S 1349 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWI'IN0 BWLDmT..ELIUTRICAL Pe ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 1349
WILDING PRO.IF.CI'IDENT'IF'ICATION
BUILDING ADDRESS: Ll SANITARY NO. A'I'LICXRON SUITMITI'A.DAPI
1 ��r va CAII� 95a/
O NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
N(C CON'I'ROLM
14
•ARCHITECT/ENGINEBR�, NO: ADDRESS: �y= D ❑
CON'T'ACT: IN` PHONE!: BUILDING PERMIT INFO
µk� a��
406 T/_ Aja x. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM. ME It
E:1 El
LICENSED CONTRAMOR'S DECLARATION QTY. ELECTRIC PERMIT FE
I hereby affirm that 1 am licensed under provision,of Chapter 9lwmmencing _ JOB DESCRIPTION
K"ZO with Section70Nq of Division 3of the Bminess and Professions Cwle,and my license iv I'ITRMD'ISSIIANCI! 1
GF to lull Torre and effgcL �,r, gppWl. [I KITCHEN REMODEL
GUU License Clan—. K.yay,=_LiaM APPLIANCES-RIiSIDF.N'I'IAh ❑ADDITION El PLUMBING RE-PIPE
N'�a Dom Canon. / fs..n.
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
F 7 y INNF.IS MODIFICA'T'ION
Z Oy 7J- 1 undcrpanA my plans shill Ix used as puM1lic records
OZ-0 UP TO 200 AMPS [I INTERIOR CHIMNEY REPAIR
F+�FYI Licensed Pmf.nxion.l 201.1"WAMPS IMPROVEMENT OSWIMMING POOLS
iOWNER-BUILDER DECLARATION
O Q I hereby a bout that I am exempt from the Contranor's License Law for the OVER 10X1AMPS ❑BATH RF.MODTJIREPAI%DEMOLITION��
E U following at (Suction 7031.5.Business and Pra1'msions Code:Any city or corm, SIGNS ELECTRICAL El OTHER —�:/l�ll �f
4]3 LL h which er,mics a wento m amstmn,alar,improve,demolish,or repair any sbactore r e�� ( 2
Ff+tO prinnnits issuuncq nlxo rcquims the vpplicam for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he licenced pit muznno Ne provisions of the Contractor's License Low(Chapter 9
banninen...a with Section 7000)of Division 3aDhc lboincss unit Profs...mw Coshinr 'IP.MP.METER OR POLP ST. COMMERCIAL
6 a c K that he is exempt dominant and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
so Section 71315 by any applicant Rvapernal subjects the applicant to a civil penalty of IIOWE14 DEVICES ❑TIiNANT ❑FOOD SERVICE
t more than flee hundred doll...(85011.
F_Z_>• IMPROVEMENT
< l]Las owner of pmbruciarmyemployees with wages for theirsole7644pemminn, SWIMMING PO .9LP.COiIC
W ad dmhewmk,and the he Coeisnnts License
Law
ntapplytoan,Business ❑OTHER
4 3 mit Professions Cade:The Ces da,mrs Licenac law Ams not apply a an owner ar OVllIi TS WITCf18.S-FIXTURES
progeny who badit,pr improves t such improvements;rod won ansa such work himself or thnmgh
his own employeese provided ohm such i...Id are not intendedcur offered for NEW SIDENTIAh[LSC:R Q FT.
sale.lL however,the building nrimpmvemm�t i..anld within one yeurofcnnplminn,the SQ.FT.I�LOORARIiA 8/SQ.I'1'.
owner-builder will have the burden of proving that he did not huilA or improve fm pur-
pmcoLsulc).
TOTAL: M
P p P1
I,as ownerof the property,am exclusively contracting with licensed cummcmrs to T/
curmwa the project ISw.lDiq Business and Pm(esainns 1--a ntmem.'.Li-
lease Law does not apply to an awneofpropeny who builds or improves therenm mit QTY. PLUMBING PERMIT PEE Aar
who comrecbs for such pmjwn with.cnmmmm(M licensed pursuannothe Commcmrs jUN Y u
License Law, PERMHISSUANCE!
