S 2897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l Ott StG as_ Avg �q
ERNAME: nn ``Pf,H�OppNE: // CONTRACTOR'S NAMIii LIC NO:
7B'3
..2 1. I all -t•U� i. T NIC CONTROLp
ARCHITECPEN NEER; LIC NO: ADDRESS: ❑
CONTACC PxoNG: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ECf PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby o0irm that I am licensed under provisions of Chapter 9(commencing JOB OESCRIPTION
�QO with Section 70010of Division3ofthe Businessand ProfessionsCdc,andmy license is PERMIT ISSUANCE RESIDENTIAL:
F+LL in full forceand cheat. ❑SFDWL ❑KH'CHEN REMODEL
Lica Zlfk"�Jt' Dateae Clan Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
a 0. Das GmalDECL
F.nrn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MOIL!STRUCTURAL
O
1 undersmW my puma shall he uncA us Public records MODIFICATION
pZ�O UP'1'02W AMPS El INTERIOR ❑CHIMNEY REPAIR
[F�FW Licensed Professional 201.1011flAMPS IMPROVEMENT C)SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER 1010AMPS ❑BATH REh10 E F OI IpN
a I bunchy affirm om 1 am exempt from the Contractor's License Law for the
fLLx�6U Iidlowing reason(Section 0031.5,Business and Prnfessims Cale:Any city or county SIGNS ELECTRICAL ❑T HER
W 3 LL F' which requires a permit to contract,cher.improve,demolish,or repair any structure
`O prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
pN. that he is licensed pursuant o the provisions ofthe Contractor's License Law(Chapter 9
p0q (commencing with Section 7000)of Division 3 falls,Business and Professions Cale)or TI3MP.METER OR POLE INST COMMERCIAL_
a y c LL that he is exempt dom ffo n end me hais for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4•
Stan.703 L5 byarty applicantfar a Permit subjects Nc applicant m a civil Penalty of POWER DEVICES
m,SN,
but more man Eve hundred dollars G50% []TENANT ❑FOOD SERVICE
�a IMPROVEMENT
0 Propey,Las ownerofthe rtor my employees with wages as fheirsole contpcnsmion, SWIMMING POOL ELECTRIC
[]OTHER
!Itdo the work,and the structure is not intended or offered hostile(Sce.WM.Business
63 end Professions Code:The Commerce.License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does such work himself or through
his or employees,provided that such impravernat:w not intended or(,0end for NEW RESIDENTIAL ELECI'R SQ Cr.
sale.If,however,the buildingt is sold within one (coin Ictioo,the SQ.IT.@1np A L.q &SQ.IT.
oden of passing that he did not build or improve for put-
law,of sola.). nn
T
I,as owner of the property,am exclusively contracting with licensed cuntrdemrs to T ,Vln� a
nntsuum the project(Sec.7044,Business and ProI�AVBIfessions Code:)The Contractor's Li- 2 S REC D
the law docs not apply tit an owner of property who builds nr improves thereon,and QTY. PLUMBING PERMIT FEE -
whoconuactsforsuchpmjmtswimaconvacmr(s)liceevedpursuam tome Contractor's ���`T. r LLQ
License Law. PERMITISSUANCE uurL LINO
❑I am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
caner Uam
WORKER'S.OMPFJSSATIO CLARATION y BACK FLOW PROTECT.DEVICE
Ibech,mfiin under Penaltyof Perjury on the following declarations:
I have and will maintain a Certificate of Coaetn to self-insure for Worker's Cooper. DRAINS-FLOOR,ROOF.AREA,COND' STORIES 'TYVE.CONS TRUCTION
tur as provided fm by Section 3701 of the Whnr Code,for be performance of the
work fur which Nis permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Lulwr Code,for the performance of the work for which this perutit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance camber and Policy number arc:
Cameo Policy No.: GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASFI1NUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissestion need not Eecompletedifthapemit is[oras hundeddollan(E100) GREASE TRAP
or less) PLANCHF.CK ITE
I certify that in the performance ofthe work for which this Permit is started.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mannerto as to hecnme subject the Workerk Compem- ENERGY ME
Z ,cation Lawsof California Date
Applicant WATER HEA'TIiR WNEN'T/GLECTR
O I GRADING FEE
z Q
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEhVTRFATING SOILS FEE
I--t ti Racoma subject m the Worker's Compensation ental hal of the Labor Code,you must
W � I'nnhwith comply with such Provisions or this permit shell he Accred revoke.). WATER SERVICE
0. 0
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
Date ReceiptN
rJ Q Iherchy athmtthatthere isacunswmion lending agency(noire performance of
F+ the work for which this permit is issucd(Set.3097,Civ.C.)
Lender's Name TOTAL
U Lender's Address TOTAL:
1 cenify that 1 have read this upplication and state that the above information is BUILDING FEE
TSA correct.l agree to comply with all city and county ordinances and state laws relating it) QTY, MECHANICAL PERMIT FEF,
LlZ huildingconstraction,and hereby authorize repraenmtivesofthiscity to enmrupr the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PER ��
Iiuhilitics,judgments,costs and expenses which may in any way came against said City ANTER OR ADD TO MECIL
PLUMBING FEF.
in
consequence ofthe grunting of this Permit.APPLICAN'r UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT AIR HANDLING UNIT GU 10,OOI CFM)
MECHANICAL PEE
SOURCEJJfiGUL4TIqNS. x -
C7 AIR HANDLING UNIT(OVER PLOXICFM) CONSTRUCTION TAX
Signal •of Applivm CoZTw w Date HXHAUSTHOOD(W/DUCT) HOUSINGNINIGATIONFEE
HAZARDOUS MATERIALS DISCLOSI E
Will the applicant or future building wetipartmone or ran azarduus material HEATING UNIT GO 100.1100 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety -
Code,Section 2553200.1 11EATING UNIT(OVER 100.00)BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt 9
Will the applicant or future building occupant use equipment or devices which
•mit hazardous air contaminants us defined by the Day Area Air Quality Management BOILER-COMP(JHPOR 100,0101TD TdTAL:
Oiarct9 BOILER-COMP(OVER 100.00 BTU)
E3 Yes ❑No
I have mad the hazardous materials requirements under Chapter 695 of the Cali. AIR CONDITIONER ISSUANCE DATE
forma Health As Safety Code,Sections 255115,25533 and 8534.I understand flat if the NEW RESIDENTIAL MECIL SQ.FT.
Wilding does nm currently have a ren fro,mat it is an,responsibility to ratify the occupant
of the requirements which must be mel poor to issuance of a Certificate of Occupancy. V —
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE