S 0333 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/ItERMIT PI.uMBING-MIECHANICM. 5 0333
I41111.DING PROJECT IUEN'I'IFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
/9y � J� G
` O ERS _ PION J.(/( C 'RACT)R'S Te o Y�NO6/ NIC CONTROL.
C111T1: / GINEER: /LI O: J Jy� AUURI:S�: `C '(V_� ��P!! �,/� ❑
coCrAc'I': I t vHDN7: C]J/ f4 BUILDING PERMIT IN'
�V I ,^ �' YL/^— 3/{ ❑ consultant Fees Paid by Applicant(Initial) B G IAS IiCI' � MIiCH
YI,•, / J ��-D
LIC than I CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE JOB DESCRIPTION
1 hereby.filum Nm 1 am fthe Bu under,and
Proons of Chapter 9(commencing
WOO with Section]OfXpufUivisinn3o(the Business and Pmfessiom Code,andmyliccnm is El SFDW RESIDENTIAL
W p p PERMIT ISSUANCE
F41 in full force and effect,
❑SFDWL ❑KITCHEN NEMOOEI.
F<.UU License Clr Lica �y — APPLIANCES-RESIDENTIAL. []ADDITION ❑PhUMBING RIi-I'IPIi
N60. Date�lT)_.F6�f�-J---Comradnr ❑MULTI-UNIT' []STRUCTURAL
Fpm Y 'ARCHITECTS DECLARATION PANELS MODIFICATION
Z p I understand my plans shall be usedas public means UP
pZ-� UP TO AMPS ❑IM'IiRIVE ❑S CHIMNEY
MINGPREPAIR
OI-
,y Licensed Professional 201-100OAMPS IMP VEMIa' SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IBX1 AMPS ❑ REMODEIJREPAIR El DEMOLITION
C 6 1 hereby alftm that I ten exempt from the Connactorx License Law for the
L p 6 U following reason.ISation]031.5.Bu>incss and Pmfczsions Code:Any city or awntY SIGNS ELECTRICAL
which requires a permit to construct,alter,improve,demolish,or repair any structure
p,let Tons iasuance,alsori,mornthe npplicanl forsnch pe unit an tile.signed ormancm SPECIAL CIRCUIUMISC.
!!(} that he is Rcenzed punaanno the provisions of counselor's License Law(Chapter 9 COMMERCIAL
W..GC (commencing with Section it Division 3 of the Business and Professions Code)or TEMP.METER OR PTO
d y o y that he is exempt therefrom and the hsis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
6417 LL, Section?031.5 by any applicant for a Permit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
I..� not mote than five hundred dollars($500). p IMPROVEMENT
6 FlI,as owner o(the pmpcny.or my employees with wagers their sole compensntinn,
SWIMMING")I.F. ECfRIC D ❑OTHER
Cp will do the work.and the structure is not intended it offered for sale(See.7001.Business
W end Professions Code:The Contrectors License Low does non apply m an owner of OUTLETS-SWI"ICH S-FI%TURES
propcny,who builds or improves theman.and who muss such work himself or though
his awn employees,provided that such improvements are nit intended or offered for NEW RESIDENTIAL SQ IT. SQ,Flt FLOOR AREA LSQ.FI'.
sale.If,however,the building m Improvanem is sold within ane year of completion,the
nN
culander will have the huen of proving Nat be did not im
build or pn vc for put-
poseofsale.). TOTAL: 3�Do S'y'.
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to
msuuv,the pmjcct(Sec.7144,Business and Professions Code.)The Cotnmcua's Li-
nseLwdoes hot applyns.oiwnerof properly who buildsorimpovits thereon,and QTY PLUMBING PERMIT FEE
whocommcts fursuchpojects with acartmem(s)licensed pursuant tomcContractors
License Law. PERMIT ISSUANCE.
