S 2022 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONJLY
CITY OF CUPERTINO ' ' BUTLDING-ELECTRICAL. Pelyyl'r lvD. ^LO
BUILDING DIVISION APPLICATION/PERMIT22
PLUMBING.MECHANICAL J
BUILDING PROJECT IDENTIFICATION
SANITARY N(1. APPLICATION SUBMI'I'fAI.DATE
HUILDINGADDRESS.
IM—rl
OWNE^S NA PHONE:/n�/� CONT'RACTOR'S NA E: LIC NO.
t �e biILI"UI L / NIC - CONTROL.#
ARCHITECT ENGINEER: LIC NO: ADDRESS: ❑
TACT - �n A7 PHONE:I� BUIILECPERMIT INFO J7 '� �,—y of 1._ 3116 J�n/[/!1/r) ❑
Consultant Fees Paid by Applicant(Initial) SLUG .-LOTT PLUME MF❑CH
LICENSED CONTRACTOR'S DECLARATION QTY FLFCTRICPERMIT FEE
I hereby about that Into licensed under provision,of eaapmr 9 ....mooring JOB DESCRIPTION
Oa•zwithSection 701%0 omlmaiolu
Es .fthe Ba,ine�and rror cions ende,aw myEcense is RESIDENTIAL
1+100PERMII'ISSUANCE
full force and effect. D SFDWI, D KITCHEN REMODEL
�U$U .license Class Lar, APPLIANCES-RESIDENTIAL DADDI'HON D PLUMBING HE PIPE
h d w Duro Connacmr
❑
ARCHITECT'S DECLARATION MULTI-UNIT El STRUCTURAL'
Z Q y Z I understand my plans shall he.,ns table records PANELS MODIFICATION
O Z_in UP 10 200 AMPS [I INTERIOR El CHIMNEY REPAIR
F,�.,.F'.,W Licensed Profromnd 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
f'^1
OWNER-BUILDER DECLARATION OVER IOfX1AMP5 L3 BATH RISMOOELMEPAIR D DEMOLITION
C I hereby aRrm m thI am exempt from the Contract...'.License Law lot the
GU following reason.(Section 7031.5,Basan.,and Professinns Gale:Any my nr county, SIGNS ELECTRICAL D OTHER rI
'3 y which requires u penal t.ever saact,tire,improve,demolish,or repair say ob can .J
ird-lon,'.. 9 'the ripti. I fc,,echpe t to file a,ii,ard,hattalat SPECIAL CIRCUI'I'IMISC.
math licensedp pursuant tb p o fth Contractors L L ICMpari t) COMMERCIAL
�..Q� (connetcingxlh Seclnn7NX )t)fDsison30frhe Busine. andPr I.. GXLJ nr EMP.METEROR POLL:INST.
a y m y thea M1e ie exempt Therefrom unJ the M1nsi.for thn alleged exemption.Any vinlu0on of D NEW BLDG/ADDITION D DEMOLITION
�`"N Section 9131.5 by any applicant for a peralsoineck;the appliamlln a civil penalty,I POWER DEVICES ❑TENANT ❑FOODSERVICE
nm more than Eve hundred dollars($500).
F Z} IMPROVEMENT
DLnsownen-ol property,or my entries. ift Hts asthci,sol.compero.,on, SWIMMING POOLELIiC'I1DC
F will do Layers,and the structure d rot inte.sd doroBeredfn ode(Set.704TL Business ❑OTHER
3 m and Pmhermit,Coda.The Contractor's License Law does not apply to an at,of OUTLETS-SWITCHES-FIXTURES
property who build nr improves thenen,and who does,inch work hlnweBor through
his own ontploees,provided that such imprnvontenta are not intended or offered for NEW RESIDENTIAL ELECTR SQ ITP.
safe.if,however,also building.,improcuraftssold within year ofcomplction.lhe SQ.IT.FLOOR AREA $/SQ"FT.
er-budder will have the bn sten of proving that he did nnucot build nr amprnvc for pur-
i oe 01 sale.).
