S 1133 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 1133
BUILDING PROJECT IDRN9'III1CAT1ON
BUILDING ADDRESS: SANITARY IN APPLICAU NSUBMGTALDATE
OWNS AME: PHONH: CONTRACIOR'SeAM LIC NII:
'x N/C CON'IBOLN
ARCHITECDENGIN LIC NO: 'ApDRF S: t ❑
aT gr
COM'ACT: puONEo 117Vk y1�JV� BUILDING PERMIT INFO
,_tb _ ' 1W IION/ '//Y} G ❑ CopSulnuit Fees Paid by Applicant(Initial) BLDG ELECT PLUME MF.CII
I .k `�Ilo J ❑ ❑ ❑
LICENSED CONTRACTORS provisions
of hap QTY ELR7rRIC PERMIT FEE
1 hereby aR.m that 1 am IicenaW under provisions of Chapter 9 fnnnmcndng JOB DESCRIPTION
Oaz with Section 7000)
of Division]of the Business and Professions Code,and my Iictow is
Wr00 y PERMIT ISSUANCE RESIDENTIAL:
a n lull farce vnd ell t
FQUU Accost Clas Liap ❑SPDWI, ❑KI'fCIII?N RI?MOUEI.
N<G Dare Cnmrmmr APPLIANCES-RESIDENTIAL [ ADDITION ❑PLUMBING 1R7_P1PIi
ARCHITECTS DECLARATION I ❑MULTI-UNIT El STRUCTURAL
'Z F03 PANELS
1 understand my plum sNJI he nsal ns puM1llc records MODIFICATION
O Z-'0 UP 10200 AMPS 0IN'I ERIOR 11 CHIMNEY REPAIR
WNW Licensed Prnfenxional 201-1010AMPS IMPROVEMENT []SWIMMING TOOLS
Y f'� OWNER-BUILDER I ma
DECLARATION
y�W� 1 hereby affirm tM1m I am exelnp[from the Comractnr's License Law nix the OVlik I(DOAMI'S ❑BATH REMOI�il/REPAIR (]DEh101.1TI0N
�d a L F following reason(Section 701 .5,Bualness rood F'ndossinw CnJe:Any ehy ur..maty SIGNS HLEC'I'RICAL 'li-;AdTI IER
Yl Ir,y which requires Of permit m construct,alter,improve,demolish,nr repair any summe
.F. 0n� prior to its issuance.also requires the applicant for such permit o file a xignedstatemom SPECIAL CIRCUrvidisc.
} CA iAA-
that he is licensed pursuant la ns
the provisions of the Commences license Low(Chapter 9
W GCO (minmencimg wish Section 70(10)of Di vision 3 of the Bnsinessvnd Po,fe,ions Code)or 'I PM,METER OR POLE INS'1'. COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violatinn of 0 NE BLDG/ADDITION 0 DEMOLITION
aYXX1I 44.•
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
F Z Y not mare than rise hundred dollars(S50). ❑TIiNANT ❑FOOD SERVICE
W6I,as owner of that ro m,orm bees with wa'esus their vole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O D P P Y Y employees b P
CL�o
will do the work,and themunme is not lntendef coffered for sale(3t..7044,Business DO'I'HER
G3 eo and Professions Cale:The Contractor's License Law does not apply m an owner of OUTI.ITS-SWITCUES-fl
- property who builds or improves thereon,and who dies such work himself ot through
his own employees,pmvidel that such improvements ate not intended ur offend for NEW RESIDENT Al.ELECT FT.
sula If,howeveathe building on impr..vcannot is sold wkon one ycarof cwapleion,the SQ.FI.171.001 AREA $ISQ,Fr
wner .
o -builder will have the harden of proving that b'did not build m improve for pm-
pom of sale.).
❑ I,as owner of the property,am exclusively contracting with licensed contract...w
instruct the pnsject(Sec.7044,Business and Pr fire,[ns Cud_The R:nttadnr'.Li-
cease law does not apply rot an owner nfpropeny who builds or improves therenon,und QTY. PLUMBINGPERMIr FEE RECEIVED
who contracts for such projects with a contortions)licensed pursuant the Contractors
License Law. PERMIT ISSUANCE 3 SD
❑ I am tannin under Sec. ,B&P C lar this rmson
AMER-DRAIN&VENT,-WATER(EA) V .GAIT
Owner Date
WORKERS COMPENSATION DECLARATION BACK IIAW PRCTfECT.DEVICE
1 wahy affirm under penalty of pe,in,me til the following declarations: By.
