S 0578APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PF$MIT NO. 0
`V 578
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMI'TFAL DATE
L
OW F.R'S NAMf::
t`�\/
ONTRACI'OR'S NAME: LIC NO:
NIC
CONT OLX
ARCHITECT/ENGINEER: N� /
l/
DGET Si I+jGVl Lr
❑
CONTACT: -
BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT_ PLUMB MECH
❑ LT�Jr`J C�A
LICENSED CONTRACTOR'S DECLARATION
I hereby a1Rmt that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70100) of Division l ethic Business and Pofeasions Colima my license is
to It forceand G.
Licc Cnsx Lieyua
Date ConINGo
ARCHDXMDECLAR 1 N
lunderstand myplans shall heated as public records
QTY ELECTRIC PERMIT FEE
aaZ
+100
��
�UZtj
Vl4
FQa
ZOPJ 74
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCH17N REMODEL.
❑ADDITION ❑PLUMBING RE-PIPE
C] MULTI-UNIT El STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
CES-RESIDENTIAL
PANELS
0Z=f0
1.=
Licensed Professional
UPTO200AMPS
201-IIXNPAMPS
❑INTERIOR ❑ CHIMN17Y REPAIR
IMPROVEMENT []SWIMMING POOLS
C6 sCj�
36U
OWNER-BUILDER DECLARATION
I hereby eM m that 1 than exempt frmothe ConIrmtm', License Law for the
Code; t chum
g mora y city or y
in st(Semon 7t0L5,Business and
[IBATH REMODEUREPAIR ElDEMOLITION
❑Ol'HP.R
OVER 11X10AMP5
SIGNS ELECTRICAL
0
0
ffixady`�
deaonc
which requires a permit to csms, the etre. improve, demolish, or repair any stmeum
which improve,
theapplimam for Contractor's aa(statement
priorm its lensed pursuant Cnmmmols Liceree LawlChapter9
that he isliccnwidaSomfi
SPECIAL CIRCUIT/MISC.
4 y da a
n700nprnvisionsnfthe
(commencing wird Seainn91X0)of Divisinnlof the Business and Professionx Gsle)or
that he is exempt therefrom and the basis for the alleged exemption, Any smalion of
Section 9011.5 by any applicant for a permit subjects the applicant to a civil penalty of
TEMP.MEI'ER OR POLE INST
COMMERCIAL:
❑ NEW BLDG/ADDO'ION ❑ DEMOLITION
C1 TENANT ❑FOOD SERVICE
POWER DEVICES
CSQ
555E p..
u1
4' 3
nm more than Eve hundred dollars SSW).
❑ I, ns owner of the pmjwrty, ar my employees wish wages us their sale c..ousamdom,
will do one work, and the structure is not immndWoroRered for sale (Sm. A/W. Business
end Profession, Code: The Contracmrs License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvemems are not intended ,, affcmf for
sale.If, loweve, the building or improvement is sold withinone ycmofcomplariat the
IMPROVEMENT
THER
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FUCTU'S
NEW RESIDENTIAL. ELEMR FT.
SQ. PI'. FLOOR AREA
&SQ. FT
owneolmilder will have the burden of proving that he did not build or improve for pur-
pose of vale.).
❑ 1, as owner of the property, am exclusively contracting with licensed cummeam to
S�
PAID
IAL'
construct the project ISec. 744, Business and Pro&,xiom Cale; The Contractor
M
cranic law does not apply to an owner of pmpeny who builds or improves thereon,and
who contracts for such prsgects with it comrmor(0 licensed pummin to the Contractor'I
License w. La
E]Pum exempt under Sec. , B K P C fon his mason
QTY, PLUMBING PERMIT FEF.
