S 1039 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMH NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PRODX,'P IUF.NI'IFICATION
BUILDING ADDRESS: ISANITARYO APP'LICATVIN SURMIITAI.DAT1
c6qOW 'SNAME: /��� PHONE: CONT CTOR'S NAME: LIC NO: TA CHITECT/ENGINEER: LIC NO: ADURESs:
CON ACT: PHO :O$ BUILDING PERMIT INFO
i / 0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ •❑ ❑
LICENSED DCONTNACfOHB DF.CLAR PION QTY, ELECTRIC PERMIT FEE
F hereby antra Inns I am licensed antler provisions of Chtmter 9 a mmnetciag 1013 DESCRIPTION
wOZ with Scction7000).1 Division 3ofam Points,and Pmfcssion,G,de,andmy license in
{FU�
in ffallfCla.ndeRect.d/O fl/) PERMIT ISSUANCE RUID .NTIA
a V bicap C/(/ ❑SFDWL ❑KI"ICHENRF.MODEL
Fzul Date Cnnwctor APPLIANCES-Nh'_SIDIiNT1A1' ❑PLUMBING RL'-PIPE
y Q L ❑ADDITION
'D. A C ITF.CI'S DECLARA' ON pANChs ❑MULTI-UNIT
Z O El STRUCTURAL
z I undcrotnnd mylane,had pMe used m pnhlie records
O Z-p UP TO HOAR(C5 MODIFICATION
F,N,E' L¢cnscd Prnfcnstonal ❑INTERIOR CCHIMNHYREPAIR
OWNER-BUILDER INICLARATION 201-I000AMI•S IMPROVEMENT OSWIMMING POOLS
�C) , OVER 111(M)AMPg
y ly< 1 hemFy eSoc thin 1 a.5 exempt(runt the Contractors Co e:An,c Law far the []BATH REMODE V II_C pp.M01.1'I'ION
>(3 a F following"Imam-.(Section]onalu Business aid improve,
dr ions Cade:Any city dcounty SIGNS ELECTRICAL ❑OTHER �'(�fF77
YI�Oma wmen regahe:a perltJl m ptnamel,idler,nnprove,dclnnlinh,or repair Itny"elruanre
��m.] Poor to is issuance.also impacts the applicant for such lwrmitro file a signed statement SPECIALCIRCUIT/MISC.
5;q is
the(he is licensed pursuant o the previsions of the Comrecmr's License I aw(Chapter 9
IY (commencing with Section of Division 3ofthe Boniness lnW Pmlbssions Cudeh'r
p0 EhfP.ME'T1:1t OR POLE INS'I'. OMM R IAL•
S S K that he is exempt dercfrom and the basis for the alleged exemption.Any violation of
LLXI,,,�y4• Section]031.5 by any applicant for a Permit s,,hjenx the applicant to a civil Tonally of POWER DEVICES C NIiW CERCI
BLDGIADDITION C DEMOLITION
_zr
not more than five handled dollars S500). El TENANT ❑FOOD SERVICE
=< C Luffial as owner of the the pacto,,or sucatum is ma inopintended
with wages eyed far are
i(Site compensation, M0§1; PA1D
LECTRIC IhIPROVIiMENT
L � will dothewon,and the he Clreis all's Orme ohs,111 or sulc(Sly to an ownn,,lotCO•flll?R
and i'mfessinns Code:The over thncon Lad w Iwo tiro not apply m an owner of lis-PIX'1'URES
progeny who builds or improves thcall l and who does such wad himself or though
his own empinyccs,provide)that such imprnvcmena no sol immnJal car offered for 17 LEC SQ Irl'.
xale.If,hssi the mining or impavamem is sold within one yeocriftonch int,the SQ.FII FLOOR AREA .5/SQ.IT.
ser-builder will have the burden of proving that he did not hvild or improve for pur-
pasc of,ale.)
