S 0061 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL I'F.RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /_
BUILDING 1'ROJ{{CT IDENTIFICATION 0
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALUA'I'li
I a 3ry'8�9 10,
fIWNER" I I'IIONF.: CON'I'I<�ORsy`IAML:,1� LIC�.� NIC CONTROL
ARCHITECTIENGINEER: LIC NO: AT DRESSY11
WWTT�I ''C�_9✓/ IY/ ��✓� ❑
CONTACT: PHONE: BUILDING PER INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTU B MUCH
El ED ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I herchy ri irn Thin I at licensed under provisions of Chafe,9(canntencing JOB DESC 10
WOO with Section 7000)ofDivision 3 of the Business and Professions Code,and my license is RESIDENTIAL:
ulOp PERMIT ISSUANCE
F_ to full force and vb{p CI9ps ❑SPDWI, IT ' 'MODEL
aVV License'Clll�. Lich APPhIpNCES-RESIDENTIAL ❑AUDITION LIJ BING RE-PIPE
.F•7�-W Umc L— '� Contractor
y a ❑MULTI-UNIT ❑S UCTURAL
I-.7 va ARCHIT[CTS DECLARAT N PANELS
ypW2�' lundentvndntyplans shall beaseduspuhlie rewNs MODIFICATION
p•z,,on UPTO200AMPS (_1 INTERIOR [_1 CHIMNEY REPAIR
F�fW.�j Licensed Promotional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
h _T [I ❑
OWNER-BUILDER DECLARATION OVER IINXIAMPS BATH REMODEVREPAIR DEMOLITION
a 1 hereby uflirnt that I um exempt from the Conuucmr's Liens,Law for
fiy5 C,4 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELIiCfRICAI. C1 MITER
W LL LLO y which reyuires a permit to comm n.aIle,.improve,demolish,or mpair any swcmm
prior o its issuance,also requires the applicant for such permit to file aligned statement SPECIAL CIRCUIT/MISC.
Ian that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
QD (commencing with Section 7")of Division 3 of the Business arta Professions Code)or TEM P.METER OR POLE INST COMMERCIAL
6 q e q That he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLCI 4y
Section 71131.5 by any applicant for a permit subjects thenppli,cn to.civil penult,of ❑
POWER DEVICES TENANT 17001)SERVICE
?� not more than five hundred dollars($500x. IMPROVEMENT
❑ Los owner of Ne property,or my employees with wages us Their sole compensation, SWIMMING POOL .ECTRI
will do the work,nod the struawm is Bol Intended or inflicted hn cola(Sec.7044,Business [DOPIER
'
and Professions Code:The Commemr's License Low docs not apply m an owner of OUT LEAS-S TCHIS-FIXTURFS
c. .. properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEWR• ll)
IiLECTR S T.
sale.If.however,The building or improvemmnt is cold within one year of completion.the SQ.I'I'.I>LOORA :A- $ISQ.IT. .
