S 0128 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF§IT NO. O 1.L 28
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'IA14Y NO. APPLICATION SUBMITTAL.VAT I
OWNER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO:
(1UJ NIC CONI'NOT.#
cwuep-
�,ARCHITf /EN, LIC N-O�: ADDRESS: - ❑ �
Q-q
- CONTACT: PHONE ' BUILDING PERMIT INFO
pAM I� ❑ Consultant Pees Paid by Applicant(Initial) pC eLycT Plf MECH
1-1 LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE I,Yr_ 7dIC fF��y
1 herehy affirm d t I licensed ti p f Chapter 9(tle
om is an, JOB DESCRIPTION
aa'z with Sechot 7000)of 3 of Business and professions Cade and toy license. RESIDENTIAL:
LL 00 In PERMITISSUANCF:
FFp--� full farce and effect
OSPDWI. El KITCHEN REMODIiI.
6UV License Class Car If APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING IE-PIPE
F z W Dam Commo or
,Do, ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
vn K I understand my p[nn,shat]be used.,afew manuds MODIFICATIONOz,+, UP TO 200 AMPS El INTERIOR [:J CHIMNEY REPAIR
Ir r3 [[[yyy Licensed Pmfess...or - - 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�,�1y OWNER-BUILDER DECLARATION 0y1µTWO AMPS D BATH REMODELIRF.PAIR El DEMOLITION
310.'a 1 hereby affirm that 1 am exempt from the Contract,),',Litems Law f...the
YqqY55 yU following reason.(Section 7031,5,Business and Professions Ctale:Any city or county A SIGNS EL13CTRICAL ❑OTHER /h� -
pl which requires a permit m construct,alter,improve,demolish,or repair any structure P
st prior tons issaance.aleorechise,theapplicam firamoh permino Tile tognadmiltemeat SPECIAL Cl RCU /M ISG �—
j'--I that he is licensed pursuant the provisions of the Contractor's License Low(Chapter 9
0C (commencing with Section 7")of Of,e.in3 of he Business and Professions Code)or TE MP.T LE INST MM - IIh��...
n'y e C that he N exempt therefrom and the basis for the alleged excavator.Any vioWtinn of ❑NF.W_V I.DG/ JN7 IiMOLITION
- N
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER D.VICES �yy�TFN46Vf�x/'[��� SERVICE
0 not more than five hundred dollars($5M), - IMPROV14&1t
Dl,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTµ
will do The work,4nd thouruemml,md intendedoroffered battle(Sce.]044,Business El OTHERVU
and Professions Code The Contmetou'a License Low does not apply to an owner of OUTLETS-S H' -17;URE.
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not]mended or oBereJ for NEW RE$IUP I L� T SQ FT. _
sale.ILhowewrlhebuildingorimpmvemeni is sold within ancywrofcompleti,)n,the SQ.FT.FLOOR AREA $ISQ.FT.
owner-huilder will have the burden of proving that he did not huild or improve for pur-
pose of salt.).
D 1,as owner of the pbi as exclusively contracting with licensed emtruuors m
construct the project(See.7044,Business and Profession,Cod2U The Contractor's Li-
censeLaw does not apply toanowner ofproperty who builds or improves thereon,and QTY. - PLUMBING PERMIT I?
who contracts for such project with a,mtrector(s)licensed pumuodt tomContrncta.'s
License Law. PERMIT ISSUANCE
El Ism exempt iteo. .B&P C for this ream,) -
ALTER-DRAIN&VENT-WA'T'ER .A VALUATION
ne Dote
'RKER'S C M rN5 '(ION DECLARATION BACK FLOW PROT .D E ��
IT, Mortanderpene of pepury ono of the folhnving deeletmlone.
