S 0277 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
HUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL (� O
-t'- BUII.DINGPROJECTII)ENTIFICATION J
BUILDING ADDRESS: � NN SANITARY NI APPLICATION SUBMITTAL DAT Ii
OWNI3MS NAME: P IONIi: ONTRACfOR'S NAMIi: LIC NO:
NIC CO ROI.X
ARCHI'fELTJEN(i1NEliR: LIC No: ADDRESS: ❑
eIx
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) nLD ELECT PLUMB MECH
1 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby olrrm that Iran licensed ande........ionr of Chapter 9(commencing _ .. JOB DESCRIPTION
IA00 wish Secdoa70aEol'Uivision3of the Business and l'ndmsions Coda.ImA mylicen..is RESIDENTIAL:
W O PERMIT ISSUANCE
i-1� in-wfullerom Claw eR 1. ❑SFDWL ❑KITCHEN REMODEL.
U L+cen G1asa 1 q 6 4
Q U �� D�gs APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Pzw Dae Commnnr ��n nD�-.
WnQ ARCHITPC`PS DECLARATION _r ❑M1NLTI-UNIT Cl STRUCTURAL
p-w7�J oo PANELS
O Z�1 1 undeedand my plans shall he used as public records DIFICATION
IlPT020DAMPS C1 INTERIOR IMNI:Y REPAIR
rin.F.u1 Licensed Pmfessinwl OWNER-BUILDER DECLINATION 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OVER 1000AMPS C3BATH REMOUEI/REPAIk ❑DIiAfD1.1'L'LDN
Q 1 hereby affirm that 1 am exempt from oho Cnnvacmr'x Liccnsc Law for the
ippi55,r O U following reas.n.(Section]031 5,Huslm',ar and Professions Code:Any city or county SIGNS ELECTRICAL E)OTHER
ta+'3
,tti which m,nim,d pennit m,consumn,alter,imps...,.Jemolixn,or m,dir any wool c
� N..1 primmi.c isuance,alw requires lhe.,plicart forw1h permit to flea signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed pennant o the provisions of the Commelor's License law Claque,9
0 (commencing with Section 7")of Division 3 of the Business and Professions C x Iof TEMP.MEfF.k OR DOLE INS'1'. COMMERCIAL:
ay aa dead he is exempt therefrom and the naris for the alleged exemption.Any violation or El NEW BLDG/ADDITION El DEMOLITION
bEIN Section 71131.5 byunynpplicam turn permit nmjmtx the opplicam m+a civil penally it POWERDEVICES EPREMENT NANTOVEl FOOD STRVICl3
W nm more than five hundred dollar.+1&5110).
IM
❑QDl,os owner of the prnpeny,or my nnaoyees with wego aslheirsnlecompenrmion, SWIMMING I'OOLF.LECI'RIC
f G will do the wart,and the simulate is not intended or oBeted forsnle(Sec.]DW,Business THER
and Professions Code:The Contractors License Low does not apply H)an owner of Cut'LETS-SWITCHES-FIXTURES
prof a ty who builds a improves thereon,and who does r.uch work himself or I krough
his own employees,provided that.such improvements are not intended or offered for NEW RESIDENTIAL ELEC'I'R SQ Irr
sale.If,however,the building or improvement is sold within one ycaof completion.the siPrAIR&EA $ISQ.FE
.am embuilder will have the burden of proving that he did not build or improve for put-
"°e JUL 10
❑ L f owner of the prripatY.am exclusively cnmrucdng with licensed a+mmnr+s.w TOTAL: .MYL-
Xs,M
..nand the Irojen(Site.9044.Be,iness.rd Prol'exxons Cmle:)'Iho Conrado,,.',Li- -
censel.uw does not apply m drown,,of property who builds,,,improve.+meremo,und QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contrzctortsl licensed punuanun the Contractor's - '�Ul' L;UI.EUr,11lly
Licerm Low. PERMIT ISSUANCE 111V
❑ 1 an+exempt antler Sec. ,B&P C far this reason
ALTER-DRAIN&VENT'-WATER(EA) VALUA'1'I ON
Owner Doc
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty to of
one of the Fallowing Je Worker's
m:
❑ Ehaas and will for
ibyS rou3c:ne of CeudimCodonsor dhe Worker'sccof b- DRAINS-FLOOR,ROOF,AREA.COND' S'IORIHS TYPE CONSTRUCTION
roar ..provided rpe mi secE..n 39no lar the lamm c..de,for o+,neH..maanee..r me
work rot which this permit is Issued, FIXTURES-1'EK TRAP
❑I hath and will ode,o r e peffod mmpemte w Insurance,h mquireo t i Section
3)0tlof the Wks Crxlc.far the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP AI'N
M Wnrke's Cnm ...mien insula tunJ P..tic j.YCC�
Currie, �(1L� .« '(�,re pamePolicy Na, �l 7 Q �� GAS-EA SYSTEM-OVER 4(ILA
CERTIFICATE OI'EX
dEMPTION I+ROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INI'ERCF.FIGR
IIIIILDING DI VISION PERS
(This sectionnceJ nothn+mplemJ iOhc.,maid is(oronehundred dollars(SII«)1 GRP.ASE TNAI'
or he's.) PLANCHECK FET:
I certify that the performance of the work for which]its color is issued,I soul SEWER-SANITARY-STOIC M EA.2s)FI'.
