30198 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Al Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 019 8
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL �)X�/ I
HUII.DINO PROJECT IDENTI PION {// u
BUILDING ADDRESS: UBMITTAL DAD
Vim b v fr.�/TJO SWIMI"t -010,.
OWNER'SNAME: PHONE: CONTRACTOR'S NAME: LI O:
J N/C/C CONTROLp
ARCHITECT/ENGINEER: LIC NO: ADDRESS: / /� �/ ✓r//C 4
C�A�� 1,,/ TONE: ,v v/!BUILDING PERMIT INFO
E^` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MP,CH
v a.7 lJ
I hereby afirm that I..licensed under provisions nl'Chapler 9(commemi.A QTY. ELECTRIC PERMIT FEE
AS JOB DESCRIPTION
�00�2 with Smtion](XllpofDivixion3afthe Business and RofessinnaCsdc,and mylicenseis RESIDENTIAL:
0 PERMIT ISSUANCE I.full force and effort.
QU License Class l.ic.X ❑SFDWL ❑PLUMBING
FFZd Dme Cnnvacmr APPLIANCES-R151DfWT1AL ❑ADDITION ❑PLUMBING RE-PIPE
Iy„py ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
Z O m Z 1 understand my plans shell ha used us public memds MODIFICATION
OZ— UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P4H Licensed Professional - 201-1000AMPS 'IMPROVEMENT
gg OWNER-BUILDER DECLARATION OVEREMIAMPS [:1 BATH REMODEDREPAIR El DEMOLITION
1 hereby affirm that I Am exempt from thee Controntrucmr's License Low for the
ig5O6U following reason,(Section]031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER /�
f LL'y which requirca a permit so emamin altar,improve,demolish,w repair any structure ���(f Me s/k'�l /"rrOl
qq prior m its issuance,else requires the applicant for such peanut to file a signed statement SPECIAL CIRCUIT]MISC. b '(f�_
2 y orommexlicenwit pursuan700o pro visions of the
eBusinessnd Professions
Codter9
(commencing with Smtion]tlfl(B of Division3of rh<Busineas and Professions Code)or TEMP.METER OR POLE MST. COMMERCIAL:
a e' Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�,rn Section]031.5 by any applicant for a penton subjects theapplicanttua civil penahy.f POWER DEVICES []TENANT ❑FOOD SERVICE
Onot mom dun rive hundred dollars($508).
❑I as owner of the pmpety,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
5 will dothe work,and Ne snielure is nut intended ar offered hostile(Sec.7044,Business ❑OTHER
'EE33,3 and Pmfestrou Code:The Contractors License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended w offered for NEW RESIDENTIAL ELECR SQ PT.
side.If.however,the building or improvement is sold within one yew of completion,the SQ.FE FLOOR AREA $/SQ.FT.
ownerbuilder will have the burden of proving that he did not build or improve far per-
poseaf.E.).
❑ 1,as owner of the propeny,am exclusively contracting with licensed conuacwrs to TOTAL:
mnstmm the project(Sm.7044,Business and Professions Cale:)The Conuacmr's Li-
cause Law docs not apply to an owner of properly who builds or improves thereon.and QTY, PLUMBING PERMIT FEEe�--
who contracts forsuch projects with s contmnof(s)licensed pursuant m the Conuactor's
License Law. PIiRMIT ISSUANCE
C]l Amexemptundar Sec. ,B&PCfoldir son
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dale
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE n) �.,l U„\
I hereby afess under penalty of perjury one of the following declarations C/ (IULT
•(]I have and will maintain a Certificate ofComent in salf4risam for Warkers Compam- DRAINS-FLOOR,ROOF,AREA,COND.
scion, provided fm by Section 3]00 of the labor Cale.for the pcnbrmence of the STORES TYPE CONSTRUCTION
work for
which this permit is issued. FIXTURES-PER TRAP
❑I have and bill maintain Workers Compensationw Insurance,ns required t i Section
37W of MyWwhes Co peNe,fonthe Insuracee.ieofthe work for which this permit is issued. GAS-G.SYSTF.M-1 INC 40IITLET$ OCC,GROUP APN
My Workers Compensation Insurance carrier and Policy number ere:
Currier. Policy Nn.: CAS-LA.SYSTEM OVER a(EA)
CERTIFICATE OF EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
(This section need nm be completed ifthepermit is for one hundred dollars($100) BUILDING DIVISION FEE-9
or Iass.) GREASE TRAP
PLANCHECK FEE
I employ
any Pet in the anyPerformanceinrof the work for which Nis permit is issued,[,halt
nut em lay un person in any nunnersn urns become subject to Wnrkerv'Com en- SEWER-SANITARY-STORM EA.200 FT.
P Y Y p ENERGY FEE
ration Laws of Califomia.Data
z O Applicant WATER HEATER W/VENT/F.LECTR GRADING FEE
ti NOTICE TO APPLICANT.117.4er making Nis Cenificam of Exemptioa ywshould WATER SYSTEM?RGATING
a ' necome subject to the Workers Cia,awsmioa provisions of the Labor Calc,you mea SOILS FEC
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.t•T. PAID
L)0 I hereby affirm chat there is a construction lead'ag agency for the performance of Date R iptX
hL ss the work for which this permit is issued(Sm.3197.Co,C.) '
O F' Lender's Name TOTAL:
WLenders Address TOTAL:
Q., 1 certify that 1 have read this application and state that the Above information is BUILDING FEE
IZI correct l agree to comply with all city and county ordinances and state laws relating to QTY_ MECHANICAL PERMIT FEE
L) z building construction,and herchy author.rcpresantativex of this city to enter,upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,iadmindly and keep hamdess the Cry of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way Avenue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10,000CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTIONTAX
Signature of Applicant/Contracmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hrsandous material HEATING UNIT ITO I cad"BTU) �
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Ileckh and Safety
Cale,Section 25532nd? HEATING UNIT OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt X
ermt hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
District?
❑Yes ❑Nn BOILER-COMP(OVER 100,0X10 BTU)
I have real the hazardous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 25505,15533 and 25534.1 understonal that it the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant that it is my Armonsibilay to notify the occupant
of dee regoitements which must be met prior to issuance of a Certificate of Occupancy.
Ownmoramhadaed Agent Date TOTAL: ISSUED BY:
OFFICE