S 1074 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
;ARLCH1TECt/1rNGIN
F CUPF,RTINO ItI111.DING-F.LF.LTRICAI, PgiW11T N0, O
74
ING DIVISION APPLICATION/PERMIT DING PROJEB NG h IDENTCHANICAL. PIT
NUILDINO I'ROJEGT IDNMIFICA'1'ION
ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
b NA E PHONE: . 'TRACT'OR'S NAME: LIC NO: N/C WNTR04g
CER: I`J LIC NO: ADDRESS: - ❑
1. c u VVV
CONTACcPHONE: BUILDING PERMIT INFO
Lrkt 7ig7 Z� ❑ Consultant Fees Paid by Applicant(Initial) BLDG F rLU ME
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affront that I nm licensed under prrvislom,of Chapter 9(commencing JOB DESCRIPTION
1i1y aZ with Section Division 3 of The Business and Professions Cade,and my license isRESIDENTIA
f400 in full force and eqe PERMIT ISSUANCE L:
hiccnse Class LiC.mM ��/� SFDWL El KITCHEN REMODELGREMODELAPPLIANCES-RESIDENTIAL (TION ❑PLUMBING RE-PIPE
Hoa a mclr O
p.7yN MULTI-UNIT ❑STRUCTURAL
r PANELS FICATION
ARCHITECTS DECLARATI
Z O yj Z 1 undersand my plans shall he used s public records MODI
OZ- UPUP TO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
F.y.�UJ Licensed Professional 201-I0B)AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER HXXOAMPS ElBATH REMODEUREPAIR C1 DEMOLITION
Wp, 0� I hereby alTlno that I am exempt from the Contractor's License Low(or the
P� L V Inllnwing reason.(Stolon]1131.5,Business and Professions Cale:Any city or county SIGNS ELECI'RICAI. ❑OTI IIiR
aJ which acquires a permit to conswct,alta,improve,demolish, ucmrc
or repair any str
*3¢, which
prior m its issuance,also requites the applicant Gorsuch perainn file a signed statement SPECIAL CIRCUTfIMISC.
M} that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
- y'p0 (commencing wi"ection7000)of Division 3of the Business and Professions Craft)or TEMP.MEIER OR P0LE ST COMMERCIAL: p e o{t�/
0.q m K that he is exempt NereGnm and the basis for the alleged exemption.Any violation of ❑NEW NLDG/ADDITBiN p'a❑UGMOLffION
iYCI 4. Section 7031.5 byonyapplicam forapermii subjectstheapplicam to acivil penalty of POWER DEVICES Y
ZZZC�
no,more than five hundreddollars($5B0), iPROV ❑FOOD Sj ICE
F swC ❑ I,as owner of the pmpeny,nr my nnpinyceswiThwagcsaxthcinnle conmEcnsutinn, SWIMMING 11001,ELECTRIC IMPROVEMENT
�(9 gII1I�w��
3C will dothew.rk,and thestrature isnot imendedorrdlcord pronate(Sec.]0W,Business ❑D'I'NER d_h'',xxe�--�{M�(� _
W and Professions Calc:The Connector's License Law does not apply to an owner of OUTLETS-SWITCHI;_ TURES
propery who builds or imposts thereon,and who diva each work himself..through 1.
his awn employees,pmsidOd that such improvetrents am nm intended or.ffeacd far NEW RESIDENTIAL ELE S ur
1 TO.IL howeve,the building or improvement is sold within one year ofcomplaion,the 1 SQ.E. N:A VSQ.FT.
wner-builder will base the burden of proving that he did non hill or improve fur par K� (`►"JJIT•tJ
Fre of sale.).