F71 oat exempt under Sec. ,B&P C for this muson
ALTER-DRAIN&VENT-WATER THAT VALUATION
Owner Date G
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,� O
I hereby ufprm under penalty n1 perjuryone of the following declum ono
WI have and will maintains Ceruficaoof Comment to self-insure for Workers Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCT ION
ration as provident for by Section 3700 of the Labor Code,for the pia m tram.of the
work for which this permit is issued. FIXTURES-PER*TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700(if the ls�bpm Code.ffunhe performameennce of the work for IP I which pound,is issued. GAS-EA.SYSTEM-I INC.4 OUTI.E.TS OCC.CROUP APN
My W,
sJUL ^�I «�/nlicy Nsy��R rite Z��3Z GAS-IiA.SYST1iM-OVBR 4IEA)
CBRTIFlCAI'li OF f:%lib ION FROM WORKERS' GREASWINDUSTRL WASIK INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION 1`1113S
(This section need IT he completed ifthe peordes far one hundred dollars lSl W) GREASETRAP
or PLANCH[CK PEG
less.)
I certify that in the perfonnanceof the work for which this permit is issued,I shall SEWER-SANITARY-STORM FA.200 FT.
not employ any Person in any manner so as to become subject o the Workers'Cnmpen- ENERGY FEE irk
zz Tariff.Laws of Callifornia.Date WATER HEATER W/VENT/ELEC R GRADING FEE
Applicant ` -
✓pJ NOTICE TO APPLICANT If.ofnr making this Certificate of Exemption, an should WATER SYSTRIAOREATING SOILS FEE
f-t 5 become subject as the Worker's Compensation provisions of the Labor Code,you must
tx Fr forthwith comply with such TonVolonx(IT this permit shall he devoted revoked. WATER SERVICE
W
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. EPAID -
:00)
I hereby afran that them is aconsiutitn lending agency fm the performance ofUao eiptN
the work for which this permit is issued(Sec.3097,Civ.CpLendce.Name IAI.
V Lenders Address TOTAL:
1 certify thin 1 have reud this application andstore that the oMve information isFEIiiZi comes,.I agree acomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT 'LE
V z building conzwction,and hereby authotim representatives ofnhis city 10 enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE FEE
(We)agree o save,Indemnify sad keep harmless the City if Caperton aguoutlisoblims,judgmets,costs and expenses which may in any wey accuse against said City ALTERORADDTOMECH, PLUMBINFEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WIT1V ALL TN-POINT AIR HANDLING UNITOO IO."CFM) MECHANICAL FEE
'S URGE RECULJJ S ! /Gf/1'/)
AIR HANDLING UNIT(OVER 10.00I CFM[) CONS'TRDCI'ION IA%
S nmrcof Applicant)Contrector Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MAMRIAI S DISCLOSURE
Will the applicant or for=building occupant storcor handle harmulaus materiel HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and The Health atm Safety HEATING UNIT(OVER I0k(XX1 BTU)
Code,Section 21532m)?
❑Yex FNo VENTILATION PAN Sl NO LE RGSID) Date Receipt
PAT[)
p
Will the applicant or future building occupant use equipment Or devices Which
BOILER-COM
mit hazmdmin
nus air contaants m defined by the Bay Area Air Quality Manugmncm P(3HP OR 100.000 BTU) TOTAL:
District? BOILER-COMP(OVER 1OB00f1 BTU)
❑Yes 0 N
I have ream the h.mNnus materials requirements under Chapter 6.95 of the Cali- AIR CONDI'1'IONER ISSUANCE DATE
fomia Health&Safety Code,Emmons 25505,25533 and 25534.1 undcmmnd that if the NEW RESIDINTIAI.MIiCH. SQ.FT.
building does not cumemly have a tenant,that it is my responsibility to notify The.c.pant (/
of the requirements which must he tire,prior to issuance of it CeNfmum of Occupancy.
Owner or amhorized agent Date TOTAL: ISSUED BY: "' r
OFFICE