not mnpley any pnmm in ony manner xn os m heamtc subject m the Workers'C,,1,11- IiNi.1 PEE
Oz satiny Laws of California.Dam WATER HBAT ITS W/VENT/II.ECTR GRADING PEE
Z O Appliant
NOTICE TO APPLICANT:If,after making on,Certificate of Exemption,you should WATER SYSITM/TREAI'INC,
a become subject m the Worker's Cion,t aion provisions of the labor Code,you nmsd SOILS FEE
Forthwith comply with such plavialnn,or this pennit..hall bodecnaN revoked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.IT. PAID
U z Dam Receipt p
L)Q I I which
that i is ammSite 3nlerdie.agency for the perfonnnnce of
the work far which oris permit is is.ueJ(Sec.3119].Civ.C.)
V. N Lenders Name 'TOTAL:
U Lender's Address T(yI'AU
G1 certify that 1 have mad this.,plication and slam Cha the,have inf am umn is - BUILDING ITB.
h comcel.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT' FEE
U z buildingeonstructied.ondhercbyamhtirize representatives ofthisciry mercer upon the SEISMIC FEE
'-' ab..w-mentioned pmpcny for inspection purposes. PERMIT ISSUANCE
(We)egrsave,indemnify and keep hur ales me Cie, Cupenian it,dnsl ELECTRIC FEE
et w
Iiahiblles.judgmems,costsand expemse.rwhich mayirany way accmeagainst said City ALTER OR ADD TO MECII.
in consequencea
of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND KILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1100 CFM) MECHANICAL FIAT
URGE REGULATK L45.
_ AIH HANDLING I1NIT(OVER III,IIW CEM) C(1NS'I'IiUCT10N'I'A%
mf Applicamt/C,,nmacor Date EXHAUST HOOD ONMUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material HEATING ONG(TO 100,000 BTU)
as defined by the Cupcninn Municipal Code,Chapter 912,and the Henith.nd Solely
Code,Section 25532(a)'f HEATING UNIT(OVER 101,11101 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Hoe RecciPt X
Will the air comm or future building,ied by the Bt use equipment or devices which BOILER-COMP DHP OR 11101X10 BTU)
emit hnmNoux air enmaminanu its defined by the Bay Area Air Quality Management 'T[YI'AI:
District P BOILER-COME'(OVER 10400(1 BTU)
❑Yes F1 No
I have real the hazardous arsenals requirements under Chapter 6.95 of the Cali- AI R CONDI'1'IONER ISSUANCE DATE
fomin health&Safety Code,Sections 25505,25533 and 25534.1 understand that it the NE RESIDE TIAL MECII. SQ.FE.
building dries not cannily haven fusion,that it Is nay mspoholmllty to utility(lie mwi ant
of the requirements which must be met prior in issuance of a CeniEcale of Occupancy.
Owner or aumorlred agent Date TOTAL: ISSUED BY:
OFFICE;,