S 0950 _ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO 111111,DING-1A.ECI'RICAL PISITN0. 0950
C O
BUILDING DIVISION APPLICATIONMERMIT BUILDING PNti-MECHANICAL J JJ
NG PROJI:Cp iDNNI'IF'ICATTUN
BUILDING ADDRESS C/a SANITARY NO. APPLICATION SUBMITTAL.DATE
Ll�e1Y1o�1K l_lA (fir 1 NU '
O !II °U?R'S NAME PHONE: u CONTRACIOR'S NAME: LIC NO: ��
I 1 " epi RIC CONTROL#
FARCE IITEC'1'll?NGINEER; 1 LIC NO: Y ADDRESS: - ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG I..[.ECT PLUMB MECH
�F ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC P17RMIT FEE
F
hereby affiant that 1 am licensed under provisions M Chomer 9(commencing JOB DESCRIPTION
„�+DOdion](IfN))nf Division Ldthe Rosiness anJ l'ndessions Cnde,and my license is RFSIDENTIAI:
PERMIT ISSUANCL?
orce..,[affect. ❑SFDWL ❑KITCHEN REMODEL
�UF Class Lie#
.cU APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUM BING REIT PE
z LL Cmxrwtor<t ❑MULTI-UNIT ❑STRUCTURAL.ARCHITECT'S DECLARATION PANELS1 understandmy plans shall he use]vs public records MODIFICATION
OZ—O UP'TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
I:. W Licensed Professional - 201-1060AMPS IMPROVEMENT SWIMMING POOLS
Lq` raj OWNER.BUILDIIR DECLARATION OVER 1000AMPS ❑BATH RE IP R TION
I hereby affirm that 1 am exempt from the Contractor License l.vw Int the
�d U following ream..(Section]W L5,Bmimess and potassiums Cale:Any city rot cuuoty SIGNS ELECTRICAL OTHER
W'3 LL F which requires a pnmi,t.comm um,allet.improve,demolish,m repair any xwcwre
f"�f�fnn primm its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCU IT/MISC.
;!(y ohm he Ulicensetl pursunnnntba provl.lnns of the Cnmruetoh License Law(Chupnar9 OMM R IAL:
W a�pO (commencing with Section 9gM))of Division3ofthe Rusines>unJ Professions Crxle)or TEMP:METER OR POLE INST.
a G C thin he is exempt therefmm and the basis for the alleged exemption.Any violation.f [I NEW BLDG/AUDITION ❑DEMOLITION
lisfl Isy
Section 7011,1 by any applicam for apemen subjects the applicamto a civil penalty of 'POWER DEVICES [I TENANT El FOOD SRRVLCE
Zq not more than live himmad,[olli cs(55110). IMPROVEMENT
F� ❑ I.as owner ofthe proper,or my employees with wages as theirsole compensation, SWIMMING POOL ELE(.'PRIC
❑OTHER
will do the work,and the structure is nut intended or offered for cola(See"7614,Business
ase and pmfcssio.s Code:The Comment's Lice. Law dues not apply to an owner of OlIT1.FD'S-SWITCHES-PI%TURES
properly who builds or improves thereon,trod who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC'I'll .Q
Side.If.however,the building or improvement is sold within one ycm of coinpIctiamthe SQ.FT.FLOOR AREA
SISQ.FT.
owner-builder will have the human of proving that he did nut build or improve far par- D
pass of side.)
