S 1655 —APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Gl4 VL.
CITY OF CUPERTINO BUILDING-ELECT DCAL PET 1 Nol1655
BUILDING DIVISION APPLICATION/PERMIT PLUMRINC.%H?CHANICAI. Vl
^— BUILDING PROJECTIDEN'I'MUNIIIXN
BUILDING ADDI<I;SX � • • ` SANITARY NO. APPLICAI'IUN SUBMITTAI.DATE
OWNER' N PHONE: C RAC'I)R'S NAME: LICN
O r/O NIC C(JNTROLN/�
ARCIITFCT GINEEN: LIC NO: AD R'S` / u L O ❑ QWS(
lf_CONTACT'. ATqq a/•Irl. BU ILDING PERM IT INFO(}��
,a O ❑ Consultant Fees Paid by Applicant(Initial) Ln ELECT PLUMB MI°❑CH
PAC% `J7-1
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm mal I on,horax d ander proxksions of Charm,9(Imaamemg JOB DESCRIPPION
Z with Sedion]DMpol Divi.xion3ofine Busitiensapd 'rofessions Code.ardmy license is R 'Id
I ;NTIA
k� I fall force and crit PERMIT ISSUANCE �-yY
C w F ,n f I li D� -� v ❑SFDWI, ❑KITCHEN REMODEL
QVt� License Cla.x_ _ hi4 ic'a APPLIANCES-RCS1D[NTIA1. ❑ADDITION El PLUMPING RE-PIPE
Nod Dal[ Cnmraclur
ARCHIPEC'1'S DECLARATION ❑MULTIUNIT ❑STRUCTURAL
,::On PANL1 ti MODIFICATION
Z p w Z I undersmnJ my plans shall he used m'Public rceoN.x
oZ„N,Q IIP T0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
[.. W Licensed l•mfesslored 201-UX)OAMPS IMPROVEMENT (]SWIMMING POOLS
ggw OWNER-BUILDER DECLARATION OVER 1000AMPS HATH REMODEREPAIR ❑DEMOLITION
g 6 ElII
I hereby affirm Thal 1 am exempt from the Comracmrs License Law for the
aLU following.,us , San 07031.5.Businessaor Professions Code.Any ciryor county SIGNS ELECTRICAL El OTHER
3 u.ya which acquits a pem,h m autumnal.refer,imPmvC.unit fish.or repro,tray smuctme
C�m.S Prior m its issuance,also requires me applicant for such permit to rile a signed statement SPECIAL CIRCULIPAISC.
that he isllconxedpursuunt...,heprovisiarunt the Centaworsl,iumseLaw(Chapter 9
WaOC (commencing withSection 7")of Division 3 ofthe Business and Profession.Cole)m THMR h1 . O POLE INS'll COMMERCIAL:
d y o a mal be is exempt merel'rom and the bosis tonin alleged csetnption.Any violation of I , (, I]NEW BLDG/ADDITION ❑DEMOLITION
LLX] YN•
Section 7031.5 by any applicant for a permit.subjects the applicant m a civil penalty of POWI Ds ES �•��IaT El TENANT ❑FOOD SERVICE
F=Gnot nam,than Eve hundred dollars($500). IMPROVEMENT
(]I,ox owner ofinermreny,or my empinycex with wages xx their sole compcnsmion, SWIM I "BIC El OTHER
will do the work,and the saucmre,x not intended orofferaJ for sale(Sec.70sl Business V
mfind i'mfessiom Code:'Ite Contremors License Low does not stilly It,nn owner of UTLETS-SWIU�Nt FI% JRES UQ
progeny who builds or improves thereon,and who does such work himself or through
his own cmployecx,Provided,hal such improvements mu nm intended m oRmed Icer NI;W RESIDENTIAL ELEC: SQ FT.
sale.If.hnwcver.the building or improvement issold withinioneycmnlcomplmiin,the SQ,FE FLOOR AREA $SQ.D'.
,.builder will have the burden of proving that he did not build or improve torpor- p ' n
owe F4
pose of sale.).