❑U as...c,of the Empeny.am exeliowdy cartel with licensed contractors m AI
rnnstmct the project(Sec.900,Business end Pmomi,siams Co—,Tne Commcmr's
m Law does not apply to an owner.(Emptily who builds at improves thereon unit QTY, PLUMBING PERMIT FFEE
who emarnets for such projects with m contrtemn(s)licensed pursuanEm the Contractor's
Licenu Law. PERMIT ISSUANCE
Adifti,C] I am exempt under Sec. .13&P C for this reason
ALTER-DRAIN&VENT-WATER(PAT VALUATION
wner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby aRrm under penalty ofperjury,one of the following decorations: a
;37N)
have and will maintain a Certificate of Consentto self-in.sme for Workers Compel DRAINS-FLOOR,ROOK AREA,CONE). STOR 'TYPE CON STR UCTION
n,as provided 1'o,by Section 3700 of the Lahnr Code,for the pedonmanco of the
k for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compcnsution Insurance,us required by Section
ofThe Labor Code.for the Nrformanceo(the work(or which this Permit is issnul. GAS-EA.SYS'IEN1.1 INCAOUTLES OCC.GROUP APN
Workers Cnm cnsmiInytsv)cg c. and Polirynu her
Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
e R WICATH OP EXEMPTION FROM WOR ERS' GRGSI%INDUS'I'RL WASTE INTERCEPTORCOMPENSATION INSURANCE GR I) ISION EEES
finis weliunnecdom he completed if the permit is for..hundred dollars($1(X11 GREASETRAP
or fes'.)finis
FF.F. �
I certify That in the performance ofthe work for which this permit is issued.l shall SEWER-SANITARY-STORM EA.21X1 FI'.
not employ any person In any manner so as m become subject rot the Wmkers'Compem IPs.RGYFEE
Z smi.n Laws of Cidumnin.Duro WATER BEAT HR W/VIiNf/HLECTR
Applicant ' GRADING FEE
uJ NOTICE TO APPLICANT':If, he,making this Cenificmn of Exemption,you should WATER SYSTEM/I'BEATINC
a become subject to the Worker's Compensation provisions of the Labor Code,you mon S(IIIS PEE
Lal forthwith comply with such Erovidimis or this perrnit shall be deemed revoked. WATER SERVICE
d n
U z CONSTRUCTION LENDING AGENCY NEW RGSIUIiMTAI.PLM,. SQ.Ff. PAID ate ai T p
I hereby affirm thin mitThemi is s contraction(Sce3 lending7.Cagency for the Performance of p
V the work for which this permit is issued(Sec.3(197,Civ.CJ
u" Isnder'n Name TO'fAl:
U Lenders Address -
LL I certify That 1 have read this application and slate that the above m6n m bon is
BOE. m EE
Vl correct.I agree to comply with all city and county ordinances and stale laws reining to QTY, MECHANICAL PERMIT FEE
V Z builJing cnnswmi.n,and hereM1y euthoriu representatives of this city To enter upon the SHISMICFEP,
abnve mentioned proPerry 4e inspection purposes. PERMIT ISSUANCE O
(We)agree to save,indemnify and keep hamdess The City of Cupertino ii,mna ELECTRIC FF.E
liabilities,judgments,costs and expenses which may in any way acerae against aid City ALTER OR ADD TO MECH.
seyuencc of the Ting of this limit. PLUMBINGFEE
imm� BST p
AI'PLICA NDF�4T NI D LCOMPLY WITH ALL NON-1'OIN'f AIR HANDLING UNIT(TOIa,fNNI CPM)
SOUR EG IL IFI S MECHANICAL FEF. 5-11,710
d- r I_ Z C3 AIRIIANDI.INOUNI'f(OVERI(I,INNICIrM) CONS'I'RUC'HONTAX
17
Signamre.f App1w.m Ccmmmor Dara �! EXHAUST HOOD(W/DUCT) HOUSING MITIGATION r%
HAZARDOUS MATERIALS DISCLOSURE
Will tbeapplicant or far..building necupanutone or handle haeardousana.trod HEATING UNIT(To 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.124 and The Hca1N and Safety
HEATING UNIT(OVER 10(1.000 BTU)
Cade.Section 255320d?
❑Yes ❑No VENTILATION TIAN(SINGLE REMD) PAID
I Date Rccelpt X
Will the applicant or future building occupant use equipment or devices which
emir haamdous air puna rinan s ns defined by the Buy Area Air Quality Management BOILER-COMP(3HE OR 100,00013.1'ID ,TO,TAL.
District? BOILER-COMP(OVER 100,000 BTU)
E]Yes F7 No
I have mad the huxmmus materials requirements under Chapter 6.95 of the Cali, AI R CONDI'I'IONER ISSUANCE DATE
Tornio Health&Safety Cale.Sections 25505,5533 and 5534.1 undo stall that B the NEW RISIDENI'IAl.MECH. SQ.FT.
building doesnm currently haveaenact,That it is any esponsihility minify the occupant ..7�./�� ,
of the"airemems which must he net prior to isuance of a Cerrificaa of Cecupancy. q.\�V�V/���
Owner or auNonmd agent Dace I I AI_ ISSUED BY:
OFFICE