S 0645 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO. BUILDING-ELECTRICAL PFRMIT Nn.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MRCIIANICAL
IIIIILDING PROJFICT IIIF,NTIFICATION t
BUILDINGADDRESS: - SANI'T'ARY NO. APPLICAOON SUBMI'PIAL DRI Ii
2ra3 63 t 2� .. .. q2 4
OW;4.URSNAME: . PH NIi: CONT'RACTOR'S NA LIC O:
CONTNOLN
ARCHITECUIISGINHHR: LIC NO:- AilORiitiS: U ❑
S`s 7
CONTACT: PHONE: BUILDINGPERMITANF0
j I D ❑ Consultant Fees Paid by Applicant(Initial) ,BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION 7 +
I herchy ulTrm that l um ficenled Audit,p f
'�FXUS
holder
9 Om n gQ
wanbe,fmtmxn)+mnaanT+one nmx nitr.nr aloma,ale:aIn,1f se 7T. +'ELL'CTRICPER ;-
JOB
.DESCRIPTION00mbmand effect. PERMIT ISSUANCE RESIDFN'I'1AI:
UU License CIA,,
Looe ❑SPDWI. ❑KITCHEN RCh10DEl.
hQi Uum Cnmmvtor AI'PLInNCiiS-RIiSIDiiN'I'IAh - OADDI'L'ION 0PLUMBING RE-PIPH
'Do, ARCHITECTS DECLARATION ❑MULTIUNIT ❑SIRUCI'URAI.
OZ�4 lundersmad.,,[an,shall be.wrimipablic recoPANELS.,ads • STUII'ICAA[.
pp UI+'1020OAMPS
�.°)F'Ly Lmcnscd Prnfcsoonal ❑INTERIOR ❑CHIMNEY REPAIR
251BaIMPROVEMENT OSWIMMING FOOLS
.E OWNS -BUILDER DECLARATION _ r
RIiMODIiURi?PAIR ❑DIiMO1.ITIQN
I hereby
form that I exempt front the C tam 1'c haw far the
OVER lOBOAMPS
X
low U folio g rc. (Sect o
7031.5,B ine d Profession,C N A yary or manly SIGNS Iii CCOtICAL ❑OTHER
LLO{'] which q p It nt et 'AItrp e d Ida epa Y 't aura
N}7
Prior t,"'mance,al'ooe'ane, be applienanl h peoral1 life aO,ned,ou,noran, SPECIAL CIRCl111/MISC.
Sh y
that he licensed tt thep of the Contractors L cnsela IChapar9
�p^I'0yOy (cammctang with Section 7000)of Division 3 of the Business and l'rofcnsions Cnde)nr 'IRMPMHTERORPOI.BINST. COMMERCIAL:
X,a, that he is exempt thercfmm mW the M1a,ia fnr the allege)exemption.Any violudn°of O NEW BLDG/ADDITION ❑DEMOLITION
Q-,y Sectio]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Xxy not mare than live hundred do11ma($50(B. ❑TENANT El FOOD SERVICE.
C El 1,as owner of the prnperty,or my employees with wall,,As their sole compensation. SWIMMING POOL ELECT RIC IMPROVEMENTd.y wfldo the wods.anifficamcture is not imm�dedoroffened forsale(Sec.J(H4.Busin,¢ - ❑OTHER
W and Professions Code: the Contractor's License Law does not apply to nn owner of OUTLETS—SWITCHES—VENTURES
'L 3 property who huilds nr improves thereon, it who does to work himnell onhnmgh
his own employees,pmvidW that such Impmventents am not intended or offered for NEW RESIDENTIAL ELECTR SQ Fr.
sale.If,however.the hailhatior nomme,mem iN,old wlthinoneyearotcamtpletlnn,theSQ.FT.FI.fR)RARRA $ISQ.FT.
nenhuilde,will have the burden of proving that he did not build or improve fnr put-
you of sale,).