1,as owner of the property,am exclusively contracting with licensed eommemm to
construct he project(Sec.70,14,Business vad Precisions 1—:1"Commmors Li-
seLawdocsnotapplytoanownerofpropertywhobuildsorimprovesthersm.and QTY, PLUMBING PERMIT FEE No�p ry xny�
who conlmcts mi-meh projects with a amtmon,ri licensed pursuamu,the Communes {{�� C MCI)
Licemc Law. PERMIT ISSUANCH
❑ Iamexemptunder Sec. ,B&PCforthisn:asonCITY O�
AUGER-DRAIN&VENT-WATER OLA) ON
caner Dme
WORKER'S COMPEN. TION DI?CLARATION BACK FLOW PROI ECT.DEVICE
I hereby.flirm ander penalty of perjury ane of the,allowing Aed:uations:
❑I have and will mamma..Cmlfcileaf Consent a self-instar,far Worker's Campen- DRAINS-FLOOR.ROOLARIIA,CONED, STORIES TYPE:CONSTRUCTION
sauna,ms provided for by Section)IDB of the Latin Cale.for the performance of the
work for which this permit is issued FIXTT TRES-PER TRAP -
Fj I have and will maintain Workers Compensation Insurance,as required by Section
3700 ofthc Labor Code,far the performance nflha work far which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number ore:
Carrie,: Policy No.: GAS-EA.SYSTHM-OVER 4 EA)
CERTIFICAT'II OF EX INPOON FROM WORKERS' GREASILINDUS'I RE.WASTE I NTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This swtianneed.,he aompletct time Main isfimme hundred dollars(SIM) GRBASHTRAP
PLANCHECK Plili
or less.)
I cert ify thin innhe pcdnnmme of l he work for which this permit is issued,l shall SEWER-SANITARY-STORM IIA.200 FT.
not employ any person in tiny manner so asubject x to become subjeco the Workers Compen. ENERGY FEE
� 0 sation ApplicLawof California.Date WATER HEATER W/VENTIF.LECTR
GRADING FEE
NOTICE TO APPLICANT:If,after making his Certificate of 1?xemplian,you should WATER SYSTEMIfREATINO
(~ become subject ns the Workers Comp made.provisions of toe labor Code,you must Solus FE,
Wforthwith comply with such provisions or this permit xhallM deemed revoked, WATIiR SERVICE
Q PAID
� zCONSTRUCTION LENDING AGENCY NI?W RI:SIDENfIAI.PLMB. SQ.FT. Date Reccim#
1 hereby uElrm that there is a nmmntmo
ion lending agency,. tic perbmm�nce of
w the work far which this permit is issued(Sea.3157,Civ,CJ
TOTAL:
OU Lenders Name
Lit Lender's Address TOTAL:
I card ly Nat I have read Ihis application and snore than the above mfornmian Is ONLUING ME
4is
E4 correct.I agree nr comply with all city and county arduorces and.arae laws reluti ng to QTY. MECHANICAL PFRMIT FEE SEISMIC FEE
U Z building construction,and hereby amhodm m,eaentatives of this city to enter upon the
imove-mentioned propemy for inspection Ismano s. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino.gninst EL[Cl'NIC FEF.
hah11'nies,judgments,costs andexpensen which may in any wayacemeaglimst said City ALTER ORADDT(I MICH. PLUMBING FEF.
in consequence of the granting of this permi6
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1XNI CFM) MECHANICAL FTH
SOURCE REGULATIONS.
- AIR HANDLING IJNI'f(OVER 111,1N111CFM) GQN$'TRHCTIQN'1'A%
Signatureof ApplicanVComtaetor Data EXHAUSTHOODIW/DUCTI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamar alar,building occupant score mhnndle buwmouslwrodal BEATING UNIT(To IEd,0(IB 11'TU) ,
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the health and Safety BEATING UNI.'(OVER IDI,IXXI BTU)
Calc,Section 25532(a)?
❑Yes -1 No VENTILATION PAN UANGLI!RESLD) PAID
(Jure Rctt'ipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(JHP OR 1110,1X18 RTU)
emit hururdus oair contaminants as defined by the Bay Area Air Quality Management T
District?
L]Yea Na
NO]LER-COMP(OVER 100.000,gBTU)
O
I have madnhe hamrdnus materiakx reyuimmcros under Chapter 6.95 of the Cvli- AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 85115.25537 vnd 8534.1 u.dersmnd that if the NEW RUIDENI'IAL MECII. SQ.FT
building does not currently have a annual,that it is my resrymsibility m notify the srcnpamt
of the rr onenmme which must be men prior to issuance al'a CeniGeme of Occupancy.
Owner or amhurivW agent Date TOTAL' ISSUED BY:
OFFICE
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