neraphuilder will have the burden of proving That he did not build or improve for par- X .1
0x1,a sown)er of The property,van exclusively enmmeting with licensed commul ns to or T A
conswn the project(Sec.9114,1,Business and Professions Cole:)The Convector's Li- V
cense law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE b
who contracts for such projects with o contmetons)licensed pursuannn the ConTracmrs 'I''l Uh fl L")I-CtU IN
License Low. , PERMIT ISSUANCE O
❑lam exempt under Sec. ,B&P C far this mason
Dote ALTER-DRAIN&VENT-WATER(EA) VALUATIONOwner
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT DEVICE
40 1 hereby affirm under penally of Iwrjury one of the following declarations:
❑I have and will maintain a Certificate of Conxem to self-insum for Workers Compen- DRAINS-FLOOR,ROORAREA,CONT, STORIES 'TYPECONS'TRUCI'ION
Sutton,as provided for by Section 3700 of the Labor Code,for Ne perfomtvnce of the
work for which this permit is issued. FIXTURES-PER TRAP
Fl I Invented will ommirm Worker,Compenxaion Insurance.as required by Section
37000A be Latin,C, Thcperformnce al The wnrkfnr whichat pesm�1n isissued. GAS-EA.SYSTEM-I INC.4 OUTLETS (N`C.GROUP ANN
My r k o ✓! a�r wdh1and Policy m V
C Policy No.: '�3 MCI GAS-EA.SYSTEM-OVER 4(IiA)
CERTIFICATE OF EXIiMI'l'ION FROM WORKLRS' GREASFJINDUSTRL.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILUINO UI VISION FEES
Clhis sect to need not hecomplcteJ if Ne pemtit is foranehundreJ dollars(5100) GRL'ASE'TRAP
nr less.) PLANCBECK FEF
1conily that in the performance of the workfmwhich thisperma is issued.I shall SEWER-SANITARY-STORM EA.200[IF.not employ any gcrvm in any manner so a to became subject m the Workers'Camper ENERGY FEE
,z saloon Laws of Ciddhorla.Dam WATER HEATER WNENT/ELECTR
Applicant 1 GRADING FEE
y NOTICE TO APPLICANT:If,otter making This Ceniltem of Exemption,you should WATER SYSI'EMOREATING SOILS FEE
1"! become subject the Workers Compensation provisions of The Labor Cade,you must
I3�•7t forthwith comply with such pat,incia,or Ilii,permit shall be dcOradmItAcd. WATER SERVICE
6 Q
7 z CONSem is I c ON LENDING AGENCY NEW RESIDENTIAL,PLMB. SQ.FT. PAID 1 c Receipt g
V 0 Thereby affirm thauherc isaarnstmction lending agency for the perfomtnnce of
the work for which this pomtit is isaucd(Sec.3099,Civ.C.)
Q F' Lenders Name
C) TOTAL:
lender's Addres TOTAL"
Q. 1 ecnify that I have runt this application trod arum rho the ubnve infnnnoriat is BUILDING FET?
W caned.l agree to comply with all city and county ordinances and sone laws relating to QTY, MECHANICAL PERMIT FEE
V 2 building construction,and hereby nation.reseaudive,of this city to cupon the
SEISMIC FEE
pmmer
above-mentioned property for inspection pure w,. "HIRMIT ISSUANCE
(We)agree ut save,indemnify and keep haeless the City of Cupertino against ELECTRIC FEE
Liabilities,judgments,costs and expenses which may in any way accrue against said City AIIER OR ADD TO MECH.
PLUMBING FEE
in consequence of the 6 unTing of this permit.
APPLLCAN'UNDIiRS'I'AN A 'D WILL COMPLY WI ITT ALT.NON-POINT AIR UANDI.ING UNI F(TO 10,0X1 CFM)
MECHANICAL I'IiF.
SOUR GUTAI'IONS.
II AIR HANDLING UNIT(OVER In'"CEM) CONSTRUCTION TAX
I rcnf App rue tmnor Date EXIIAUS'THOODONMUC) HOUSING MITIGATION FEE
HAZARDOUS ATERIALS DISCLOSURE
Will the dicam orfuatrc building oecupum store rehandle hazard�usmmerial HEATING UNIT(In I(XLM,B'Tl
as eHBed by the upedino Municipal Code,Chapter 9.12,and the HadTh and Safety
Code,Section 25532(a)'I HEATING UNIT(OVER I )BTU)
❑Yes ON. VIiNTIIA'1'IDN FAN Gl.li 12ESID) PAI c n
snrci
Will the applicum ar furore IwilJing cecupam a equipment or devices which BOILERCOh1 JHP OR IOf1.gM1 BTU) VV
emit hadous air numainants as defin -
ul by the Bay Area Air Quality Management TOTAL:
District? BOILER-.)MP(OVER 100,010 BTU)
❑Yes 7 N
AI NDITIONF.R
I have read the haaNnus materials rcquircmm�ts under Chnptrr h95 of The Cali- ISS ANCG DATE
h If HculOt&Safety Cale,Sections 25505,25533 and 25534.1 understand fl then if the N: SIDENTIAI.MECH. SQ.Fi'.
hmoungd on cnrrcntly o nanL.Nm it ism sihilityto unity the rwcupant
of th u' menu w t men prior nuance n Ce of an
r
Own or uuthori dugent Dam TOTAL: ISSUED BY:
OFFICE