenedprssa pyo the thovisiosotfremchpenninoices Law(shapterl SPECIAL CIRCUIT/MISC.
r that heitcingwiit pursuant tolheprwivisio of the Contractor's License LawlChode)or
0000
(commencing with Section 7000) Division Sof Ne Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
that he is exempl therefrom aW the hasis far the alleged exemption.Any violation of ❑NEW BLDGIADDITION []DEMOLITION
iLLG1 Y• Section7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�.yy not mom than rive hundred dollars($500). IMPROVEMENT
❑❑O ❑ I,as owner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the smucmre marl intended or atfered fa..ale(Sec.7044,Business ❑OTHER
W % and Professions Cale:The Contractor's License Law does not apply to air owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Not such improvements are not intended or offered for NEW RP.SIQ IAL ELECTR SQ Fri.
sale.If,however,the building in,imprnvemenlissold within one year of cnmpletian,the SQ.FT.FLOOR AREA &SQ.EL
ownrobu cler will have the burden of proving that he did not build or improve for pun- pp p '
Pose of sale). TOTAL
f4
❑I,as owner of the property,am exclusively contracting with licensed compactors m TDPAL:
construct the project(Seo.7044,Business and Professions Code:)no Compactor's Li- 20 flltlTD
Orion Law does not apply to an owner ofpropenL G
y who builds or improves thereon, QTY. PERMIT FEE R
who contracts for such projects with a amtmclops)licensed pursuant to the ContraemrMA
's
License Law. PERMIT IS
❑lam exempt under See. ,B&P C far this reason ur FCr,I nsitj
ALTER-DRAIN E WA (EA) VALUATION
Owner Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT
1 hand will
mai under penalty atperjuryone of the following declarations:
❑ Ihave and provided
maintainSection 370 of
Codeinsorohe Wader'sre of the DRAINS-PLOOR,ROOP, P.A.COND. STORIES TYPECONSTRUCTION
soden,as provided far bi Season 770E aF the Labor Code,for the purfnnnance of No
work far which this maintain
is issued FIXTURES-PER TRAP
I have La will maintain he per or Compensation Insurance,h his perm by Section
3700 of the Labor Cade,for the performance of the work lar which this permit is issued. CAS-F.A.SYSTEM-1 INC.4OUTLETS OCC GROUP APN
My WorkPensmian l osis ace wrier and Policy
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(PA)
ERI'IFGATF. F EXEMPTION FROM W ItKERS' GRIiASPIINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(Thlsmelion need not be completed ifthe permit is for one hundreddollarsN100) GREASETRAP
or IecW PLANCHECK FEB
I cenify that in the performance.flhe work forwhich this permit is issued.]shall SEWER-SANITARY-STORM GA.200 FC
not employ any person in any mannfH� esueet)3aX Igect to pCompen- ENERGY FEE
z Cation Lawsof Culifarnio.Date 'Ck L( zl WATER HEATER WIVLNT/F.LECTR
Q Applicant GRADING HE
y NOTICE.TO APPLICANT.If,after making this Certilicaw of Boulder.you should WATER SYSTEMITREATING SOILS FEE
hecome subject to the Worker's Compensation provisions of the Labor Cud,you most
Fy forthwith,imply with such Provisions or this permit shall be deemed rcvaked. WATER SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.Ff. PAID Date Receipt k
U O Iherebyfwhich rat thatPermit I is a construction landing agency for the performance of
Leads work far which this Permit is issued ISce.309'i,Civ.CJ
u'' Lender's Name TOTAL:
LUkI Lender's AenmiryTO'CAIn BUILDING FEE
i cify that I have read this application and spam that the above information is
V7) correct.I egmero comply with all city and amnty commo ce.,andsmm laws plating ,, QTY. MECHANICAL PERMIT FEE SEISMIC AEE
V G building construction.and hereby authorize representatives ofthis city mentarupon the
above-mentioned property far inapecnon purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmleN
ss e City of Cupertino against ELECTRIC GTE
Iia611'nies,judgments,costsand expenses which may inany way no crus acoura aid City ALTER OR ADD TO MECH. PLUMBING PEE
in consequence ofthe gran It or this permit.
APPLIC '01 tSTA A AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURC.I EGI ., fI NS. -
3,�,, AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signe re 'A tic r Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA DOLS MATERIALS DISCLOSURE
Will the applicant or furore bmidiogncupant oureor handle hasardaus nmterial HEATING UNIT(TO 100,000 BTU)
as defined by he Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 1011,000 BTU)
E]Yos ❑No vENy'ILATION FAN(SINGLE R ESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which
\�I emit harurdous air conteminantx as defined by the Bay Area Air Quality ManagHOII HR-
ement COMP(2HP OR 100,000 RTU) TOTAL:
/ District1
❑Yes Elise, BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
panic Health&Safety Co ,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.Er.
outined .nomnr if Pee en aril is my responsibility ton
notify the onpnt
.[them - pact oto issnaoda Certiliwm of Occupancy.
Owner nNorize Dam TOTAL ISSUED BY:
OFFICE