S 0746 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE5U NO. 0746��w
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MF.CIIANICAL �`7 I6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. . APPLICATION SUBMITTAL DATE'
oyc7 2
OWN911'.NAME t I PHONE: CO 'SN E
N/CII CO fROL#
s• Aµ HITECTIENGINEAW
LIC NO: AD !SY I--LJ
w s
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUNIB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEh:
1 hereby vffrm that I Am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 7000)of Division 3 ofthe Business endP kssi.ns Cade,end my license is R -ID NTIA
F O= i.full farce u.dc�s L - PERMIT ISSUANCE
SSE- C-2- ❑SFDW'L El KITCHEN REMODEL
<—U License Cln. LIC.N APPLIANCFS-
fI"i�66 Date Contract", kESIDENTIAL ❑ DI
ADTION El PLUMBING RF,-PIPE
F,7rn ` AR ITECPS DE LARATION PANELS ❑MULTI-UNIT ❑$TkUCTURAI.
ZOtt2Z Iu land my an al c uhlic recdx DIPICATION
m
OZ—� uP TO 2(XIAMPS ❑INTERIOk HIMNEY REPAIR
rlicenser ocssio.n 201-IIXXIAMPS IMPROVEMENT mS 1MING POOLS
Oat I am exempt ifr mDECLARATION OVER 1000 AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
py. I hereby.(Toro that 11. exempt from the Contractor's Licensee city
o for the
jtj 3 t F following reuutn(Section]1onstr t,Altai,
and improve.
demolish,
Corte:Any city err arlmy SIGNS ELECTRICAL. El MITER
O which its issuance,
s u n permit us construct,the,aper,i t for such
h permit t or repair any stmmurc
prior he isl,cA,eegvlsarequircrmoatpplinnn for C.Onmemrs License Law(Chapter
em SPECIAL CIRCIID'/MISC.
�y Shot he is alae,sedtSectinn ENofDlelonsnDho eBmiw,'andenseluw(Ohore).,
g000enanmumingwith Section i Ithe basis for heidleed essund Pn.Anyonsctim or TEMP.METER OR POLI:INti'I', w COMMERCIAL,
d W C Shut Section
Ix 31 5In tberofrom and the en I'nr the e,fli J excro,applicant
to Any vlpenalty of ❑NEW BLDG/ADDITION ❑DEMFew s TION
Rvi
W^y A., I' than
five
Any upplicum for a 00). sunjecw Sha nppliwnno a civil penalty of POWER DEVICES
nnS more than five hundrnl Jnllum(ESIXO. ❑TENANT El Few SIiRVICIi
6 IMPROVEMENT
❑ Lasowner oftbe properly,or my employers with wages as their sole compensation, SWIMMING POOL ELECTRIC
O El OTHER
will do the work,and the ntructum is not intended oroffarcd forwla tSec.71A,L Business
Gand Professions Codv.Tm Contractor's License Law does not apply to an owner of OU'1'LITS-SWITCHES-PIXT11121iS
r property who builds or improves Ihemon,and who does such work himself or thmugb
his own employees,pmvideJ that such improvements am not intended or offered for NEW RESIDENTIAL MEM R SQ n
sale.IL however.IhchuildingorimpowermAl is sold within oneyearofcompletion,the SQ.FT.FLOOR AREA VsQ.FU
owner-builder will have She burden of proving that he did not build or improve for pur-
poseof sMe.). ,
[]1.mowneroffla,property.Am exclusively cnntmeting with licensed comorcrorsm TOTAL:
construct the project(So,7014E Business amt professions Code:)The Caron rs Li-
cense Law do,%not apply to an owner ofpsousarly who builds or improves fluman.and QTY PLUMBING PERMIT FEE DECD[p
who contracts for such projects with a convonor(s)licensed pursuant to the Comocmh X11177 b RC{I
License Low. PERMIT ISSUANCE
❑1 am exempt under See. .B&P C for this reason t
Owner Data ALTER-DRAINAt VP.NT-WATER(EA) L T
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby AM=under penalty of perjury one of the following declarations:
I have and will maintain a Cenifcam of Consent to self-insure for Workers Camper- DRAINS-FLOOR,RODE,AREA,COND. STORIES TYPE CONSTRUCTION
amino,m provided for by Section 3700of the LAW,Cole,for the ,(...a of am
work for which this permit is issued FIXTURES-PER TRAP
❑I have And will maintain Workers Compensation Insurance,as required by Section
3700ofthe La rCOxlq for he perl; server
,meof the workfoyrrywEhiichhtthhiis permit is issued GAS-EA.SYSTIiM-I INC.40UTLRfS OCC.GROUP APN
C�Worke s s tin slytcrE me and Policy
Policy N., (1 L/'��IJ-silkGAS-ITA,SYSUBO.OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This amlimi need not he completed ifthcpenau is Im..a hundred dollars($100) GREASETRAP
err less.) PLANCHECK FEE
I ceni fy dual in the performanco of the work for which this permit is issued,l shall SEWER-SANITARY-S'TORM IIA.2(X11'1'.
