00010071 / APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
\/// CITY OF CUPERTINO BUIL DING-ELECfRICAI, PIiRMIT NO.
RUItUtING DIVISION APPLICATION/PERMIT PLOMIIING-MECIIANICAL
IIUII.DINIi PROJECT ii)i Nm1'IF'ICA'PION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
O �a /o }�P' -'1,- 2&,60
OWNF�AC /� PHONE:4,99
9 CONNTRACT R'S NAME: LIC NO:
�V/JJ (.mil F NEC CON'I'RULa
:IIITEC(ENGINEER; IC NO, ADDRESS: ❑
CONTACT: PHOPM BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG ELS PLUMB ME❑CH
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE •L7 rJra/
1 hereby affirm mal 1 am licensed under pmvisinns of Chapter 9(commencing JOB DESCRIPTION
Mi34Z with Section 7")of Division S of the Business and Professions Cade.and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE 5s��
FW in l all Ilse,and all"r 0SFDWL p KITCHEN REMODEL.
QUU hiccnw Class Lac. APPLIANCES—RESIDENTIAL ❑ADDITION [:1 PLUMBING RIbPIPE
F Z W Dae Cnntnnur
rn¢a ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECPS DECLARATION
F tn Z I understand my plan.%shall be used as public records PANELS MODIFICATION
ZO Z4G UP*10200 AMPS []INTERIOR [3 CHIMNEY REPAIR
F'W Licensed Profec%inial 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER BUILDER DECLARATION OVER IWOAMPS []BATH REMODEL(REPAIR []DEMOLITION
C W Q I barely affirm that 1 am esempl from the Contractor's License Law Ru the
L U following mason.(Section 911.31.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL. []OTHER _..(�..//
W
0 3 y which cre te,a permit m conswn,alter.Intprme,dmnalisM1,or repair any wmemm
F x'06 prior to its issuance,also rtyuires the applicant for such permitto file a signed statement SPECIAL CIRCU[TOM ISC.
f }-
that he is liceal pursuanuuthe prm8fonudthe Contractors Licemo TO.(Chapter 9 nil
OM
(conuncncing with Section7g)0)of Division 3 o[the Businessland Professions Code)or TEMP.MER OR POLE INST. COMMERCIAL,
w5OD L/ `s
d ke tow he is exempt theretma,told h,basis faille alleged-amila on.Any 6da lou of ❑NEW BLDG/ADDIITON �6UM)LITTON
W h Section 70315 by any applicant for a loran subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZ
t more than five hundred dollars(5500). IMPROVEMENT Q 01.u%owner of the property,or my employees with wage%as their sole compensation. SWIMMING POOL ELECTRIC
b=. all do lhework,and hcwruclum isms intended m offered forsale(Sce,7W4.Business OTHER
and Professions Code:The Contractors License Law doer not apply In an owner of OUTLETS—SWITCHES—FIX'TURBS
pmpcny no builds or improves thereon,and who does.such work himself or through
his own employees.provided mmnts
at%non improveeam not intended or offered for NEW RESIDENTIAL ELECTR SO Ff. Ile
O SQ.Pr
sale.If,however.the building or improvement is sold within one year of completion.the
OOR AREA ESQ.FT.
