31512 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
COFRTINO BUILDING-ELECTRICAL PERMIT NO,
VISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31 V1L
BUILDING PROJECT IDENTIFICATION
BUI DI I1DURESS; �� ) / I I OOO SANITARY NO. APPLICATION SUBMITTAL DAD
sell_,is
HR'S M': n HONE: NTR R'. NA LIC NO: 7! W
lis1/sG 1/ NICNT�L M
•A IITECT� ER. LIC A. ADDRESS: v (/fit^1
C W G 2`I
L
C NTC . !�' .avE: BUILDING PERMIT INFO
Sickv 06
e l r M 11 C S 1\ �54�J��� n 5/1r ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB CH
LICENSED CONTRACTORS DECLARATION I/ YI QTY. ELECTRIC PERMIT v
I hereby affim rshat I am licensed under provisions.f Chapter 9(commencing JOB DESCRIPTION
yQ{utg ZO with Section 7")of Division 3 ofthe Business and Professions Code,and my license is PERMIT RESIDENTIAL:
�F WC n fen a Classarned effect. CSFDWL C KITCHEN REMODEL
Uo, License Class - ConaY
Z1� Date Conuactor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Ig-•=y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O a 1 understand my plans&hall be mud as public records ( MODIFICATION
OZO UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P Licensed Poessi...I 201-1000AMPS MPROVrNENT
yy� raj ds.,I.exempt o.temannaDECLARATION
1 hereby affirm that I ern exempt from the C.mmcmnh License Low(or the OVER 1000 AMPS ❑BATH RF.MODEVREPAIR El DEMOLITION
Sd 3 V following reason.(Section 9031.5,nosiness and Professions Code:Any city or county SIGNS ELECTRICAL C OTHER
4F 0 which men.a permit to con&wcL alter,improve,demolish,or repair sww
any cre
-Vat pd.,to its issmace.,riho requites theapplicmmt for such p rmius file.m,mad statement SPECIAL CIRCUITIMISC. /
r1. (comm
(commencing
with
apSectanuo He of Division 3 theeBusinesandProelaw(&Code)r9
q� (cat he is xempt tScdlo nt and the
basis for of theeged exempt on.Any
Code)or TEMP.M[TER OR POLE INST. COMMERCIAL,
that io is exempt therefrom and Ne basis for the alleged exemption.Any viper ion of W BLDGIADDITION ❑DEMOLITION
ro
Section 1.5 by any epplicam fora permit suhjecmx the applicunnoecivil penalty of POWER DEVICES -)9-"WANT ❑FOODSERVICE
r.., } not mom Nan five hundred dollars(SSW). IMPROVEMENT
Ej 06 I] Las owner ofthe pooped,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 10 OTHER
dZ will do be work,and the swmum is not intended oroffered for sale(See.]04q Business
a and Professions Code:The C.naactor's License law does not apply to an owner of 6 OUTLETS-SWITCHHS-FIXT 1
property,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 NEW RESIDENTIAL ELECTR Q
.]a.If,h.Ceveathe building or improvement is sold within one year ofcomplelum,the ;Q®�00 A SJSQ.FT.
owner-builder will have she burden Of proving that he did not build or improve for pur- �"19/
pose of sale.). C�
co 1,at owner of the property,amu exclusively contracting Coda licensed oma toe's i- ` }s `� 19996
consau;Nmproject(Seo]044,Businessvel contracting CrdeJThed contrhn's to ,I l�/[ C/
&nae Laos does nm apply toan ownee.f property who holds or impm eas Hereon,and QTY. PLUMBINGPERMIT FEE
who contracts for such pmjecta wit a amtractm(s)licensed pusauan(to the Contmcmrs r
License law. PERMIT ISSUANCE nJJyF(/
C 1 nn exempt under Sec. B&P C for this..on
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
• I haffirm hereby affiunder penalty of perjury one.f the following declarations: �5; W000N
V
C I have and will maintain a Certificate ofCmnsenn.self-insure for Workers Camper- DRAINS-FLOOR.ROOF,AREA,COND.