I,as owner",rho property,nm exclusively romtuaing with do ansed.otuosxtm m TOTAL:
onb met the pmjeet(Seco] ness and Professions Galey Tha Canrracmra L-
mLawdoesnotap ter ofpmpeny who bui : promsmorcon,and QTY. PLUM OPERMIT FEE
who,aIorNforsulpro, ilhuwn0ndo�Im pun�em rot 1, Cmlmcmr's
Licnnu Law. PERMIT ISSUANCE"
I at B&P C fnr This Terson
ALTER-DRAIN& R(EA) VALUATION
Dale
ca
KERS COMPENSATION DECLARATION BACK FLOW PROTECT DE C
hereby sffum under t enuhy..l'perjury one of the fallowing dedaralinns
I have and will maintain a CenlEelneof Cnasenn.self-insure,..W.rker'.s Ctmpon- DRAINS-FLOOR,ROOF,AREA,CON STORIES TYPECONSI'RUCTION
cation,as provided for by Section 3700 of Labor Code,Ibr the P'Th"n ince of the
work tar which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Connpensation Insurance,as required by Section
3910 o1'the Labor Code heffit, orrormanceriff,work lotwhichuni,tworal i.issued. GAS-EA.SYSTEM-I INC.4 OUTI.F.TS OCC.GROUP APN
My Workers Contprnsmion Insurance carrier and policy nmnber are
Cmric,: Policy No GAS-HA.SYSTEM OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORK17RSGREASFANDUSTRL WASTE list ERCHFFOR
COMPHNSADON INSURANCE "9IJILDING DIVIMOTTER5S' `
(This section need oat h.mmplcled ifthn pennll is fnronehundroddelbtre($10n) GREASE'DtAP s
or less.) PLANCHECK FEE 8
I certify that is the perfera...rat the work barwhuch,hi,Fermin,i....d,lshall SEWER-SANITARY-SI ORM HA.200 FT.
m
ko
nemploy any person in nnymmsu
nare,ut ax to becoe bject t.,he Worker,'Con ... ENER TEE
O z smioa Laws of Cal;fbran, Date WATER HEATER W/VENT/ELECTR RADI PEE
Applicant
NOTICE TO APPLICANT:If,after making this Cenificula of Exemption,you should WATER SYSTENTIREATING 50 S'Rho
become sub'lect to the Worker.C..mpensalion provisions oftire Labor Code you must q
forthwith rnmply with such provisions or this permit shall b,deenned revoked. WATER SERVICEUOCONSreis ac10NLENUINGAGENCY NEW RESIUIiMI'IAh PLMB. SQ.IrIPAID Date Nttmiptp
I hereby tflinn thin there is n wnshvcri..n lending agency[Or the Perfnrmnnco u[
F
the work for which this permn is n.suad(Sec.3097,Or.C)
C Louder',Nnme TOT'AI.:
U Lender's Address TOTAL Ix
Da I certify that 1 have read this application and stale that the shove infornnati.n is BUILDING EEE
.�. IM correct.I agree to comply with all city and county ordinances and.um.laws rabling to QTY. MECHANICAL PERMIT FEE
bullring crambation,rad hereby authorize representatives of this city to enter upon the SEISM IC FEE
abovomanticned pmpeny,terrorization purp.ses. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep TO.Moas the Ciry cf Cupertino ugainsr ELECTRIC FEE
liabilities,judgmenls,costs and expenses which lnay in any way accrue egainstsaid City ALTER OR ADD TO MSCI I.
PLUMBING FEE
in ..sequence of the granting of this permil.
APPLICANT UNDERSTANDS AND W ILL COMPLY WITH At.1.NON-POINT ' Alk I IANDLINC UNI'P('I'O 10,0(0 CPM)
SOURCE REGULAIONS. MECHANICAL PEE
T
AIR HANDLING ON[F GVER 10,100 CFM) CONS"FRUC flON TAX
SlgnaturoofAppli,srusTthruchr Date EXHAUST HOOT) W/DUC'1) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingoccupant stare or handle hazardous mamrial HEATING UNIT(TO 100.010 BTU)
it,defined by the Cupertino Municipal Cn le,Chapter 9.12.and the Health and Safety
Code Sectio 25532(x)•! HEATING UNIT(OVER 100,(XX)If H)
Yes No
D VENTILA'f10N FAN(SINGLE RP.SID) PAID Dale Receipt#
Will the applicant or future building vacation use equipment or devices•� which l emit h e ureas air amtaminants a.defined by the Bay Aron Aur Quality Managelnesn BOILER-COMP LAIP OR I(i BTU)
TO AL:
DislrirnP
(]Yes No
BOILER-COM P(OVER 100,000 BTU)
❑
AIR CONDITIONER
Ih need the h . d Materials y- r. d Charter 695 fm Cali- ISSUANCE DATE
Earn,Health&Safety Code,Socnitan,25505,25533and255341 d of dthntTrc NEW RP.SMENTIAL MCCIL SQ CE
hull gd t contend,t T l,TO,a,a,,o,,zawibifityhr nardifyderterinnal
otlharequienons Much must he DIG pnm rll issuance of a Coniheam of Occapalay. �r
Owner or authorized agent Date TOTAL ISSUED BY `�✓" - 1
OFFICE