S 1917 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEIt��+Irr NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. _ J 1 Q17
BUILDINGPROJECT 1 V IDENTIFICATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
Z Y` V-q—
A N RSNAME: PHO ? CONTRACTOR'S NAME: LIC NO:
lipRCIfI"F.CT/1NGI E. LIC NU: - O ADDRESS: ❑
CONTACT: PHONE: I "BUILDING PERMIT INFO
VA /- Consultant Fees Paid by Applicant(Initial) BLDG ELHCT 2 PLUMR r MECH
6 ZS SS i!m / erYJ
LICENSHUCo (RAC'IOR'SD I.ARADON QTY. ELECTRICPERMIT FEE
1 hereby apion that Ili Eeenam anacr vicionx of Chapter 9(commendnl JOB DESCRIPTION
E0GCz with Section 9000)of Division 3 offhe Businessand Professions Coda and ney liwnsc is RESIDENTIAL:
p in full Fane and cweca PERMIT ISSUANCE
nl^ ❑SFDWLITCHEN REMODEL
Liccnsc Class Lia# APPLIANCES-RESIDENTIAL. []ADDITION E:1 PLUMBING RE-PIPE
QZ 0. Dvtc TSConDE or
ARCHITECTS DECLARATION ❑MUI:I'I-UNIT ❑MODIFCURAL
F❑N PANELS
z-14- lunders,pntl my plans shall he used as public records MODIPICA'I'ION
OZ..O IIP To 200 AMPS El IN 17FRIOR ❑CHIMNEY REPAIR
rr�f"'{r1 Licensed Professional 201-1001 IMPROVEMENT OWNER-BUILDER IIECLARA'I'ION [-]SWIMMING POOLS
ca
C I hereby affirm that I am exempt from the Cnnwaor's Llceme Law for the OVER 1000 AMPS ❑HATH REMODEI./REPAIR ❑DEMOLITION
X y E follow m.1Sea, n 90315,Business and Pmressiens Code:A rcou I ❑OTHER
llaall following must i s s Any city o county SIGNS ELECfRICAI,
W rp whid,myuipes a Permit to"no rutl,alter.improve,demolish.or repair any etmdum
[�-'�'.c� pdunoitx issuance,also reyuims the vpplicnnt fnrsuch pennil4,filen eignedstnternnt SPECIAL CIRCUITIMISC.
that he is licensed pamoate in the provisions of the contractors License Law(Charter 9
(commencing will Section 7000)of Division 3 ofind Business and Professions Code)or TEM P.METER OR POLR I NS I'. COMMERCIAL:
d o c
that he is exvmpr mwdront and the basis for the alleged exemption.Any.natation a] ❑NEW BLDG/ADDITION ❑DEMOLITION
px. Ir. Seclian 9(13 L5 by any applicant for a,,e a,sullen,the applicant to a civil penally of POWER DEVICES
1+1 m ❑TENANT ❑FOOD SERVICE
Fr nm mare than five e propd dollars(5500).
i]
^.� Q 1,as owner off Wo pmpmy,or my en,ployces With wages as their sole con,pensnlinq SWIMMING POOL ELECTRIC OTHER IMPROVEMENT -
Ea willdolhssion, ode The
Lu,ndnn,wdosnot apply 90 an.Business ❑OTHER
and Pmfcavions Code.Tho Contractors License Law dans not apply to in owner of OUTLETS-SWITCHES-FIXTURES
property who holEver itnpmvcv Iheman,and who does such work himself...through
his awn employees,provided that such improvements ere nor intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however.the building or improvement is sold within one year ofeauddion,the SQ.PT.FLOO REA VSQ,rn
ownerTudder willk the broker f Polvingthin h1'd noth II(it insponve or - /
Pose of ) IA
1 r of IM1 ( I ly a I s y rollbacks,I' w,In licensed I ar1S a,
constructhprojecta4B IPF TheC1 )'11 Contenders t:
con Law d apply it)
fproperly h builds p thereon,and QIY PLUMBING PERMIT FEE CJ
who contracts fiasuchpchp 3cn wuh veno t (\)I caused Pu and to the ConOaanns
Lied ,,Law. PERMIT ISSUANCE
I.,is twenlp,muter Sec. .B&P C for this reason
AU[F14-DRAIN&VENT'-WATER(EA) VALUATION
Owner Ut -
WORKER COMPHNSA'rION DECLARATION
N RACK FLOW PROTECT.DEVICE
1 hereby andW affim,nnderpennity ti perjury one of the following tledltnnians