'
X�a�.,
(� h
UG 18
teECV
�a XRV{{II ((��
PERMIT ISSUANCE
Owner
RIEA) CI
VALUATION
U/•UUr�HJ(VV
11
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT, DEVICE
I hereby am under Penalty of perjury one of the following declarations:
affirm
El I have and will maintain a Certificate of Consenuo self-insure for Wodefs Comfort-
cation, as provided for by Section 37M of the Labor Code. for the perfommnce of the
DRAINS_ FLOOR, ROOF, AREA, GOND,
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
Iq %TURPS - PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, its required by Section
1900 of the Labor Code, for the performance of the work for which this permit is issued
GAS -EA, SYSTEM- I INC. 4 OUTLETS
OCC, GROUP
APN
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
GAS - EA. SYSTEM -OVER 4 (EA)
GRP.ASIII NDUSTRI. WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION IBES
(This senior need not he completed if the pcnnit is Toren, hundred dollars (SIM)
or less)
GREASE'IAAP
PIANCIIECK FEE
z2
P cenily that intbe N formence nfthe van kfnrwM1ich thispermit is issuedlsbull
not employ any person in any ma bjact1e the Warkcri Coal
smion Lo Cobb,mi a
SEWER-SANT TARY-STORM EA. 200 FT.
ENERGY FEE
WATER HENrldl WNEW/F,LECTRAppli
GRADING FEE
IA
a�
0
�O
{L �+
WLenders
0.
y
U ,7�.
E TO APPLICANT. IL`aeking this Cenificam of Exemption, you should
the Workers Compernminn provisions of the Labor Coda, you mom
renhwion comply with such provisions or this permit shall be dimmed revoked.
remission
CON STRUCI'IONLENDING lending
I hereby ich,hi thanherc is s ed (Section lending agency far the performance of
'he wnrkfor which this permit is Issued (Sea 7099. Ci, CJ
lender's Name
Addles,
WATER SYSTIEsIaRIATING
WATER SERVICE
SOILS FEE
PAID
NEW RESIDEN'fIAh 1'LMB. SQ. FT.
Date Receiptat
TOTAL:
TOTAL:
BUILDING PER
I cal try that 1 have mad this ap,boation and mite that the have infnrmatiun is
correct. l agree tocomply with all city and county ordinances and state law, relatingto
building construction. and hereby audience rcpmsentatives ofthiscitymenter upon the
QTY. MECHANICAL PERM IT FEE
SEISMIC IEE
PI7RMIT ISSUANCE
so
ELECTRIC ITE
ahove<nentioned property for inspection puEmses.
(We) agree to vase, indemnify tad keep hafmlcss the City of Cupertino ugrinsh
PLUMBING P[H
liabilities,judgments, costs and expenses which may in any way accrue against said City
in consequence offire f Phis he granting opermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALL. NON..POINT
SOURCE REGULATIONS.
AULµ OR ADDTO MHCIL
APR HANDLING ON] 'TIM 10,100 CFM)
MECHANICAL told:
110
AIR HANDLING UNIT (.111 IB,gXICPM)
CONSTRUCTION TAX
(�17
Siy l�umre ol'ApplicanJConwcmr T Dme
MATERIALS D SCLOSU E
EXHAUS"I HOOD(W/OUC17
HOUSING MITIGATION FEE
Will the applicant or Burc building (occupant stomorhandle hazaMous mmcnal
BEATING UNIT(TO IIXh0111 BTU)
us chained by the Calvinist, Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25512od]!
HEATING UNIT (OVER I WpMI BTU)
❑Yes No
Will the applicant or future building occupant use equipment or devices which
chair huraMuus air emanational, as defined by the Bay Arca Air Quality Management
Uistnm4
❑Ycx [:1 No
VENTILATION PAN is INGLE RFSI DI
PAID
-
Dam Rmcipl X
BOILER-COMP(JI{p OR IIXI,IXO BTU)
TOTAL.:
BOILER-COMP(OVER 1101(4X)BOD
AIR CONDITIONER
J
P have read the hvallon; materials requirements under Chapter 6.95 of the Cali-
ISSUANCE. DATE
NIiW RB.SIDENTIAI. SUCH. SQ. 17,
frmiu Hasolor M Safely Code. Sedisnts 255115, 25577 and 25: I understand that if the
building Does not currently have otarum,that it is my spansibil ytonmify therccupam
^nlRmOntfi P) IfIUM IK mG print a C C j al ecalp incy.
ISSUF.DBY: ro
TOTAL:
nrauthonzedagent Dote -
OFFICE