❑I am exempt under Sm. ,B&P C for this mason
ACIER-DRAIN&VENT-WATER(?A) 1,1 IT Vr ,aUrLVALtJATfGN
. owns nate
WORactive COMPENSATION DECLARATION BACK FLOW PRO[ECT.❑1!VICIi /�S OU
1 hereby affirm node(penalty of perjury one of @c follarring dedmatinm: /J
❑ Thous and willmeinainuCeniB<aero(Conwnnosdf-insurefor Wodcrs Cntnpen- DRAINS-FLOOR.ROOF,AREA,COND. S'1'ORIFS TYPE CONSTRUCTION
satin..as provided for by Section 37M ol'the Labor Code,fur the sa femadve of the
work for which this permit is issued. FIXTURES-TOM TRAP
I hove and will maintain Worker's Compensation Inamni as required by Section
1M fine Labor Code,for the performance ofine work for which this permit is issued. GAS-PA.SYS'T'EM-1 INC.4 OUTLETS GROUP AIN
My Worker's¢rt tion bnuranc•wirier unit Policy`W •r rc'
Carver: � u Policy No.: > GAS-fiA.SYSTEMOVIiR4(FA)
,. CERTIPICA 1!OPEXEMPTION FROM WORKEiRS' l7 q
COMPENSATION INSURANCE! 6�cTci JAI 19•T� GREASUINDUSTRI.WAS 1'E IN' .RCF.PTOR BUILDING DIVISION ETES
(this section need not In completed if the permit is for tine hundred doll an(5100) - - --or Icss.) GREASE'I NAI' PLANCHECK FEE
I reedy that in the performance ofthe work for which this permit issued,l shall SOWER-SANITARY- 'FIRM PA.20X1 ET.
not employ any person in any member suns a become suhjem m the Weaker,'Compeer ENERGY ITE
z ,z saline Laws i fCalifbmim.Date WATER HEATER ENT/ELECB
Appl'eant GRADING FEF.
[A NG ICE TO APPLICANT:If,after making dais Certificate of Exemption,you should WATER SYST. /TREATING SOILS I BIi
abecame snhjcel to the Wnrkcr's Canpw.stnlon provisions of the Labor Coda,you mush
{lar forthwith comply with such provisions or chis permit shall be deemed revoked. WA'T'ER '. VICE
z CONSTRUCTION[.ENDING AGENCY NE TSIDENTIAL PLMH. SQ FT. PAID ~
I hereby affirm thatthere is a construction lending agency for the perftirn:are of train
te Reeeiplit
2 the work I'm which this permit is issued(See.31197,Civ.C.)
larders Name TO'T'AL:
U Lenders Address TO'T'AL:
I certify aha 1 have mail this application and state lha the above information is BUILDING FEE
It
IAA conwt. agree m comply will,all city trod count'ordinances imitate laws reining to QTY. MECHANICAL.PERMI'P FEE
U z building construction,and hereby authorim representatives.1 his city to enter upon the SEISM IC FEE
It
abavo-manlnned pmpeny fill inspection paposcs PERMIT ISSUANCE
(We)agree m rove,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Tubi lilies,judgn¢nls,cmts and expanses whichne,in any waymem,against said City ALIERORADDTOMECH.
I.curoba,m reb of the grating of this penia. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(To IB,Ixm CIM)
SOURCE REGULATIONS. MECIIANICALP i
AIR HANDLING UNIT(OVER 10.000 CPM) CONS'PRUCTION'I' X
Sigwmrcaf ApplicunJCnntrecmr Date EXHAUST HOCID fW/DUCT) HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoecvpmt same or handle hmallous material HI!ATING UNII(TO 100.00 B'I'U)
as deft tied by the Cupertino Municipal Code,Chapter 9.12,and the I Iwlth and Safety
Crack,Section 25532(.)! HEATING UNIT'(OVER Bo.000 U)
[j Yes Iwo VBN'1'ILA'1'IONI'AN( .' IS
SIN RIU) PAID
Wi11 the applicant or future milding occupant use equipment or devices which Date Rece X
emh hazurdnu air eonmminams os Aelincd by the Bay Arcv Air Qnnlity Manag.tnent BOILER-COMP Q OR 101,000 BTU)
TOTAL:
E]Yl, WQNu HotI.ER-CO (OVER I N0000 HTU)
I evcrcud the heard.....nmmrials requirements ander Chapter 695 of the Cali- AIRCO TIONER ISSUANCE DATE
arms Health&Safety Cade.Smions 25505,TbD3 and 25534.1 understand that if the N1i FSIDENTIAL MECH. SQ.PE
building does not currently have it tenant that it istny responsibility mnntify the occupant
of, require a which feast M met poor m issuance of a Certifir a f 0c mpmcy.
Owner mr.ahonsed(•cm Date TOTAL: ISSUED BY: SSP
OFFICE