❑1,as owner of the propeny,um exclusively contra ting with Iicenwal annmmom to 'TOTAL: PAID
' D
mnsuuet the pmjem(Sec 7044,Business and Profession,C«Ie:)The Cmtmemrk u- _ _ 1 t
cense Law does not Apply to an owner of property who builds or improves thereon,and Qry.. PLLJMBINGPERMIT .PEE ' '
wnnLA.. ar�enp ie,awiNa,nntmetm(.N)IiceaNcdpnraanntmtneGamm,tnr, -- -- ��� �6 C�
LicenseIaLaw. PERMIT ISSUANCE
❑Tont exempt under Sec. ,N&PCfor this reason
N:I'ER—DRAIN&VENT'—WAI'IIR(HA)
ow°" Date CITY ur uurci�YflT�IJ�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby off rm under penalty nl'perjury one of the following dedxr;nions:
❑ I have and will maintain a Certificate of Consent o self-insure fur Worker's Conifam- DRAINS—FLOOR,RODE,AREA,COND. '
nation,as provided for by Sectio 32W of the Labra Cole,far the perfnnnmme of the STORIES 1'YPL CONSTRUCTION
work for which this l am a ie issued FIXTURES—PUR TRAP
El I have and will maintain Worker's Compensation Insumtice,as required by Section
37W of the LaborCale,for the perfmnnance of the work for which this permit is issued GAS—EA.SYNITiM-I INC. OUTLETS OCC,GROUP APN
Myrier:Q Cpyyyynsntimn banrunm unrrier nnJ Polixy nu hm
Cartier: l`F' Policy Nmd C.AS-LA.SYST'IiMOVIINdfPA)
oc
CERTIFICATE OF EXEMPTION FROM RS'
- COMPENSATION INSURANCE GREASII/INDUS'IRL.WASTE IN'IF CEPTOR
(This action need not M1e completed if th,permit is Toren,hundreddmllan 151(X0 HUILIIING DIVISION FEES
or less.) GREASE CRAP PLANCIECK FEE
I¢rilly thminthe perfonnanceo,to bekforns mosOhix life W.sixwe..I en-hall SEWER-SANITARY-STDRM HA.2W Pf.
not employ any person iany manner sn os b become suhjca m the Wmdcr/Cntnpen- ENERGY JEE
o ,z. radonanwe of California,aDae
Z O Applicant
- WATER IIIiATER WNF.N'I'/ELLCI'H GRADING IgiE
a_y NOTICE TO APF the W.'D IL Mier making this voina,ale of Exemption,you shun" WATER SYSTEMORFATING
become subject y the Workers Compensation ernots Ices of the Labot Csxle,Yunnan" SOILS FF.Ii
W forthwhh,nntply with such provisions or Wie penniLNhull lie dmnted revoked WA'fURSERVICE
a
z CONSTNUCfION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.FT. PAID
VQ I for
mans issmtnSca.30lending agency lot purlinmuncc or lime ItaciplM
U. F` the work for which this permit is issued(Sec.J(Y9],Co.C.)
c) uLender's Name
TOTAL
UJ Lender's ecanyt 'I'OTA h:
C. 1 ecnee thin 1 hove read this application and sate that the above infatuation is BUILDING FEE
r. y7 horreaL!agree to comply with All city and comity nnlinnnces and sate laws Tainting on QTY. MECDANICAC PERMIT rFFE�
V Z buddimgcomdruniom and hereby Authorize represonmtivice of lhix citymvnler up:m the is 1' SEISMIC 1,17,
above-mentioned property for inspection pu,saus.
(We)agree m save,indemnify and keep harmless the City Of Cupenino against PERMIT ISSUANCE. ELECTRIC FEE
Ilabdities,judgments,fists and expenses which may in Any way ucame agaimaInd City' ALTER OR ADD 110 MECH.
in consequence of the gaming of this petmil. PLUMBING FEE
APPLICANT UNDF.RST .S AND WILL COMPLY WITH AL .NON-POINT AIR HANDLING UNIT GO IQWII CPMt
SOURCE S. MECHANICAL FHT?
r AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
flown If can on Tac or • ate EXHAUST FOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appliexnt or future building mmapam.lora or handle haramou,mmeriul H HATING UNIT('f0100,00F BT ID
m ddlned by the Cup<•nino Municipal Code.Chapter 9.12,and the Health and Sarcty
Code.Section 25532(x)? I[BATING 1/NI'T(OVER[an(0)II'TUI
Oyes ]He
VUNTILAT'ION FAN(SINGLE RESID) PAID
Will the applicant of future building v,cupa t use equipment nr dmices which Ilam Receipt A
rmit hazardous air mnmminana as defined by the Bay Area Air Quality M:magcmem BOILER-COMP(3HP OR IM000 BTU)
Distinct! 'Ifl'1'AI_:
Fl Yes ON. BOILER-COMP(OVER 100,000 BTID -
1 have read the laantdnus material,"Wrannena unda Chapter 6.95 of the Cali- AIR CONDI'I IONEIR ISSUANCE IJ
bmildinforada Bra in&Safety Axle,Sections 25505,25533 and 25534.1 understand than if the NEW RESIDENTIAL MECH. SQ.FT.
y doennnt,umnlly have a le......hat it is try Tanis+.0ilily,,ratify the cecnpam
of the mqulrca cots which must be met prior to issuance of a Cmlficate of Occupancy.
Owner or unionized!agent Date 'I OTAL: ISSUED BY:
OFFICE