B 0639APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILDING -F,I,FCIRICAI. �j PERMIT No.
APPLICATIONIPERMITnrmrMwuIlunn:r-riineNTt ir.vru)N Q. ��
1)UILDING DIVISION
I
22
5 STefLU R -D
?A`i I(Amuoe1 209 S / (,'113q
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby aft n than I am licensed under provisions of Chapter 9 ormancro chug
QTY ELECTRIC PERMiP
PEIi MIT ISSUANCE
with Soclion700lprf Dlvinion tofthe Businessland Pmfessions Crile, mal my lnshoe in
in mu force and coed. 9 L
APPLIANCES - RESIDENTIAL
:-icense C�lass��-/./�(�-�{..{�}�7�� Lic. p
)are Contractor
PANELS
UP'IY) 200 ANTI'S
I � I "
AHCHITEC'I'S DECLAItTIO
1 understand my plans shall Is, used as public retards
Liormod Probe ssinnaf
201.1030AMPS
OWNIR-BUILDER DECLARATION
1 hereby aBirm that 1 am exempt from he Commcem's Licenm Law for the
OVER IINNIAMI'S
SIGNS ELECTRICAL
following reason. (Section 7031.5, Business and Professions Cade: Any city or emeY
which u,nims a Permit to umsl ten, aher. Iupmve, demolish, or repair any shuctme
❑OTHER Ex
priori. in issuance.also firomeso,ii,ficam fnrsuch formal to file a signed statement
SPECIALCIRCUIT/MISC.
Thal he is licenud pursuanun the provisions of the Conlmeurs License law (Chap is 9
I
(commencirgwio Secti.h7rdX)of Dividmr3uflhe Business and Pmfessions Cri
TEM('. METER OR POLE INST
that Ile fx exempt ihembran and the hav,k for the alleged exemption. Any viobnian of
❑TENANT
Section 703IS by any applicant for a permit suhjecn the applicant to a civil penalty of
POWER DEVICES
not mare than five hundred dollars (5500).
❑ OTHER
❑1,00wnerofthe property. or myumployeeswith wages as their sola compensation,
SWIMMING POOL ELECTRIC
will do the work. and the aw ame,, not mun ded m oncred inside (Sir .9044, Business
and Professions Code: The Caron s License Law does not apply to an owner of
OUTLETS -SWITCHES -FIXTURES
property who builds or improves Iherean, and who doea such work himself or through
his own employers, provided that ouch improve n ad, arc nal intended or untold fur
NEW RESIDENTIAL HLECTR
xalw IL however, the M1uilding Br impmvcmcm k sold within one year of cunpldion, the
owner -builder will have the burden of palling that he did not build or improve fur par-
pose of Inc.).
E]1. as owner mf rile property am exchorivmy contracting will licensed eonmncmrs to
1(YIAL:
coosamu the project (Sec. 70,14, Business and Professions Cwle:) The ConaacmLs Li-
-
censeLowdoesnotapplymanownerof property who builds or improves thereon.and
QTY, PLUMBING PERMIT
who contacts for each projects with It eormaaor(s) Recused pursumm m the Commuters
PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec. . B & P C for this reason
AL[ Hit - DRAIN & VENT- WAT12R (EA)
Jwnin - Date
BACK FLOW ('ROT F.VICE
' WORKERS COMPENSATION DECLARATION
I hemby union under Penalty of perjury one of the following dealamtiom:
❑ I have and will mminam liCertificaunf Conant to self-irome far Worker's Chinni
DRAINS -FLOOR, , REA-
touch, as provided far by Section 391k1 of the Labor Code, for the Performance of the
work his which this permit is issued.
FIVI URFS - PERT ,
and will main Win Worker's Compensation Insurance, as m lmnot by Sectinn
Khalenc
of me labor Code, for the funlonuueaf the work liur which th'mpermil is issued.