I] I,as owner of the pmprft,am exclusively contracting with licensed mammemrs m 'TOTAL:
a.......0 the o,,W(Sri.9000.Bnsinesa and Prnmasirms Coda.)The Confronters U-
censeLawdoesnotapplytoanownerofpmpenywhobuildsorimpmveithereon,and QTY. V
PLUMBING PERMIT FEE JUN
ANSD
who..anin ss for inch pmjcets wtth a canlrael...W licensed pursuant,o the Commnnrx
License Law. RM 'SUANCE
C]I um exempt made,See .l?&P C far his Leeson f r i-IIINU
ALTER- &VENT-WAI'I"R(EA) VALUATION
Owner Date /��+
WORKER'S COMPENSATION DECLARATION BACK IRAW P EC"DEVICE
1 hereby ofEnn under lvnahy oI perjury one of the following d ..kit'inns C�
❑Ihave and will maimninaCenilicwc of Cnnwnmxelf-in for Worker's Cn,npen- DRAINS-Fi.001t. OP,AIt LA,COND. tis
STORIES TYPE CONS TRUCfION
swiom as rovided for by Section 300)of the Latin,CnJe,forme Nantrum-,m'the
tan hi ch this permit is issued. FIXTURES-PER'MAP
I have and will maintain Weakerx Compensation Insurance,as required by Section
3710 of Ilio Lidur Code,for the performance of the work for which oris paronis issued. GAS-EA.SYSTIM-I INC.4 OUTLETS OCC.GROUT' AI'N
My Workers Competiond�yOf fngpunce cal7/ d PoliqP n
CanneduD VS-Mix IIUDMUIYw.fYhcy Na`4gf. Z0 37 GAS-EA.SYSTEM-OVER4 THAT
CERTIFICATE OF EXEM PION FROM WORKERS' GR[iA51%INDUS'I'RL WASTE INTGRCEIH'OR V
COMPENSATION INSURANCE BUILUINO DIVISION FG3
(T his seeliormod not he cam,1ated Dhupenni,in tar mndr
an lned dollars($100) GREASETRAP
or less) PLANCiiECK FEB aaa�
i cenlfy ohm in 0,o performance of,he work fnrwhich ll,ix permit is isnucJ.l xlwll SEWI?R-SANITARY-STOItMHA.2D1P1'.
no;employ any Person in any another so i n to because subjecua the Workers Confirm- GNIiROY PEE li!
O z xallnn Lawsof Califnrno, Dam WATI7R DEALER WNI?NTdzIAzCfR GRADINGAPPlicum
NOTICE To APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMIT RF.ATING SOILS FIiE
a , become subjen m the Worker's Cmnpensmiun previsions of me LaMar Cade,you mull
CQ fanhwithcomply vahsuch Peo,kiods or this ximaitshzll he deemed revoked WATER SERVICE
7 CONSTRUCTION LENDING AGENCY NEW RP_SIDENTIAL PLIAR SQ.FE PATI) Date Receipt L
UQ (hereby aft!muhst lout is a conxmiaon lending again,intone perfournerCof
Ll. F'
w
the risk for whichthis Permit isixsoW(Sec.3010,Civ.C.)
0 Lenders Name TOTAL:
U Lenders Address 'IOTAU
i+ 0. '
[.., I anify that 1 have read this application and stem mm the aMwc information is BUILDING FE
y correct,)agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
U Z building mmmuction,and hembyamhorn<repremre
seativesaflhis city enter upon the SEISMIC FEE
.hove-mantioneJ property lit impectinn pnrpusc. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FLIT 3V /Q
BuhlI lies,judg,ncntscosts and e,turm which may in any wry Loco agai nil said City AL'II?R OR ADD TO MECH. PLUMBING FEE
in ronseyucnce of the Bruning of mix permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTT(TO lo,(IBn CPM) MECHANICAL FEE
Z
SDURCREGULATIONS.
L' �Q
AIR HANDLING ONE r(OVER 10,01X)CPM) �. CONSTRUCTION TAX
Signature of ApplieanVCammetor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will fie applicant or future building occupant store or handle hazanlous material HEATING UNIT TO 100,001 HTU)
it darinN by the CaPeninn Municipal Cole,Chapter 1).12,send the Health and Safety
Core,Station 25532mC IIEAI'ING UNI'P(OVER 100,00081UI �-C/� �-•���
0 Yea VHN'fILA'TION FAN ISINOI.17 RP.SID) PAID C�'-`a-- Y'33
uawe 'a
Will applicant or future building of ce equipmentof Devces which PX( B BTU)
emt hazmndams it nmtvminamx un defited by the Bay Area Air Quality Mnnagmcm BOILER-COMP IMP OR ITD
3TL:I a
Dimrict7 p7
S
]Yes �Nn BOILER-COMP(OVER IO(I,IKKI BTU)
I have rend the nnz.nloue mmcriulnrqu
rirennuAIR CONDITIONERn under Chapter n.95 of the Cali- ISSUANCE DATE
fomia Health&Safety Cole,Sections 25585,25533 and 15534.1 understand that if the NEW RESIDENT IAL MECH. SQ.LE
bnilAingJ, nrn toy comm A,I ryixmy rep sAnitymnotifydonccu,nm �p
II iemcnts it�l� CI(�lo lssuan fa Cemlacncie Occutgg//��q'y.
�ngcnt me bR-- TOTAL / �/''Y .•V V� I�hJ717�'UCCJ
3• p y ISSII[D BV.
OFFICE