S 0721 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II.UIIII.DING•ELECTRICAL PERMIT'N(T.
RUILDING DIVISION APPWCATION/PERMIT IHMR NG MECHANICAL. C 1
S 07L2'1
I UILDINC,PROJECT IDENTIFICATION J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMM 1-111 TF.
�O'A7
Unor.
NER'S N C. PHONE: CO ACTORS NAM LIC NO:
' `J— ^4Q Xy 57� NIC CONTROL
• C'ITIiCf/MGINI3ER: LIC NO; O� ADURF.S /1 ,I ❑
47 S. 62�RXfra u
CONTACT: PHONE: BUILDING PBRMI'I'INFO
_N I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
W ❑ ❑ IJ ❑
LICENSED CONTRACTOR'S DECLARATIONQTy ELIXI-TRIC PERMIT FEE
I hereby upon,that 1 am licensed under Provisions ur Chapter 9(commencing JOB DESCRIPTION
O�ZO with SechouV0,00).fDivision 3 ofthe Bodressand Pndewimns Code,andmy license is RESIDENTIAL,
u1 O
Fy� in full farce and diemPERMIT ISSUANC17. ❑SFDWL [I KITCHEN REMODEL
.ZF Lima,,Class Uwc If APPLIANCES-RESIDENTIAL []ADDITION $iT,4ARtIN0.gE-PIPIT
b Z R� Date Contractor
had ❑
ARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURAL.
F=Z I understand my plans shall be used as public recaNs PANELS MODIFICATION
OZ-Q UPTO200AMPS [I INTERIOR []CHIMNEY REPAIR
,F',W Licensed Pmfeeatonal 201-IfM1IlAMPS IMPROVEMENT C]SWIMMING POOLS
F, OWNER-BUILDER DECLARATION
CL,a.1 1 hereby off nn that 1 am exempt from the Cut...es License Law for the OVER 1000 AMT'S ❑BART REMODEUREPAIft DIiMOLITION
Lgtel
y s+ looming retrain.(Section 7031.5,Business and Poifiesoons Code:Any city(it county SIGNS ELECTRICAL ❑OTHER
which requites o permit m can...ac,plant,improve,demolish, ,,repair any swewre
tton
print n its issuance,also requires the applicant for such pcmniuo rile asigmed statement SPECIA I.CIRCA I'I'/M ISG.
ps
but he is Nanoid Fmincon 10 the provisions of the Conuacmrs Liecom Law(Chapter 9
-40 (aamor,sing with Scrlon 901101,(Division3nftha Ruvinocsmtd 11 fesxions Cmde)nr TAMP.METER Olt POLI?INST. COMMERCIAL;
dai5 n pe that he is exempt Therefrom and the basis far the alleged exemption.Any violation or El NEW BLDG/ADDITION ElD DEMOLITION
W:2Section?031.5 by any applicant for a permit subjects the applicant to a civil pevalty of POWER DEVICES 1.01
[_1 TENANT El FOOD S17RVICL
rn more than live hundred dollars($500). IMPROVEMENT
�_< I,as.swoons the norm lopes with wages.,rhetrsole coat mation, SWIMMING POOL ELECfR R`
❑ property. Yet in Y b . ❑OTHER
II do the weak,end the b.Cons is not intended or atw do for ole(Sec.?(/W,Business
and Professions Code:The Commnor's Liana Law tree not apply to an owner of OUTLETS-SWITCIIfS-FIXTUkFS
6 3 property who builds or improves thereon,and who dos such work himself.,through
his own employees,provided that such improvements pre not intended or,Ipered for NEW RESIDENT[At.ELELTR SQ FT.
,.Lt.If,hoesm.the building.,improvement is sold within ane'carofcempletinn,a he T. SISQ.FT.
w
owner-Nildcr will have the bamlen of proving that he did ant build or improve for par-
Is'.ofaale,. TOTAL; EC 0 81997
I,as owner of the pmpol a ors exclusively contracting with licensed enm icato
construct the projml(Sec.7014,Business and Professions Code:)TTe Commctnr's Li-
seLaw does and apply toanowner ofproperty who huild.s or improves thereon.and QTY. PLUMBINCPERMIT EE
who couriers for such projoct,with o conuallod,)licensed purauu u In the Cnmmmors
License Law. PERMIT ISSUANCE
I am cnenmr under Sea .R A,I'C fpr chis reason
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain aCertiftcate of Consent to selrinsure or Workers Comped- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCTION
anon,as provided for by Section 17W of Ne Labor Cale,for rhe perfnrI ce of the
work for which this permit is issued. FIXTURES-PER I RAP
Fl have and will maintain Workers Compensation Immerse.as required by Section
37M ofthu Labor Code.for the performance offs,work(of which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My W.r Cm)P7.�alt ttca,ri<r and Policy.