GAS - EA. SYS TEMI NC.4 TS
CYWmktLw Cyplrhii In -s an camePN Policy No.:Policynumber am:
hoicelIT/f'f ti-IIVIJ
GAS - EA. SYSTEMO IR4(EA)
CERTIFICA'I'F OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
pD
GRHASEINDUSTRI WA�tF.INTFRCEPIYIR
GREASETRAP
(]Its section need not he completed if pemnit is for one hundred dollars ($IIID)
SI:W13R- SAN ITARY-STORM HA. 200 1-1
Icerany thollnlas perhmmanceof,1.bework far which this crsubject,. W,rkcO'al,lsMdl
mol employ any pcmm in any manner so ns m became subjccno the Workers' Cnmpcn-
WATER DEALER WNEKIYELECIR
,ra n Laws of California. Date
Applicant i
NOTICE rDO APPLICANT: IL after muton, filk Carificatc of Bxemplirn, you should
WAI HE SYSI'13MG7RHATING
become subject o the Workers Compensation provisions of the Labor Code, you must
WATER SERV ICE
forthwith comply with such provisions art this permit shall he deemed revoked.
NEW RESIDHN'I'IAL ('LMB. SQ. ]In
CONSTRUCTION ].ENDING AGENCY
1 hereby affirm (hot there I,. ennstmetinn lending agency for the performance of
the work for which this permit is issued (Sea 31aJ], Civ. C.)
Leodn's Name
Lenders Address'I'0'TAL:
I certify that 1 have road this application and silde that the above information is
-
counsel.l agree an comply with all city and county ordinances and site laws relating'.
QTY. MECHANICAL PERMIT
building construction, and hereby authorize representatives ill this city to eller alum the
PIiRMIT ISSUANCE
abovenmemianed property for inspmtion purpoas.
(We) agree to save, indemnify and keep hamless the City of Cupertino against
ALT ER OR A UD TO M ITCH.
FII judgrotak, cost x and expcnws which may in any way aecrm against said City
in omcpho ce of the gem in, of this pemit.
AIR HANDLING UND' (10 10.000 CFM)
APPLI CANT U NDERSTA NDS AND WILL COMPLY WITH ALL NON -POINT
SOURCL TI S.
AIR IIANDLINO UNI'I'(OVER 10,000 CFM)
Q .'a
Signature afAP,licanVComocaff, Dole
EXHAUST HOOD(WIDUCH
HAZARDOUS MATERIALS DISCLOSURE
Will theap,licant or fumre huildia, eccupunl store nr handle fiasurdoosmmntil
HHAI ING UNIT TO 100.000111'IJ)
as defined by the Cuperloo Municipal Code, Chapter 9.12, and the health and Safely
Cade, Section 255321a)9HEATING
Yes V(N°
1
UNIT (OVER fiXfoo0 PTU)
VEN'I'ILA'I'(ON FAN (SINGLE RUMD)
BTI( the applicant or future building occupant use cepapmem or devices which
hamolwas air contaminants as defined by the Bay Aren Air Quality Management
BOILER -COM(' (3111' OR 100.000 BTU)
(OVER RXI00011 M)
'District'!BOILER-COMP
❑Yes %KNo
AIR CONDITIONER
I have and the hauadnusnmmrialsrluirementunderChnpier6.95 of the Culi-
NEW RESIDENTIAL. MECH. SQ. FT.
fomia Health & Safely Cade, Sections 25505, 25533 and 25534.1 m adcomnd Ilial if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
ni cBZIga tns0bpir la iswance or. Cent B/
JM1
TOTAL:
Owner or amounted agent
OFFICE
FEE -
5-7-6,9
5! ❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
IiNI3RGY FHE
❑SFDWL
❑ KITCIIIIN REMODEL.
❑ ADD) 'T'ION
❑ PLUM RING REPIPE
❑MULTI -UNIT
❑STRUCTURAI.
MODIFICATION
[]INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ 13ATH REMODDEIJREPAV1
0DEMOLI"f1IN
❑OTHER Ex
ta. CA15
'i.
I
w
COMMERCIAL:
'❑ NEW RLDGIADDITION
❑Dirm1QION
❑TENANT
❑ FOOD SERVICIi
IMPROVEMENT
❑ OTHER
SQ. Pr. FLOOR AREA
3roa.
$soCJ
5'I'ORIES
2
3 g7.Y/a
o5Z
PLANCHF.CK FEE
IiNI3RGY FHE
( 0
GRADING PIiF.
S(111.S FEE
PAID
Das Receipt #
TOTAL:
BUILDING IEE
FEF. SEISMIC IZEE
HLEMIC FEE
PLUMBING FEE
MECHANICAL FEE
CONS'IRUL I ION TAX
I10USING MITIGATION FEE
PAID--
Dote Receipt#
TOTAL.:
4n_\ 'ISSUANCEDATE
s—