S 1857 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE 13'NO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 1857
BIIILDI NG PROJECT IDEN'I'IFIC TION
HUILDINGADDRES& SANITARY NO. APPLICATIONSUBMII-I'AI.DATE
If 4AWO AVE �epw 7'-� 3^
O 'NE 'S NAME:
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"1'� lC0 RACTOR'S NAMH: 1 C NO: NIC CON'IRl
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CONTAC, p�� PHONE:
foyp,,�,� BUILUIN :Rh11T INFO
{�-A%i )'•�A- ❑ Consuhanl Fecs Paid by Applicant(Initial) BLDG MAIC, PLUMB MLCCH
/(J7 ® ® ❑ X
LICENSEDCONTRACTORS DECLARATION Q'ry ELECTRIC PERMIT FEE
I hereby ami;mat I ant heansed under proviai�n:o of Chapter9(Pmnmenebtg JOB DESCRIPTION
�a7 with Section 70DO)of Dlviomr3 of the Busia,ciand Pifessin is Code,andmylianoc is RESIDENTIAL
l+lOp / 1'F.RMITISSGANCE 3 r
'u..
in fall force ends" 'A /� D l_ ❑51'UWL E]KITCHEN RIiMODIiI.
aU�"j License Class Tie.Y� ��// 'O—���-10 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING IiI'll'li
rF Q W DmC C.mmc^
F.Oy ARCHITECTS DECIARAT'1(IN PANELS DMULTI.UNIT El STRUCTURAL
h Z_ 1 u tent my plxm shall he umd ua I�blic records MODIFICATION
OZ=O A / UPT0200AMPS IOR El CHIMNEY REPAIR
r'�',I"IY Licensed Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
••1
OWNER-BUILDER DEC1ARSDON DIiA'fIi REMODEVREPAIR El DEMOLITION
Q I berehy airm That 1 um exempt front mom
e CLi
anchor,' ecnse Law for the OVER I111111AM1'5
iq5 O tL U Billowing mason.(Section 9031 5,Business and Profenylmu Cade:Any city or county SIGNS ELIiCfItICN. ❑OTHER
W 312 y which requites a permil to canaruc6 alter,improve,demolish or repair any amemre
�-�'p� pnonnits issuance,also requireslhe uppliwm fnreudt Pemtin.files signed statcmem SPECIAL CIRCUI'IYMISC.
fp.. that he islicensed parmant to the provisions ofthe Contractors License Law(Chaplain
MS'p0 (commencing with Section?000)of Division 3 oftbe Bu.xinccs and Professions Cateter TEMP METEROR POLE INST COMMERCIAL
d X e y mm he is exempt merdrum and me basis 6r Ne alleged caemption.Any vialmion of EI NEW RLDG/ADDITION D DIHMOLITION
Scetinn]03L5byanynpplicnm torn permit subjects the applicummacivil penalty.I POWER DIiVICES Lk(,TENANT ❑FOOD SERVICE
Zp- normomthan five hundruldolim,(E50T. PIMPROVEMP.NT
^6 01,as owner of the property,or my employees with wage.,as their sale compensation, SWIMMINGPOOLELECIRICIZI
p will Aomewmk.umlIw,h lmr,,nol intendcden oflcrcd hh,ale(Sec.9054,Rosiness DOTTIER
and I'rafesonne,Gdu'I'he Corle aor..License l.aw docs not apply he an owner of OUTLETS-.SWIICUF.S-FIXTURES
.. property,who hold,lir improve.theme ,and who max such work himself or a.....It
his awn employees,provided that such improvements are not intended or offered for NEW RESIDEN'I'[At,ELECIR SQ Ell
sale.If.however,the limidingo,improvement is sold withinone ye.of completion,the SQ.FT.FLOOR AREA S1SQ.Irf.
owner-builder rill base the burden of proving shut he did not build lir improve for Pur.
of
at that.).
Z V
D I,as owner.(the property,am exclusively contracting wins licensed cnnlracmn m
,o-mart the project(Sac.IlHq.Businessand P..fit Code:)The Contemner.,Li DD
came Law does natapply to mrowner of property who hulld.nr improves them o,and QTY. 1'I BING PERMIT FEE
who comrade ror xa,h pntjena with a enotmmntts)Ii.......I p..:mm tomo Contractor:.
Liccre Law. 11 PERMIT'ISSIJANCI.
