S0263 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF
CUPERTINO BUILDING-ELECTRICAL PHRMI'I'NO.
BUI OFCUIVIS Ory APPLICATION/PERMIT PLUMBING-MECHANICAL. S 0263 n C �7
BUILDING PROJECT IDENTIFICATION t7 L v 3
BUIL MING ADDRESS: SANITARY NO. APPLICATION SUBMI'FIAU DXF
3 co LSWit ,ebAO u1Ee 01' St�Al, _CE CA of S/// .
NER S NTNG: 1 /\ PHONE: CONTRACTORS N�/AMF,: LIC NO.
A{IV�� N/C CO IRlll.#
•ARCHITECTUENGINEER: 1 AD RE, ❑
/S�LeWt► RD ;;!f
CONTACT: P ZONE: BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) HLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEB
1 hereby mmora mal 1 am namodmdur pmmsim,of Chapter 9(commenting JOB DESCRIPTION
AaZ wnnSa,i,m7NSpofDlVfFlnn 3ofl,Ba,fncssand Profe..unseode mainly licensees RESIDENTIAL
W4J0 PERMII'ISSUANCE
Fy full Torre and c0u:
n ❑SFDWI, [I KITCHEN REMODELF' ueensa Gen C ipLic.4 98 X 3 0 6
aUU APPLIANCES-RESIDfiNTIAL El ADDITION ❑PLUMHIURAL PIPIT
N. Y Dufe J"S DECL
ARCHITECTS DECLARATI N PANELS ❑NUI;1'1-UNIT ❑51'RUCTURAI,
MODIFICATION
ZZ C",ZZ Iuncrx
dtn ,M1
nd my planaoll be,eced a,public rccnrJs UP TO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
F4tWI Licumed Professional 20I-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER ITNNIAMPS [I BATH REMODEL/REPAIR ❑DEMOLITION
C 1 hereby affirm mat 1 am cscmp,brain the Comment,License Law for the ❑OTHER
01 U following reason.(Section]0315.Business and Pn Lesson,Code:Any city or cmy SIGNS ELECT RICAL
Iv 3 a y which,quires a permit a cmroaocf,alter,mrI dmnolisn,or repair any suunarc
15
pro I , :: 'l. requiresthapplicantf such motor TIsigned sttement SPECIAL CI RCUIT/MISC.
999 ,15 Thatne is licensed frommort be pro,ovim,of n Commi License L (Chaptery COMMERCIAL:
Tic yp0 (co nencngwth Sect m 7000)of Dlvlsn 3ofihe Bu,ines dP Is,man Cale)or TEMP.METER OR POLE INST. El NEW R,UGIADDITION E]DEMOLITION
L G e Thal he is exempt Ihercfrnm and,he basis for the alleged rv,m,ar n.Any violation nl
x r^, Sedinn]ID 15 by any applicant far o permi,suh)enc lbe npplievnt In n dvil penalty o[ POWER DEVICES ❑TENANT El FOOD SERVICE
nm mote man five hundred dollars S51A)).CSS IMPROVEMENT'Luer ownerof,he pmpeny.ur my employees with wage,us their Bole compensation, SWIMMING POOL ELECTRIC
2E• will dothe work,ondthe%fracture is not untended oro0ered for sale(See.9M,I,Business ❑OTHER
L a m and Professions Cade:The Contractor'.Limn,c Law dues no,apply to to owner nb OUTLETS-SWITCHES-FIXTURE'S
p.,peny who build,or imp,rves,hercon,and who does such work himself or In 11,
hi,own employers,provided thin such instance cuts are not intended or offered for NEW RESIDENTIAL ELECTR SQ FK
sale.If,howeve,the huddmgarimprovement issnld wiminon,yeanufeurn Om The SQ.IT FLOOR AREA $ISQ.FI�
owner-milder will have The burden of proving that he did nm build or improve for For-
grso 0frule). IOIAL: PAID
❑1,as owner of the pro pcny,an,exdusively contracting with licensed contractors to
mehue the project(Sec.AIM.Business and Professions CndeJ Tlie Cnmracmr'a Ir-
cause Law msrsnot apply it)anowner tit pn,thy who builds or improves thereon,and QTY, PLUMBING PERMIT FEE -
whocontmcTsr such projects with amfnmaaM1l licensed pursuant o the Ciampi JUL—7 MCI)
License Law. PERMIT ISSUANCE
1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAINT-WATER TEA) AI N
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PR .DEVICE
1 hereby of oto under penult,of perjury one of the following dManda ns
I have and will maintain a Certificate N Consent to self-insure for Workers Camper- DRAINS-FLOOR,ROO, E ,C D. STGRIFG TYPE CONS'I'RUCTIOI
satinn,as provided for
by Se:Imn 3200 of the Labor Cade,for the per armence of'he
work fir which thispcnnit is I....d. FIXTURES-PE P
Fl I have and will maintain Workers Compcn,iirn Insurance,as required ny Senim
3700 of The Labor Code.for the performaneu nfthe work for which This permit i,issued. CAS-EA.SYSTEM H4 1 S OCC.GROUT' APN
My Workers Compensadnnln}urance carrier and Policy number am: GAS-EA.SYSTUiM OVER Y(EA)
Carrier: �� Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' GR EASEINDUSTRL WASTE,I NTERCEFFOR
COMPENSATION INSURANCE BUILDING DIVISION IBES
(Thissec,ionneednotfiumnnplGed if the puna,is forms,hundred dnllan($I(s) GRF,ASETRAP
PLANCIIECK FEE
or tacitI
I ready lbar o the anyfom er11, s,,become
me-bor Is runfir, .ken,d,lshnll SEWER-SANITARY-STORM EA.200 FT.
