S 1893 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL I'F. IT NU.
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MECHANICAL 1893
IIOILDING PROJECT IDENTIFICATION
NIJILUING ADO��� SANITARY NO. API'IJCA�NSU�I'1'Ai.DATI
A 9
OWNIiR:' M1 s I'IIONIi: CO ALTO :SN 1E; LICNO. YAC
�'' p NIC CONI Rol.
'Ash,
ARCHITECHEN INF.F.R: 'A' 1.11;NO: D to �� q ac 1:1CON'IAC` PHONE: G� 'BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) y D ELECT' PLUME MECH
IJCE SED CONTRACTOR'S DECLAItA'I]ON Q9'Y. IiLL'CTRIC PERMIT FEE,
E:1 ID El
1 hdmny amainthat 1 am hden.w anddr pn,i,,00a of Chappa 9(umm loner, - JOB DESCRIPTION
h<i D Sddion7(XMB int u3 tneeusine prnfdaelo o code,. aylidanots RESIDENTIAL
Q OO w PliRhtl'f ISSUANCE
F�... ,full force and fCcl� ❑SFDWI. E3 KITCHEN REMODEL
<—U Liccnsc Lich APPLIANCES-RESIDENTIAL ❑ADDITION
EI PLUMBING RE-PIPE
ale Commdtnr
ARCHITECTS DECI, '1 ❑MULTI-UNIT ❑STRIJ (URAL
Fpm PANE LS 10DIIECATION
Z O m Z 1 understand my plans shall be used as public mcoNs
OZ UP102MAMPS 0IN'I'ERIOR INEY REPAIR
F�F-m Licensed Professional 201-1(110AMPS IMPROVEMENT wilds1NG POOLS
gY�; OWNER-BUILDER DECLARATION OVER1000AMPS ❑BATH REMODEUREPAIR I DEMOLITION
y C C, 1 hereby affirm that I am exempt from the Cnnlmmnr's License Law fer he T
X
CL U fallowing reason,(Section 7031.5.Hminess and Professions Cade:Any city or county SIGNS HLGCI'RICAL ❑OTHER
a
W W N which rnmircs a Form,In mnmmdq otter,improve,demolish,or repair any sWttme
prior to its lasanu'c,nlso ra Fuvr theapplicant rnr so at,permitmlildneigned alinement SPECIAL CIRCUIT/MISC.
y�
thad he isI :.Ipu,atufa(11tiouPlIvLlovollni d C nor La.(Chapter9
p0 eh e lah S,cfiaa 70M)orD' ,F 3 f 11c B :oes 11aolia,,maCode)or IT:MP MITI IIt o alt PGI-E INs'r. COMMERCIAL:
Ibul be Ia axcmpl(11,Vfrnm and the basis for the ullegul exmnplinn.Any viofama of ❑NEW BLDG/ADDITION ❑DEMOIJ PION
I+: Suliun](U
IS by any applievm faro permit subjects dm appliconuo u civil pcnahy of POWER DEVICHS
mnune than five hundred call., ❑TENANT E3 boon SERVICE,
Z'i IMPROVEMENT
Q �I,aanwnvndthe propdny,or myenintended wlthwnyvsusacirsolccnmpeluiomss SWIMMING 1'001.13LEC'I'RIC
$�zLan and dnthesions endo:The ontianors License Law,rod does of apply to H4,Business ❑OTHER
ly3m and Professions Cwt The Contractors Licemelaw,sucnotapply an ownere( OUTI.ITS-SWI'1CHE.S-FIXTURES
progeny who milds or improves t such i,and who docs such work dedohimself nrered h
his own employeese provided that such impm,,.Idw am nor intended or offered for NEW RESIDENTIAL ELI!C?R SQ PI'.
,all.If.however.the building.,mprovemem i,,.Id whin one year of completion,the SQ,FT.FLOOR AREA ASQ.Fr
owner builder will have the burden of proving that he did not build or impmve for par-
1 of sale.)
0 h .
as snvncr of the progeny,am exclusively contractingiiis with licensed armotne, i- TeY
,shear the projcel(Sec.71H4.Business and Pmausim,x&or mapni*1 he Conhamnr's and
.hoc
Law
modnesnmapply han with
a dfpmpeny who
sedJsurinpnwes Councillors QTY. PLUMBING PERMIT
who cnnunns for wch pmjwts with a mmrvmmisl licensed puremmt m the Conuacror's
L,nnae Law. PIIHMI'IISSUANCE.