not employ any person Lt any ntu mer ser as m hccome subject m the Workers'Compen- ENERGY FEE
,7, satin.Lawsaf California.Dam WATER HEATERW/VENT/HLEC'I'R
O Applicant I GRADING FEE
y NOTICE TO APPLICANT:11 alier making this Cerullo,of Exemption,you should WATER SYSTUbVTRH FIND
a become subject to the Worker's Compensall.n provisions of the Labor Cole,you must SOILS FEE.
forthwith comply with such provi.sionsor this permit shall be deemed revoked. WATER SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.Ff. PAID
L) 0 (herehy off nn that Sparc Tse conmm,Iinn lenJin6 agency for Ne performance of A caeiptp
the work for which this permit is Issued(See.3097,Civ.C.)
Ia. Lenders Name TOTAL:
L) lenders Address TOTAL:
yI certify that I have read this application and sram that the above information is BUILDING FEE
1A covert.l.gree m comply with It dty and county ordinances and nam laws mlmingto QTY. MECHANICAL PERMIT FEE
L) Z building cnnnrndion.and hertby uuthorive r,nesenmtives uTthis city m enterupon the SEISMICM
r alcove"mentioned pr.pery for inspection puyssscs. PERMIT ISSUANCE.
(WA)Agree to save,indemnify and keep harmless fie City of Cupertino against F.LF.CfRIC
liabilities,judgmem cAs and expenses which may in Any way nceme Against said CnY pI TER OR ADD'1'O MECH.
mnmyuence of egramiag of this permit PLUMBING FE
APPLICANT I' UERSTAND AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00X1 CFM(
S)URCER CATIONS. MECHANICAL 'E
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION X
Signature oFAppliv.n oAtmmor Dau EXHAUST HOOD(W/)UM HOUSING MITIGAT NME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant o zza
future building Occupant store or handle hrdous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 912,and the Health aml Safety
Code,Section 25532(.)^ HEATING UNIT(OVER IIXI,IXM)BTU)
❑Yes g� VENTILATION FAN(SINGLE RISID) PAID
Dale Receipt If
Will the applicant or future building occupant use e.Air u of dMana When BOILER-COMP OHP OR I00JRl0 BTU)
emit hazardous air contaminants as Jcfined by the Bay Arca Air Quality Management TOTAL:
District? BOILER-COMP LOVER 100,OXI BTU)
AIR CONDI UONCN
1 have ret I/h hvanloto ran mis remlirnncnes under Chapter fi 95 of the Cali- ISSUANCE DATE.
fornix Ileuld& '6' y CnJo.Secdonx 29yB5,255y3 trod 255J4, nnderslund that if She
NEW RESIDI?NTIAI.MSCI I. SQ.PI'.
M1nilJlAg Joust a rtrcntly v�my(y7camm,Ihmhlxm ponxlM1ilitymnotify the occupant
of the'quir•_ans which aaR r tpr' miss ce ul'a Certlficamof Occa'oney.
Owner. muturicada cot Dam
TMAL: ISSUED BY:
OFFICE