not anpiny any Person in any nwnner an o,nc become wbjec,,o the Wnrkerk Compere ENERUY FEE
Z Orion Usw,of Califnmia.Date WATER HEAT ER WIVES r/ELECTR GRADING PEE
Z O Applicant
NOTICE TO APPLICANT: ,after..king this Cendicate of Exemption,you should WATER SYS"1'EMI TRENINC,'V1 If, kthSOILS IEE
a �
become
ilitco ply ,I Worker 4Cornpenmhis Permit'
hall of The in WnoreCode,you must
6,nnwnn comply whhsncn pmvhsinm err mi,perms.Ban be aeemw revoked. wn9ER Seavlee
Q PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMB. SQ.FT Data tee in W
Z I hereby affirm mot there is irradiation lending agency for the performance of
Uthework for which flax p,am i,issued(Sce.30v7.Civ.C.) TOTAL:
Q Lenders Name
Lender',Address 'IT)TAL:
L1 certify that I have read this application and state thou the ahoy information ix BUILDING BE
fes. N roman.lagmc,t wmbly with all city and county ordinanr s and nhnc laws relating, QTY. MECHANICAL PERMIT FEE SGISMI FL
Uz budding conlrun'ren,and hereby authorize representatives ofmLtchym constraint the
abovamentioned property for in,pectam purposes. PERMIT ISSUANCE F,LECTRI E.
(We)agree In save,indemnify and keep harmless the City of Cupcninu against
habiliics,judgments.ena.and expenses which mayln any way accrue a,linnsnid City ALTER OR ADD TO M ECK PLUMBING FE'
in cnreequence of the granting of Thin Perini,.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MF,CHANICAI FEE
SOURCE REGULATIONS, 1�
AIR HANDLING ON]r(OVER IOJHN)CFM) CONS9'ItUCTI)N TAX
igratureol'ApplicaparCon" to EXHAUST HOOD(W/DUCT) HOUSING MIT TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tar uppliwnf erlumrc huilJingoccupam store or handle hazardous. credit HEATING UNIT(TO HNI,WO BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the health and Safety
Coda Section 25532(al'! HEATING UNIT(OVER 1 W j)(00 BTU)
❑Vias ❑No VF,NTILA'U'[ON FAN ISI NGLE RESID) PAL[)
Dam ccip,a
Will The applicant or lmure building occupant not ar,myranor devices which BOILER-COME(3HPOR 1110f)(nl BTU)
mil h o,ardtun air communion,is defined by the Buy Arca Air Quality Managemen, i'TO'I'AL:
Diarc,? BOILER-COMP(OVER HxIApO BTU)
❑Ye" [-I No
AIR CONDITIONER ISSUANCE DATE
1 have read the hazardous materials nequi,mcros under Chapter 6.95 nbthe Cali-
an
Health&Safety Code,Sections 25505,25533 end 25536.1 r re,land,hat if the NEW RESIDENTIAL MECH. SQ.PT,
building dos nor currently have a Iconic IM1e,it is my'a"ac'mility to notify the ocupam
ofthc¢quhcmma which ma,,lame,prior In nemencca(a Cunilirete of Orropanry,
Owncroraulan,rd agent Data 71
TOTAL: ISSUED BY:
OFFICE