I amexcmpinwcr Sec. ,E da P C far this maann
Owner Ilam
N:I'FIR-DRAIN&V HNT-WA'f1iR(EA) VAI.UXI ON
���s
WORKIiR:SCOMPENSA'1'ION DIiCI.ARAIION HACK FLOW I'indEC'f.OF ICE
hasty omnis ower penally of perjury one 'llif fidlowing dcdnras Con
Ihave providl main minaCicat37 h of the Lilo Coa.for da, Worker'sce m theen- DRAINS-PLOOIt,RWP.AREA.GOND.
sminn,es pmvicW for by Sermon 3]00 of the Labor Cwe,for Inc performance df the ORIP.S 'I'YI'li CONSTRUCfIOb
cork far which this permit is mund FIST URES-PER'1'RAP
1] 1 have and will maintain Workoes Compensution Inmmnee,us required by Section
3710 oldie Labra Code.for the perinmmnce notate wink for which this pernin is issued. GAS-RA.SYS'I EM.I INC.4 OUTLETS OCC.CROUP Also
My Worker's Cmnpenmrion Insurance carrier and Policy mmnher am:
Cmricc Policy Nn.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGRIiASIlIN0l15TRL WASTE IMTERCEPTOR
BUILDING DIVISION PfiIiS
(TM1ix minion need not be completed if the permit is for(nchundrcldollars($100) CRI?ASR'I'HAP
or co.)IYLANCIIECK FEE
I ochddt in lheparformanceorlhe wnrk I,,, hill,Ills permit is Issued,I shall SEWER-SANITARY-S'IORMEA,200PI.
nal cnlpnY any Perron in any manner so us m Mmnne xubjcdl m the WnrkerV Gunpen- ENERGY PEE
acsofCalilornla
Zto NOTICE'IUAPI'LICANT.Ilealicrntaking this Ccnillcntc of lace, lion,you should WATER ti33A'I13R W/VI:N'I'/IJLECTR
Z Z A i....Lot 1 GRADING PEP.
P I'HSE-I REAPING SOILS FEE
a ; neen,ne sobiea m the Worker's Compensation prove ious 0 the labor Code,you mast
Lkl li Ahwitbcou,plywilh such prnvi.ainnsorlhinpennil shall nndconal revoked. WATER SERVICE.
D
CONSTRUCTION NEW RESIDENT IAL SQ.FI'. PAID
D Z Dae Receipr p
U lherenyi,h his
pero.ni isaed(Seei30lending agency limhc Performance of
me work for wmm�tins pennh is lamed($e,.3(n7.cis.c.) '
1-' lender's Name TO'T'AL:
U Lender's Address TOTAL:
} 0. 1 colony that 1 have read this application and state that the atone Infonnaion is HI111.DING FEE
F (n nmdcL togas mmmplywitvllciry and amnrynrdinancea ann.aaelaws relining to QTY. MECHANICAL PERMIT �jFiF
U Z huilding nmamcrion.and hereby authorize reprcsenunives this city to emerupan the PSMICFEE
uhnomentioned propom,for inspection purpoms, PERMIT ISSUANCF.
(We)agree m save,indemnify and keep hannlos,the City of Cupertino against ELECTRIC FEE
linbilitiesel u,ceras andvxpensea which nary in nny way uea'mc against said City AUf1:H ON ADD TO MECfI. Qt
In an,xe o the gmnling of this pvm,it. 1T NG PEE
APPL !1`vl DERSTAND$ ND WI PLY WI'ITI AL1.NON-119;NT Allt HANDLING UNI'I'1'f()III,hfNI CFM)
SOII C IiV ,. MECHANICAL FEE
LAIR HANDLING.UNIT(OVER IgO(N)CFM) CONSTRUCTION TAX
Sig inure of Applica Cnamic ate EXHAUST'11001)(W/DUCT) HOUSING MITIGATION FET?
HAZAR US MATERIALS DISCLOSURE
Will the applicant or future building occupant shad(It handle hazardous material It P.ATING ON I'f('IO I W,W(1 BTU)
its deftnnl by the Cupertino Municipal Code.Chapter 9.12.and the Ilealth and Safety
Cada Section 255329)1 HEATING UNIT(OVER EXLWO BTU)
❑Yes F]No PAID
VENI'ILA'I'[ON PAN(SINGLE RFSIDI Date Receipr N
Will the ap,l,..t or Bohan,building cecupam use gmpno,n on devices which
emit hazardous air contaminants us dermad by the Bay Area Air Quality Management BOILER-COMP(31411 OR 100,000 BTU)
IOTA
Uiatrim7
❑Yes 7N BOI LER-COM P COVER 100,000 BTU)
Ih rcuJ the huaurdnus materiels is under Chu mer 6.95 oRhe C:di- AIRCONDIT'IONER ISSUANCE DATE
rc circ
11 it ellh Sad y Gale,Semi ,25505,155331nd 2.5534,I andenwnd that if the NEW RHSIDENTIAI,MECH. SQ.FF. �� 2 3'" 4 �[
bail .do 2hav u, h tont is my tmpnnsihity to 11 11
upas 1, V.
of `t hichr s el ridno isswnrn nlnCcnillr apf c
mer or amhnrire ahem Date TOTAL: ISSUED BY: X(_rY .so
OFFICE