❑Ihave andw maintain a Certificate of Consent to self-insure for Worker's Contain- DRAINS-FI. .ROLE ARB CO STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3401 of the Labor Cade,for the performance of the
went,fm which this permit is iswed. FIKTUR -PER TRA
❑ 1 have and will coalition Workers Compensation Insurance us required by Section '
3700 of the Labor Cade,for the performance ofthe work for which Thi,permit is issued. G AA.S BM. N TL' OCC.GROUP APN
My Worker,Compensation Insurance omrie.and Polley somber are:
Coale,. Policy No,: A. .S B RR 4 )
CERTIFICATE COMPENSATIO INN FROM WORKERS' GR E/INDUSTRL JNTERCEPTOR
A.-
COMPENSATION INSURANCE - - BILBLIJINGD ISIQN-FEB$
Ord"ection need not beeampl,edifthe'mitis femme hand.,]dollars IS 100) BHA, TRAP -
or less) PLANCHECK FEE I
I comity that in the performance of the work Rn which this porrou is i...vd.ldmll SEWER I'1'ARY-STORM BA.200 PC
not employ any Person in any manner se as to become subject to the Workers'Camper- ENERGY PP.5 r----
,Z ,.tion l.awnof California.Dote Wp HEATfll WNF.NT/F.LECTR
O Q Applicant 1 GRADING 1
G4 NOTICE TO APPLICANT:11 4112,making This Certilieam of Exemption,you should 00ATER SYSTHMGTEATING
SOILS FEF
F become subject m the Workers Campensminn provisions of the Labor Cade,you must
forthwith comply with such provisions or this pe,mit shall ba deemed revokW. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMµ. SQ.FT PAID —Date Receiptq
U O l hereby which
i is a constructionSo, 3lending agency for the perfennane of
V. Fthe work far which this permit is issuetl(Sec.309],Cie CJ
0 Lender's Name TOTAL:
U Lender's Address TOTAL
a1 owd,that I have mad this application and stun,that the above information is BUILDING FE
to correct l agree to comply with all city and county ordinances and state lows relating m QTY. MECHANICALPERMIT - FEE
G building commuction,and hereby awhine nrrepresentatives of this city to enter upon the SEISMIC PEE
shove-m,nianed property for inspection purposes. PERMIT ISSUANCE
(WO agree to save,indemnify and keep harmless the City of Cupertino against ELEC'1'kIC P G
Iiabilities,judgments,corm and expense,which may in any way account against xold City ALTER OR ADD TO MECII.
In eonsuryenceof the gr ting of this penult. PLUMIi1NO +HE
APPLICANT UND PA S AND ;O WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(ORCFNG
SOUR .(' T. S. MECHANIC LIEF
AIR 14ANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signuwrwe Ap icnnt/CarTtm,or Dme EXHAUST IfOOIJ(W/DUCT) HOUSING MIT'IGA'TION NEE
HAZARDOUS RIALS DISCLOSURE
Willih pplicam or future building occopent store or handle liandou,material HEATING UNIT(TO 100,000 It I'U)
as defined by the Copenine Municipal Code.Chapter 9.12,and the ficulth and Safety - -
Code,Section 25532(4)7 HEA'T'ING UNIT(OVER 100,000 BTU)
Dyes F1 No VENTILATION FAN(SINGLE RES]O) PAID Date Receipt If
Will The app onto in Comm buildingytheaccolade use equipment or Mania which
emit heaardous air emaminants as defined by the Rey Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TrifA1
Disvict7 BOILER-COMP(OVER 100,1011 BTU)
❑Yes DNo
Ih4ve rwd the h4wNoas metentde requirements under Chuptu 6.95 of the Cali- AIR CONDITIONER ISSUANCE E
forma Health&Safety Code,Sectime,25505.25533 and 25534.1 understand that from NEW RESIDENTIAL SUCH SQ.CC
building does nm correctly have a terant,that a is any tespondbillty to notify the eccrpant
of the mquirearrob which must be met pnor to issuance of a Campton,of Occupancy.
CPOwner or authonmd agent DateT ISSUED BY.
OFFICE