I havarnd will mainnor a ConiBcane ol'Coustnl to.elf-inxare lint Work,,,Coarpen- DRAINS-FLOOR,ROOF,AREA,GOND,
RUC'i'ION
Ction,is provided for by Section 3701 of the LuM:r Code,far the performance of the
Kk far which this permit is ixmed. FIXTURES-PER TRAP
I have and will maintain Worker'.Compensation Insurance,as required by Section
77(0 of the Lubar Cale.lar the pert'iournce of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC,GROUP MIN
My Work Cnknpcns t Insurance cumerind Polley I . �sp�
Cartier. uhlCA.bPi Policy No.: ILL IGAS-FLA.SVS'11I.M-OVIiR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR17ASFANDIJS'I'RL WAS OF INTERCEPTOR
(Thisscnion mp
nein not M1m colnul if roti
he pan is Future hundred dollars($FDNB BUILDING DIVISION FEES
is,R's.) GREASE TRAP PLANCHECK PER
I citify that mine performance of the work tinwbich this permit is issued,l shall
nm employ any person in unymannerso as m bee.nm'subjecuothe Workerk Can / SEWER-SANITARY-STORM EA.200 IT. O
Pen- ENERGY FEE
Z 7.o Appliaircant
Lioant Colrfornl:t.Date WAI'HR HEATER WNEN'OPLECTR
zO Applicant GRADING FEE
sirN. NOTICE TOgPc,ha WoCIf,afteCiarspactinpr Ccnifis le of came Labor
lord,you
Wq'rERSYSTEM/1'RF.ATING
abecome subject m the Worker's Compensation provisions h the Lobar Cale,you must SOILS PF,E
� forthwith comply with such pmvi,vnns nr this pennln xhvll he dronmd rcvnkal. WA'f1iFi SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RISIDIiNl1AL PLMH. SQ.P1. PAID
ILO l for
rishich ren that there is lending agency for@e performance til D:ne ' ptN
W r-I that work for which this permit ie ixvuul(Sec.3097.Cie.C.)
O L.I Lender'.Nan a 'IOI'AL:
Landers Address AL'
� I renily that I hove read this application und xme that nhc nitove infnnna[ion is HUILDING FF.E
(A contact,1 agree to comply with all city and county initiatives and state laws relating In QTY. MECHANICAL PERMIT FEE
C„) x. building wm,vucom,vnd hareby vmhnrire rcprtnentatives tilthis city[center upon the SHISMIC FEE
mewc-mentioned p.Pcny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hailess the City of Cupertino against ELECTRIC FEIi
m
liabilities,judgments,costs and expenses which may in any way accme vgain.sisaid City A17ER OR ADD TO MECH.
in con sequence of thegnanir,ofdfix pctmit PLUMBING FEE /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT qlk HANDLING UNIT(If)111,(100 ChM)
SOURCE REGULATIONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.00 CrM) CONSTRUCTION'1'AX
Sigmturc of ApplicanUCnmmcmr Date EXHAUST FOOD(W/DUCT? HOUSING MITIGATION Fiili
HAZARDOUS MATERIALS DISCLOSURE
Will theappflcarn future M1uililm,oecuptmsmre m landle hazardous malarial BEATING CN1'I'(TO FfD,DD if TU)
as delined by the Corcoran Municipal Cafe.Chapter 9.12,and the Health and Safety
Code,Seat0 25532(a)'I HEATING UNI'.(OVER I011,I)(1)BTU)
❑Yes.- A. VENTILATION I-AN(SINGLE RESID) PAID
Dam Receipt#
Will the applicant in(marc defined by the
use equipment of devices which
S,
hazaNnus ulr nmwminams as defined by the Buy Arra Air Quality Management BOILI?R-COMI'(3HP 012100,fKKl B'I'ID
)tante@ BOILER-COMP(OVER 100,000])TO)
TO'I'A L:
❑Yee �No
Ihvve rcaJ the hw:nJons mantrialxr is under Chapter fi.95 of the Cali- AIR CONDITIONER ISSUANC��A'Ili
eyuirclnco p `r] {//x/
fnmia Health&Safety Cale,Sectiones 25505,25533 and 25534.1 undemand than if the NEW RESIDENT IAL MECH. SQ.
FT.
building does no[currently have a tenant,that i[is my responsibility us notify the occupant
ofthe ircgwrnn whic est ma pdono issuance of a ce., 'ato auk, ancy.
Owner rat n mirulagcra Dme TOTAL:h: n _17-0"�
ISSUIiD 6Y: Ob of
OFFICE