S0001 B0140 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECERFCALPERMITI'Q.V 14 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOO111 TL/,
BUILDING PROJECT IDENTIFICATION
BUI DINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
00lA At. C 1550' R6 — 23 '9119
OWNER'S NAME: PHONE: )"A )RME: �-'g ICNOy� N/C CONTROL#
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ARCHITECTIENGINEER; LIC NO: D iSS: „4 �r�� ILL ❑
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CONI'ACt': PfIONE: BUILDING PERMIT INFO
n ❑ Cansultant Essex Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
- isIZ
LICENSED CONTRACTOR'S DECLARATION QTy, ELECTRIC PERMIT FEE u/
I hereby offirm Nal I rem licensed under provisions of Chapter 9(commencing JOB DESCRI ION
�,m0p with Section]800)af Divi`i`aoeBusiness aaJ Professions Code.wed my license is PERMIT ISSUANCE Q RESIDENTIAL;
�F fullonerrind effe _7J IT(ITC7Sq'x ❑SFDWL ❑KITCHEN REMODEL.
aUV Liana Class Lic.# APPLIANCPS—RESIDENTIAL []ADDITION [I PLUMBING RE.-PIPE
F'7yy W Dam Cmd actur ys�f�
y¢6 e#�sr [I MULTI-UNIT []STRUCTURAL
ARCHITECTS DECLA A'
f D y PANELS MODIFICATION
I understand my plans shell be aed arecords
public cards
CZ�C , UP T0200 AMPS ❑INTERIOR EI CHIMNEY REPAIR
Licensed Professional 301-10100AMPS IMPROVEMENT SWIMMING POOLS
••1 OWNER-HUILDER DECLARATION OVER IGM AMPS ❑BATH REMODEUREPAIR DEMOLITION
<.I I hereby affirm that I am exempt from the Contractor's License Law for the ❑OTHER
,fid y s+ fallowing Mason.(Section 7831.5,Business and Professions CWe:Any city or county SIGNS ELECTRICAL ^ �a
u1'3 W h which rtme
its issuance,
e a permit ac consumer,aheq nt for
h permdemoliit t or repair ed swment
O� poor to met no
sliensed pursuant
arequites previsions at for Commmmitaofile a nse signed em SPECIAL CIRCUIT/MISC. 'rl
pppq�y Nat ha is licensed purnuanuntha jsrovixi,,nx of the Controetnr's License Low(Chapter /
aQO (commencing with Section]O80)of Division 3ofthe Business and Professions Code)oI TEMP.METER OR PO 'INST. COMMERCIAL;
6 y M M that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Sul1 N
Section 7031.5 by any applicantfar.permitsubjece.the applicant,,is civil penally of POWER Up 'S EI TENANT ❑FOOD SERVICE
of more than five hundred dollars($500). IMPROVEMENT
=Q 01,us owner ofthe pol,rat,army employees with wages as their sole compensation, SWIMMING ECTRIC
will do the work.ond the structure is not intended oroDbred far to Scc.7044,Business 71 OTHER
and Professions Code:The Commences License Law does not apply to on owner of OUTLETS—SWITCH ' I TU ES
LLL property who builds or improves thereon,and who dues such work himself or through
his own employees,provided that such improvements are not intended nr offered for NEW RESIDENTIAL ELE SQ FT
sole.IL however,the building cur improvement is sold within one yew of completion,the SQ.PC FLOOR AREA $/SQ.FT.
ter-builder will have the burden of power,that he did net Wild or improve for par-
p of sale.). D
TU'
L:
❑I,as owner of the property,am exclusively contracting with licensed corrosion to
o...tract the project(Sec.7844,Business and Professions Code:)The Cram acon s Li-
censeLawdoes and apply toAm am r of poi who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjats with a cuneastra s)licensed pursuanto the Coutmcmrs
License Law. PERMIT ISSUANCE ro
❑ 1 oro exempt under Sce, .B&P C far this mason
ALTER—BRAIN&VENT—WATER(EA) 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 a Certificate of Consent to self-moure for Workers Compen. DRAINS—FLOOR.ROOF,AREA, OND. STORIES TYPE CONSTRUC7101
sation,as Provided for by Section 3]00 of the Labor Code,for the performance of the
work for which this permit is issue). FIXTURES—PER TRAP
If"have and will maintain Workers Compensation Insurance,as required by Section
)of Ne labor Code.for the perfomence of the weak for which this pemtii is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wurkf _Cam ersalimi Inns'���yj,!RL[[L ccorierand Policpry pimb yrs}/le qct d/_ GAS—EA,SYSTEM OVER 4(EA)
Cartier. __.Ga $ L�MM-PI lNFR l(.�xi'rO�LyGT
C AAp PE ION FROM WORKERS' GREASEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becompleted ifthe Permit is foram,hundred dollars($100) GREASETRAP NdT
nr less.) P H -Vc""
I candy that in the performance ofthe work forwhich this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to Weems,subject o the Workers'Compen- IENERGY FEE
,sZ sation Laws of California.Dam WATER HEATER WNE.NWELEC R
7�Q Applicant I ftUAN(2
MbU
q .~N. NOT ICE TO APPLICANT If,after.,.king this Certificate of Exemption,you should WATER SYSTENUTREATING -tE
F become subject the Worker's Compensation provisions of Ne"am Code.you must 357-FEE
forthwith comply with such provisions or this permit shall W deemed eevoked, WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)0 1 hereby affirm that ix a construction lending agency for the performance of Dam ptp
{1a F the work for which this#malt is issued(Sec.3097,Ci,C.)
Q U Lenders Nome _ TOTAL
Leader's Address AI"'
I certify that 1 have read this application and,tote Ill., he offset,
information is BUILDING FEL
(A7 comeLI.,me um comply with al)city.nd county milmome.,and stare 1-11 Mining in QTY. MECHANICAL.PERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon the ELECTRIC
PEE
G
.base incidental property for inspection purpoeea. PERMIT ISSUANCE LF.CIRIC FEE Q
(We)agree 1.ave,indemnify end keep hatmleu the City of Cupertino against
liuhilitiee,judgmrnu,coxa and expenses which moy in any wayaccme'rubstuid City ALTER OR ADD TO MECH. PLUMBING FEE fD
nnsequence of the gmnting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT TO 10,088 CFM) MECHANICALFEE 0
SGURCE REGULATIONS.
AIR HANDLING UNIT(OVER Iq(NOCPM) CONSTRUCTIONTAX
Si,noturcef Applicart/Comimem, Date E%HAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant same or handle hazardous material HEATING UNIT(TO 100,080 BTU)
12
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safdy
Code,Section 25532(0)1 HEATING UNIT(OVER 100,008 BTU)
Cl Yes No VENTILATION FAN(SINGLE.RESID) PAID Date Receipt#
Will the applicant or future building acupunt use equipment or devices which BOILER—COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOT
District? / BOILER—COM P(OVER 100,001)BTU)[]
TU) a
❑Yes 3th
I have read the hazstJaus materials requiremerm under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fames Health&Safety Cade,Sections 25505,25533 and 25534.1 undersand that if the 0' NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that it is my responsibility to unity thmccupot V !%
,,f the rtq rents which must M p no iu ore of a Certificate Oceu /
Owner or an
odzN agent Da AISSUED BY: i 3 f/fl
OFFICE