Carrie yv�.�FEXE Policy FROM
' GAS-EA.SYSTEM WASTE IEA)
CF.RTIPI COMPENSATION
PROM WORKEkS GNEASI'IINDUSTNL WASTF.INTERCEPTOR
COMPENSATION INSURANCIi BUILDING DIVISION FENS
(This smmn need not becomplcrcd if the peril is lir one hundred dollars($100) GRF.ASHTRAP
or IcssJ PLANCHPAK FEE
I moodyrhmt in the performance nfihe weak fm which this permit is ismed,l shall SI?WEll-SANI'1'A BY-STORM F.A.200 FT.
net employ any perm.in any manner so as m hecome nvAlcer m rhe Workers Carmen- ENERGY FEE
z sari,.Lawsnf Culifomiu.Date WATER nEATI3R W/VINT/F.LECTR GRADING HE
�y Applicant '
NOT ICE TO APPLICANT,If,alter making this Cettilicare of Exemption,you should WATER SYS'I'UNIT REA'1'ING
h ^�' become subject to the Workers Com tion f the Labor Cale,you must SOILS FEE
a , pease provisions n
{k1,
forthwith comply with torch provisions or this peril shall he decmcJ revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW BESIDES GAL PCMB, SQ.Ff, PAID
LJ O I hereby aRmn thin them is a construction lending agency f. the perforance of Dale Raepv'
IL F the work for which this pemnit is issued(Sm.3097,Civ.C.)
QU Limiters Name AL.
U lenders Address TOT
1 certify that I have reed chis application and sane that dm above information is BUILDING FEE
VasrerA.,me ro comply with all city and county ordinances and nude laws relating m QTY. MECHANICAL PERMIT FTE SEISMIC Fie
U bei Wing construction.and hereby aatharim representatives of this city to enter upon the
abnv-mentioned property for inspection Purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
linbilities,judgmcnu,mels endexpinum,whichmayinany wayme......tnn said City ALTER OR A DO TO MECH. PLUMBING FEE
in con,,ocna M'the"an"'yOf this per tyro e
APPLICANT UNDL'RST IID"AN ICI 'OMPLY WITH ALL NON-POINT AIR HANDLING UNI' UO 10,000 CFM) MECHANICAL FE
SUUR iREGUI.
14 ��®� AIR HANDLING UNIT(OVER 10,0(10 CFM) CONS'fRUCIONTAX
Signemre\ p,e onlrector O Dade EXHAUST HOOD(WNUCD HOUSING'MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT LTO 100,000 B'1 U)
Will the applicant or future building occupaw
nt store or handle hard.us material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1110,000 BTU)
Code,Section 25532(u)?
❑Yes [I No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt
•
Will the applicant or future building occupant use equipment or devife5 -C
WhICh BOILER OMP(3HP OR 100,000 BTU)emit Invitations air comominanls as defined by the Buy Area Air Quality Management TOTAL: 0 A O
District! BOILER-COMP(OVER 100,W BTU)
❑Yen ON.
AIR CONDIDONER
I havercml the humrdaus materials raryiremaus under Chuprer Q95.f rhe Cali- ISSUANCE DA'Pli
fomite Heelm At Safety Code,Sections 2550.5,25533 and 25534.I undcmund thud if the NEW RESIDENTIAL MUCH SQ.FT. y�AJ q I
huilAing Jces nu currently have a tenant,that it is my rtspannibiddlY at rodfy the nccupam -
,fthe nalmenmmn which muabeme,priorto kmarm nf.Certificate of Occupancy. or �/J
Owner oruathaued agent Dam TOTAL ISSUED BY: .2- !
OFFICE