B 0375 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PZ'NO. o
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BtfILDINGP,ROJECTIDBNTINICATION - SOOO1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL CAM
ps PI e. L N • ///P
OWNS 'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
�,� C 1 f NIC CONTROLH
ARCHITECT/ENGINEli LI NO: ADDRESS: X4�9 ❑
CONTACT. PHONE: BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
e 'l o ❑ ❑
El
LICENSED CONTRA 01t DECLARATION QTY. ELECTRIC PERMIT FEE,
1 hereby aferm that 1 am licensed under pr'vismms of Chapter 9(ao.mneacthg JOB DESCRIPTION
Q=Z with Section 9000)of Division 3 of the Business and Professions Code, dory license i. RESIDENTIAL
p OO I'F.RMIT ISSUANCE
Fa in full force and t. ❑SFDWL ❑KITCHEN REMODEL
QUzU License Class Lic.W �-�C� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y 6 L Date Comm
r ARCHITECT'S DECLARATION ElMULTI-UNIT ❑STRUCTURAL
PANELS MODIFICATION
Z O.ZZ 1 understand my plays shall be used m public rmomds
Oz•,O UP'1'020"AMPS ❑INTERIOR C1 CHIMNEY REPAIR
F��ul Licensed Podficoional 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOI.S
Q.ye a OWNER-BUILDER DECLARATION OVER I(IIIO AMPS [I BATH REMODELMEPAIR El DEMOLITION
WWF C4¢¢11 Q 1 hereby aitch that 1 am exempt from the Conome nr s License Law for the
x O C V following reason.(Section 1031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
W a L y which rectums a Permit to cnnsmuc.alma improve,demolish,concern any simdure
^O� prior to its issuance,also requires the applicant for such permit an rile a signed statement SPECI AL Cl RCUIT/MISC,
m�]y that he is licensed pursuant to the......ions or the Contractor',License Law(Chapter 9
W s�"p0 mimpowncingwith Section]O(Ognfl i,kien3ofthe Bmimessand Professions Cmde)or 'fE.MP.METER OR POLE INST. COMMERCIAL
dWx ca that he is exempt 0erefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
W.m.N Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
^�N not more than five hundred dollars($500). IMPROVEMENT
y6 ❑ 1.as owner of the progeny,or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC
a� O willdothework,ond thestrumob le tot ioendedorofieted Ease],(See 91140 Business ❑OTHER
and Is..Ro ions Code:The Contra m's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
p'
property who bolds or improves thereon,and who does such we himself or through
his own employees,provided that such Improvements are not intended or mRerod for NBW IEESIDENTIALELECTR SOFT
sale,If,however,the building Or improvement is sold within,ne yearmfcompletlon,the FT"F EA S -r'C
canerje ilder will have the burden of proving that he did not build or improve for lar-
pure
un
pLl '
ose of saleJ' T AL:
1,as owner of the prnpany,am exclusively contracting with licensed contractors to JUN 2 9199
construct project(See.7144,Business and Professions Cede)The Loan ar,I Li-
Ase Law does not apply to an owner of propeny who builds or improves thereon,and QTY. OEE
who contracts for such projects with a commemr(s)licensed premium to We Contractor's
License law. PERMIT ISSUANCE: Qp
❑I am exempdunder Sec. ,11&P C for this reason Y
ALTER-DRAIN&VENT-WAFER(EA)
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ^ O�
I hereby ll maiman under penalty to penury one of areell following declarations:Ca
Olhave and will forbyineCion 37te ofConsentr ode,fumfer Workersce of the
.RAINS-FLOOR,ROOF,AREA,GOND. S"TORIES r'1'VPP.CONSTRUCTION
workstrumn,f as hick chi for d Seisms 3]00 of the Lobar Code,for the perl'nmmncc of the
work for which thixlvrniris issued. FIXTIJRES-PER TRAP
Cava, will maintain Worker's Campcnsetion Insurance,as required by Section
00 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP MIN
MyWo c..x�tw in- roue earner and Policy number aro: 1n GAS-EA.SYSTEM-OVER 4(EA)
Carier: (�S r{tet \ `��j Policy Nov:1,/.(.C.. .�y�._
CERTIFICATE OF EXEMPTION FROM WORKERS'j`l�jCt GREASH/INDUSTRL WASTE INTERCEPIDR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed it permit later one hundred dodars(SILS) GREASETRAP v e
orlessJ PLANCHFAK FEE
I certify that in the performance of the work 6rwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 IT
sol employ any person in any manner so as In hecnme subject m the Workers'Compact ENERGY FEE
oz sadiron Laws of California.Dam WATER I IEATER WNENT/ELECTR GRADING FEE
z Applicant _
NOTICE TO APPLICANT.IL after making this Cenlficnte of Exemption,you should WATER SYSTEM/TREATTNO SOILS FEE
(� hecoate sobjecno the Workers Compensation provisions of the Labor Code,yet must
„'may (monsoon comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
F G
CONSTRUCTION LENDING AGENCY NEW RHSIDF.NTIAI.PLMB. SQ.FT. PAID
V O k far
rwhichinn that there ism issued(Sec.
agency for the performance of Doe Rtaip
tis the work fur which this permit is issurA(Sec 3097,Civ O)
(ti Lender's Name TAL:
C)
� V Lenders Address TOTAL; .
'T a I certify Thal I have read this application mads ate that the have information is BUILDING FEE
o-F.l Vi correct.l agree to comply with all city and county ordinances and state lues relating to QTY. MECHANICAL PERMIT FEE
C..) 7- building coronation,and hembyamhorize rePreaenmtivcs mUhis city dm radiation the - r SEISMIC FEF.
above-mentioned property for inspection purposes.
(We)agree to save,indemnify tad keep harmless Tho City of Cupertino against PERMIT ISSUANCE I ELECTRIC FEE
liahilities,judgments,costs and expenses which may in any way awme studied said City AI.TERORADDTOMECH.
in consequence of the grating of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT U 010,000 CPM)
S 1 CE REGULATIONS. MECHANICAL PF.F.
m ^ AIR I IANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature orAppliicar Commcimr ld Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ile. plicaminfar..ban,[..goccupamsmm or handle hazardousmaterial HEATING UN]'1CIO I(1 BTU)
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 2553200? HEATING UNIT(OVER 11X1,000 BTU
❑Ycs etvm PAID -.
VENTILATION FAN(SINGLE RCSIII) Dam Receipt W
Will the app oodu in future buildingdefined occupant use Area
Air est of devices which
emit hazardous air emmvmitvnds as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) Q
Disorder?
❑Veto ,_/ BOILER-COMP(OVER 100.000 BTU)
I have read the hazurdmis mammals mquiremmarts under Chapter 695 of the Cali- AIR CONDI GONER ISSUANCE DATE
fomia Health&Safety Cede,Seeing 25505,25533 and 25534.1 undersou d that Like NEW RESIDENTIAL MECH. SQ EI'.
building does not arently have a tenant,that it is my responsibility to notify the occupant 7
o regmre cora h hnIDn be coed prior to issuance or a CeriOcrnm of 0c upancy.
Ownero tharized ag t Date TOTAL: ISSUED BY:
p OFFICE