satin,as provided for by Section 37M of she labor Cade,for the pM.mmom of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FI XTURIS-PER TRAP
C 1 have and will maintain Workers Compensation Insurance,as tenanted by Section
Zfan Labor C.de,f.rs eperfotmance of the work for which His pemmitisissued. GAS-EA.SYSfEM-I INC.4OLOLHTS OCC.GROUP APN
o
r e s r x '! nm nee 'e dP licy nwnher arc:
c GAS-EA.SYSTEM-OVER 4(BA)
CL iTIFICATE OF fiXEM 1 OM WORKERS'
COMPENSATION I URANCH. GREASF/INWSTRL WASTE INTERCEPTOR
(Thixmctinn rad not be completed Balers(S
ed ifthepeit is for one IW) BUILDING DIISION MIS
GREASETRAP �g _
or le..) PLANCHECK FEE W
Loy anythminthe mymanerformance nfthework becom whichHis thepermitWr=*Colahall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manna m u to become subject m the Workers'C.mpen- ENERGY FEE �+
Z smart Paws of Californiz.Date
O O Applicant WATER HEATP.R W/VIiNT/1?LECTR GRADING FEE
N NOTICE TO APPLICANT.IL after making His Cenificae of Exemption,you should WATER SYSTEM/TREATING
abeen,subject to the Worker's Compensation provisions of the Labor Code,you must _ SOILS FEE
farthwida comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
CONSTR UC'1'IONLENDINGAGENCY NEW RFSIDENTIALPLMB. SQ,FT PAID
V O
the wI hereby thi thenhcrt is i iage
ncy lnce peromance of apM
Hk fa,which His permit is issued(See,7097,Cis.CJ
0
UJ Landers Name TOTAL:
Lenders Address TOTAL:
• � G 1 certify that I have read this application and&(me the(dam above informoion is BUILDING FEE
m /R
M correct.l agree comply with all city and county oidinances and state laws minting to QTY, MECHANICAL PERMIT FEE
V 2; building construction,and hereby verbatim representatives of Nis city to came upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep hardest the City of Cupertino against ELECTRIC HE
liabilities.judgments.costs and expenses which nay in any way maxima against said City ALTERORADDTOMECH.
in consequence of the germi
ming of this pert. PLUMBING FEE
APPLICANT UNDER$ . AND WILI,COh PLY WITH ALL NON-POINT %A1RHANDLINGUN1T(rOI0."WCFM)ING UNIT(TO 10.0W CFM)SOUI 'E REGULATIO S MECHANICALFELING UNIT(OVER 10,000 CFM) CUNSTRUCf10N'A%
Com Date HOOD OVIDUCT)US MATERI S DISCLOSURE HOUSING MTTIGA FEE
Willtheapplicantorframebuilding a pain smrem handle hazerdeas materialNIT GO I OQ000 BTU)as defrad by the Cupertino Municipal Code Chapter 9.12.and the Health and Safety
Code,Section 25532(a)'! NIT(OVER 100,00l❑Yes ❑NoON PAN(SINGLE REBID) PAID
Wtllthe applicant orfumrt building by the nt Bay Aea Air ntor dManaemes entOMP OHP OR IIg4000 BTU)
emit hmsardous air contaminants ea defined by the Nay Area Air Quality Management TO L.
LDis�ct? BOILER-COMP(OVER IW,W0 HTU)
e ❑Nn mats the hmcodous materials AIR CONDITIONER
rtquirtmm�u under Chapter 6.95.(the Cali- ISSUANCE DATE
&Safety Code,Sections 25505,25533 and 25534.1 undialand that ifthe NEW RESIDPMIAL MECH. SQ.pT.not currently havea tenant,tho it is my mamsibilitymnotify the occupant
ments which must be met prior to issuance of a Certificate of Oce,upatny.
anned agent Dare Vl\wasy:giv, ISSUED BY:
OFFICE