❑1,an owner of Ne progeny,am exclusively contracting with licensed contractors aTOTAL:
construct the poojeet(Sec.](44,Business and Professions Cade:)The Cnntturie's Li-
come Law docs not apply to to owner of properly who builds or improves(hewn,and QTY. ING PERMIT FEE i � l'] A I D
whocontracts forsuchp jeers wit llandranmnd liecowilpuroant to wContractors s Y- A
License Law PERMIT ISSUANCE
C F not exempt under Sec. ,13&P C for this rennin
1
Owner Date ALTER-DRAIN&VI:NT-WATER(EA) WWI U
WOR KERB COMPENSATION DECLARATION• BACK FLOW 1•ROTGC'1'.DEVICE IherebymmrmunderPenalty(ifpapmy ti"".:one
(have and will maintain aCenifcum ofConxnnn uhf-i,nmalireFoerpWernrnknenraanCeenmpen- GRAINS-FLOOR,ROOP.ARI:A.CONII.
CITYUh < UreHIINU
said om
nF the STORIES TYPF CONS'UHJC'IION
I,which this permit is issued, FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance.as required by Section
3 the LoMtr Coda,for the performance of the work for which this peradt is issued, OAS-13A.SYSTEM-I INCAOUTLET5
My W'or n er and Policy numOCC.GROUP APN
`' ".- QQ
Cnrticn /A11�Policy No.: S /1_/ 41 GAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
(This section need not be completed dthe panni)in Finite hundred dollars(S I00) BUILDING DIVISION FEES
or Inn.) GREASE'TRAP
I candy that in the performance ofthe work for which this t is issued,l shall PLANCHECK FEE
not cut In an the
SEWER-SANITARY-STORM F.A.20)FT
p ,s y personal in any Ionone"en uxmhmome nuhjcauolhe Wnrkera'GingOn ENERGY FEE
Z Applicant
of California.Data
O Applicant WATER HEATER WNIiNLIELF:CTR
.y NOTICE TO APPLICANT: Cori making thin Corof Exemption,you should GRADING FFai
WATER SYS'fEM/I'RI?ATING
17" Toronto,subject Io the Workers Compensation provisions of the Labor Gds,you must
�i forthwith comply with such vision mobil S
OILS a Q pro permit shall MJecnled mounted. WATER SERVICE
off. z CONSTNUCTIDN LL'NDING AGLNCY NEW RESIDENTIALII.MB.Ihrody affirm thatthem iseconmuetion lending agency for the perform:mae ofDam Receipt#
0 the work for which this permit In issued ISec309],Civ.CJU Lenders Namelender's Address TOTALI certify that 1 have read this application and state that the above info-nation in _ G FEEV) correct.l agree to comply with:dl city and county ordinances and state laws relating m QTY, MECHANICAL U � building construction,and hereby authorize reposenuJiven of this city a cm`er.' ,the I:LEabove-mentioned property for inspection purposes.VA)agree to save,indemnify and keep handles the CiI f Cu vino a ain, PERMIT ISSUANCEIiubilities,juAmenu,teas and ex eases which mu y g FEE
6 p y in lily way tame agai not and City A LTER OR A DD TO MICH.
an omegaenc egranting F'his permit. PLUMBING FEE
APPLIC . UNC 3 jTA ' S NO
WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT( IOW CFM)
SOU E r lI1 MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0(11 CFM) CONSTRUCTION TAX
Sl nmure uhrom .oaaary Date HXHAUS'PROUD(W/DUCT)
1 ARDOUS MATERIAL-S DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazallous maerial HEATING UNIT(TO Fill BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heldlh and Salley
Code.Scott..25532(a)'! HEATING UNIT(OVER 110,001 BTU)
❑Yes ElNo
VENTI LAI'ION AN INGLE RES ID 1 PAID
Will the applicant or future building occupant me equipment or devices which Dae Receipt of
emit bmard.un it acntaminzns as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,(1(10 BTU)
Lhuildingdmillotcu"colly
sOTAL:
Cl❑No BOILER-COMP IOVER I00,Otlf1 BTU)
and the hvnNnns natetiaB requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
&Safety Cade,Sections 25505,25533 and 8534.1 understand thin if the ISSUANCE DATE
ilolcurrently have t tenant,that it is myresonimiliry tonality thececupant NEWRESIDEMOALMECH. SQ.Fr.
mentn which must he met priono issuanceofu Cenifcate of Occupancy.orized agent Data 'TOTAL:
ISSUED BY;
OFFICE