I blurand will nwlnby Si Ceri fcnteol the Tal la Code,Care for Worker's Compcn- DRAINS-NI,oOR.ROOF,AREA,GOND. CORIES 'TYPE CONST HOC LON
weaki,,, presided for ne Section 39011 of the I,ahor Cade,Carol pcdanrvmce of fie
work for which this permit is issued FIXTURES-PF,R TRAP
❑ 1 have and will ode Ear Workers Co Grid the Ilk I,,, hi h his pacqueril by issued,
3900oflic rkersCmCode,1'ortherdlo ulail,eanccr and Poork aparkpch,hie pemtil it icsnrd. • OAS-P.A.SYSTEM-I INC.40U'rLE'TS OCC,OROUY' APN
My Wnrkefa Compensmion Inwrnnee currier and Policy number am:
Carrier. Policy No CAS-QA.SYSTEM-OVER 4(EA)
CERTIFICAI E DE EXEMPTION FROM WORKERS' GREASE/I NDUS'IBL WAS I'E INTERCEPTOR
COMPENSATION INSURANCE • 'BU DfNGQIV1S10N PP,li$ _
This section need nor he completed ifthe permit is foronc hundred dollen l$100) GRP,ASF,TRAP
or less.) p1.ANCHPAK FEE 4
;ccnify tho in Ibcperrnrmmlm orthc work for which this permitises.Cpdr,ull SEWER-SANITARY-STORM F.A.200 FT. -
notemployany onfor In any muna:rsn acmbecome suhjwfte the Wnrkec'Compcn- ENERGY PP.F. 3
Q Z radon Lucas of Cnllrornia.Data WATER HEATER WNENT/ELECTR -
O Applicant I GRADING FEE
wr, NOTICE TO APPLICANT:If,alter mukin fill Certificate of Hxem lion,you should
S r WATER SYSTEM/TRP.ATING
abecome objecttothe Worker's Comperavatis pm Is halo(the LolmrCode,ked, mus, CA .(3 .S PEE
W forthwith amlply with such provixions or this permit shall he deemed revoked, WA'1'Ek SERVICE
A
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMH. SQ.PI', r/s1U�
I hereby utfm,mpuhcrc in aenmWClino lending agency fnnhe perfnrmunw of w Dnlc Receipt#
rhe work fur which this,,Donn is issued(See 3099,Cwt C,)
QE-' finder's None v, LI\t 111 s I TOTAL:
U Lender's Address TATA I )
y1 certify that I have read this application and s0nclhm the above information is - - BUILDING FEE (f7
Vi cornet.1 place n,wmply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z bulldingenn weinn,and hereby aumoriu repmvemnlives of this city lalate,upon the SEISMIC FEE
shove-mentioned property for m%pMion purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PBRMI'r ISSUANCE ELECTRIC PEE 0
Iiabililics,laRr us,contsvndexpeaw,Whichoety in any way amml,ioneslmid City ALTER OR ADD10 MLCII.
in sequcnee III the lrandng of this peaniL PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,WO CPM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 1(1,0(111 CFM) CONSTRUC'r10N TAX
Signature of Applicanl/Conpecor Doc EXHAUST I IOOU(W/DUC) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE.
Will the ii,lictmt all future build,ng onappn,stem or handle h.zardnus nmcoal HEATING ON]'P(10100,000 It I'U)
as defined by On Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(.)'! 11EATING UNIT(OVER 100,000 BTU)
E]Yes Ko VEND]LAI'ION PAN(SINGLE RESID) PAlll
Dole Reel
Will the applicant or ruwro building occupant use equipment or devices which
emit haeallous air wntnminants as defined by the Hay Area Air Qualify Mumgemenl BOILER-COMP pHP OR IIX),OIXI BTU)
Uisnied,
(]Yes No BOILER-COM PHTV HR I 0 RTU)
AIR CONDITIONER
I have and the h.mmaua twmriuls rcgnirenenn under Chapter 6.95 or the Gdi- ISSUANCE DATE
ramie,I lentil,&Surely Cale,Sedions 25505,25533 and 25534.1 understand that if the NEW RES IDENUAl.MHCI I. SQ.UP C '-'
huilJing Aa�iioI eurrcmlyhuvcaten,at,thaliris my responsibllnytquandyme n..a,pl �� l (((//!
of there rams which mucy a 1pdorloisemnea aCeni not Occupnn,
O ronlare,ed agent Dale TOIL ISSULD BY:
OFFICE