crhaiWer will hove the harden of proving that he did not build or improve Iia par- O
pose=c y. TOTAL:
�f r of the progenoro exclusively contracting with licensed contractors to
construct the project(Sec.71144,Business and Professions Code:)The Cormarmrs Li-
se Law does not apply it)an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmje,ls with a a ctmclnr(s)licensed pursmmtnlhe Cmnmlcnds
Limns,paw. PERMIT ISSUANCH
❑ I am esnnpl under Sec. .B X Is C for this reams
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKER'S COMP17NSAI'I0 )ECLARATION BACK FLOW PROI'EC'1'.DEVICEOV V
I he alBrn under Penally of pe jury, mre
one of the following dcclatlo : v
L1 I have and will maintain o Certificate of Consenuo sept-inure for Workers Compen- DRAINS—FLOOR.ROOK AREA.COND. STORIES TYPE CONSTRUCTION
nation,ton provided for by Section 3701)of the Labor Cale,for'he performtoncc oaf the
work tar which this permit Is Issued. FIXTURES—PERTRAP
❑ 1 have and will maintain Workers Compensation Insurance,os rt0uind by Section
m
3700 of the Labon Code,for the perfmmuce of th,wmrk for which his permitw issued. GAS—EA.SYSTEM.I INC.4 OUTLETS GCC.GROUP APN
My Worker's Compensation Insurance currier and Policy number art:
Carrlar: Pol cy Na.: GAS—BA.SYSTEM-OVER 4 EA)
CERTIRCA'11;OF U GWIP TION FROM WORKERS' GREASIsIINDUSTRh WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION(FES
(lais.section need not be completed ifthe permit is formic humped dollars(EIW) GREASE TRAP
or less) YLANCHECK FEE
Icertify that inlheperlirrmanmofine work for wlalM1 his lemon is@rued.irhall SEWER—SANITARY—STORM F.A.200 EI',
not employ any person in any manner ser as to become subject to the Workers'Conif en- ENERGY FEE
Z nation Laws of Califmmia.Data WATER HEATER W/VENf/ELECIR
Z 2 Apt licom GRADING FEE
NO]PCH TO APPLICAN'E N.after making This Cera fcme of Exemption,you should WATER SYSTEM/1'RI?ATINC
became mbjmt m the Worker's Compensation provisions of the Lubar Code,you muss SOILS FEE
moth.id,comply widamch pmnisiml this permit shall the,deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ,FT 'PAID--
U O 1 hereby alfrm hat3herc is aeonswctimt lemdin t'orm, fornunce of hales- RecnplN
g agency Pc+ 1 �/ a t I rA
D. F Nowork(orwhiuhthis hermit is issucall Ser.3097,Civ.C.) �I a "VA LJ
0 U Lender's Name TOTAIIoI'
rU Lender's Address TOTAL:
jy 1 cantly(bar 1 have read this application and stat,'he,the aMwe iofnrmntion ism 1 E
F h correct.1 ogres m comply with all city and county ordinances unit state laws Mining w ()T MECHANICAL PERMIT I FEE
UZ building construction.and hereby authorim aprewmatives ofhis city lea enter urym the SEISMIC I'IHi
done-mentioned progeny for inspection Pumoves. PERMIT ISSUANCE
ELECTRIC FEE
(We)agree ser nave,indemnify and keep hanynlexr the Caof Cupertino against
Indaditia,judgnlcros,cusps unit span,,which may n any way:nvOur r,naslodd Cry ALI'Ilk OR ADD'10 MECH. .PLUMBING FEE
in mnscquonce of the gaming tit Potion.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.001 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNI'1(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApIdicantiCantracmr Date EXHAUST HOOD OODUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT 110100,000 BTU)
as dained by the Cup,rllno Muniaipul Code,Chapter Y.12,and the Health lord Safety
Code,Sectio 25532m)9 INA'I'INC.UNT1(OVER 100,0P)11'fU)
[]YO, []No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt a
Will the opplieanl or furore landing ocoupanc use equipment or devices which
"r I humNous air contaminants as ill by the Hoy Arco Air Quality Management BOIL(?it—COMP(311Y OR lIg),OW BTU)
tnmP TOTAL
BOILER—COMP(OVER I00.(N)U BTU)
' ❑Yes ON.
I hammad In,ltueardoars mmortal,mutual, con,under Cha mer 6.95of thea Cull- AIR CONDITIONER ISSUANCE DATE
lads Health n Safety Code.Satinet 85115,255y}and 25534,D I ndcrsmnd Nuc if the NEW RT:SIDEMIAI.NOTCH. SQ.FT.
hauldiorthengdms noat,w;h curree a ntly Lthat n ismy.of.Cerilytee Sify the Ocuavy. �lZ Jnr
mane rgaar nu wMm astx poor to isaaan«m[aee 'fcamo capaney.
t
r uuthnrierA ngsnl Dam T1n'n1.: ISSUED[IV:
OFFICE