D 1 am exempt under Sec. ,B&P C for mix mason
Owner Dam ALTER-UNAIN&VE AI VALUnT10N
WORKERS COMPENSATION DECLARATION BACK FLOW PR01TCr.DEVIC �
I hereby affirm under penalty of perjury one of the following declarations: Vol, BSD
❑Ihave and will maintain a Certificate of Consent o self-insure for Workers Compem DRAINS-FLOOR.ROOF.AREA,CONE). STORIES TY PE CONST'RUCT'ION
ration,as provided for by Section 3900 of the Latin Gide,for the performance of the
work far which mix permit 1,issued FIXTURES-PERT RAP
D I have and will mei nein Workers Confansadnn Inosine,as required by Sao an
391MInf the laborCale,for performance of the work lhm which this permll is issued. GAS-EA.SYS'I'HM-I INCAOUT'LEIS OCG GROUP APN
My Workers Gtm •Bsmlon Msuraneeya{n vnd Policy n n I/
CanieLllb, 1 t �fl/n Policy Nu: r GAS-EA.SYS"I'ICM OVER A(EA)
CER'I'1FICA'IL Op EXEMPTIONIBOM WORKERS'
COMPENSATION INSURANCE GREASHIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION RFS
(Thix section need nm hrontpleted ifthe permit is fortune hundreddnllanlll(MTI GREASE TRAP,it bass.) PLANCHECKFEE ), 2-- 0-
z
L p
Iramify thin:,me pedo,munceofthe work lot which this phe Worker,'
Isbell SEWER-SANITARY RM MI
urn cmpl.y any pusnn in any mmhnareo os to become xnhjaun me Worker:Cnmpen- I ENERGY FEE.
O � cation LawsnfCnlil'nrnia,Unto WATE1t11EA'I'I7It WIVRMIIELECTR
DO
Applicant GRADING FEE
Q
V1 NOTICE TO APPLICANT:11.eller making this Cerificme of Exemption,you should WATER SYSTE 1 B
a ; become subject m the Workers Compensation provisions of the labor Cale.you must .PTI�F V V I L SOUS FEE
Lk1 forthwith comply wilhath provisions.,this pemtit,all he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENT[Al.PLMB, SQ,FT PAID
L)O I hereby am,m that there is a corotruaian lending agency forth,p,rfnromme of Date
the work for which this pernit is issued(See 3099,Civ.CJ Ale
0V. r Lenders Name TOTAL:
4UL1 Lcndcr'x Address 'RTI'A1.:
I real that I have read this upplicmion and sane that the above infmmntinn is IIl11LUING FEE O
C N comet.l agree to comply with all city and countan
y ordinces unitstate laws relining m QTY. MECHANICAL PERMIT' FEE
U ,Z building conmmetion.slid hereby aumurize represenmtives ofthi.s city to enter apnn the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(we)agree to save,indemnify and keep hurno the City of Cupertino again.a ELECTRIC FEE Z Z Q
liabilities,judgments,costs and expenses which may in any way accrue against and City ALTER OR ADD TO MUCH. L 7-0 PLUMBING FEE
in n"itame of'he'mining of this pernit,
APPLICANT UNDERSTANDS ND WILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IT010,000 CFM)
SO RF,GULATIUN� CONSTRICTIOAL N ( 7
AIR HANDLING 11Nff IDVER Il1,fNM1 CIIMI CONSTRUCTION
Taaare.fApplicit dContmmo, Dme II((ll EXHAUST I,E]U(W/DUCE HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Nall me applicant or future building occupant store lir handle transitions material HEATING UNIT TO 100,000 BTU)
as defined by the Cashion Municipal Code,Chapter 9.12,and the Heath and Safety
Cad,Scctinn 25532007 / HEATING UNIT(OVER 100,004)BTTH
❑Yes (175 VENTILATION FAN(SINGLE RESID) PAID
Done Receipt H
WHlthe m,uppllcant or future building occupantuseAlla
pmenl.r devices which BOILER-COMI'(JIIPOR 100,000HTU)
emit h;IznNous air ummminnntx ns def ncJ by the 11ay Arca Air Qnal'ny Mamtgement DT L:
It'hia'!
❑Yes [ - BOILER-COMI'(OVER 100,0001STID
I have mad the location,mmerials requimn cut,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safely Cook.Sections 25505.25533 and 2553J.I understand that if the NEW RESIDENTIAL MECH. SQ.14. p �]a/�
M1uilJing dose nm curtentI�lyy�camnant,emit is yresptntsibilitymnotifylheoccapa t L/ �' ` J—
c require ` tP met pno,o's (LxCenihcmc of Occu
r m amhnnznlugea� I Data
T 1^ ISSUED BY:
OFFICE