S 0574 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO C
IRA LDING-ELEIRICAL P1511 NO. 05—A 5-4
BUILDING DIVISION APPLICATION/PERMIT ILUMRING-MECHANICAL
IIUILDISGPROJEC'tIDKN'IIFICAIION
BUILDING ADDRESS: SANITARY NO. APPLICA'I ION SUBM1'I'I'AL DA'F11.
CA I logQ
OW ER'S NAME: I'IH)NB CONTRAC LIC NO.
61991;�LA to N/C CONTROL#
• A CHPTECTIF.NGI EER: LIC NO: ADDRESS: ❑
CONTACT PHONE. F BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
T *Kr ❑ ❑
LICENSED CONTRACTOR DECLARAI ION QTV ELECTRIC PERMIT FEE
I hereby union that I am licensed under provisions of B
Chapter v mmnencing JOB DESCRIPTION
DMZwith Section 7000)of Divisinn3ofnne Business and Prnfesaons Code,and my license is RESIDENTIAL:
LL O PERMIT ISSUANCE
1LLO in full fore.and eet. to,SS`18d(i ❑bFDWL ❑KITCHEN RIih10DEL
¢ U License Class hw.a ` R OlT4w7l.r FGJ APPLIANCES-R RESIDENTIAL ❑ADDITION ❑PLUM BING RE-PI PIi
1-1W Date Con'.
m¢a ❑MULTI-UNIT [I STRUCTURAL
F.Dy ARCHITECT'S DECLARATION PANES MODIFICATION
OZ=z I understand my plans shall b[used as public records UP 10200AM15
❑INTERIOR [:J CHIMNEY REPAIR
1- W Licensed Pmfecsional 201-1010AMP'S IMPROVEMENT C]SWIMMING POOLS
5 C' 1 hereby firm OWNthat I amexemptfrom the onlrec uta License Law for the OVER 10011 AMP'S ❑BATH REMODEVRIiPA1R [I DEMOLITION
O a U following ruwa(Section 1roati Business and veP[ssinna Code:My city o structure SIGNS ELECTNICAI. ❑QTHER
6:3LLy which its issaupermit ascores due,altar,it for
demolish,ore a sig-1yawment
FNON j priormits issuance,also requires the applicant for such Pennino filcusignedsta¢menl til'T:CPAL CIRCUITIMPSC.
fy)Y that he is licenseApumuam lathe pmvixinnsoflhe Commcmrs License Law(Chapter9
�IypO (commencingwim Section 7000)of Division 3 oftbc Busincssanl Profesdons Cad0or I IN P.METER OR POLE INS'L COMMERCIAL
a ac C that he is exempt therefrom and the basis for the alleged exemption.Any violation of 11NEN'BLDG/ADDITION El DEMOLITION
X m_LL Section 1031.5 by any applicant for a permit subjects the applicam to a civil Penalty of POWER DF ICES ❑TENANT [I FOOD SERVICE
LL �' not come man five hundred dollars($500).
P-=QI,as own[nd the n,nrm to ea with sen cex their ole coo tion. SWIMMIN .ELECTRIC IMPROVEh1 �TMa�r�w�„A
O ❑ pope Y Yer^p Y 6 penia DOTTER EK\ \1M�
F willdothework,.ndthsurtworersnot intended or offered for sale Nec.10,14,Business
W m and profexsionr Code:no Contractors License law dam nm apply bn an owner of OUTLETS- HES-FP "S
property who builds or improves Ihemun,and who Jas such workM1imsdf orfIhmugh
his own employees.pmvidcd than such improvements are not imended or nfcmd fnr NEW RESIDEN AL R SQ FD.
sale.If,however,the holding.,impmvemem in sold will.one Ycvrnfcompletion.Ibc SQ.FT.FLOOR AREA 95Q.Fr.
owner-builder will have the burden of proving that he did not build or Improve for pun- PAID
pose of rola). TOTAL:
❑I,m owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.1044.Business and Professions Calc:)The Contractor's Li. AUGense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLU NG PEUG o
R FEE V u REM F■
who contracts for such projects with a camractorpl licensed Pursuam ns the Cnmracnrta a�
License law. PERMITISSU
C]I.m eaempt ander Sec. .B&P C for lis reason II Y UI- Wre
AI. 'R-U N&V AT (EA) VALUA'1'10
Owner Unm
WOR KERS COMPENSATION DECLA RATION RACK FL WPRO" DEVI F:
1 hereby affirm under penalty of perjury one of the following declatatinnn
[have and will maintain a Cerilicale of Comwat to self-insure for Worker's Cumpero EDRAINS-11.0 .R( .A .0 STORIES TYPCCONSTRUC`RON
inas provided for by Section 31Wof the Labor Cala,fir the perluna.ce of Phu
work for which lis permit is issued. T R1 have and will maintain Workers Compensation Insurance,as required by Section
.T ofthe Labor Gude,bathe perfnfmanecofthe work for which this pernnil is WsUN. M-I INC UTLET: OCC GROUP APN
My WorkerC p,araian Insurance carrier and Policy nnsber umCartier: Fel mLa� Policy No.: iM(1VF:H4(HAICERTIFICAIEOFEXE PTIONFROMWORKiRS' F �H 'RL WAS DE INTERCE H
COMPENSATION INSURANCE B L )I VISION F'>S
(Thlxseclion need not In,crn.pl[Fed if the pe,all,is fornne nundreddulluts 1$11X) GREAS Ii TRAP
r hx I PLANCI{ECK FL
I mylktnthe pen ofmc work for whivhth pe t : sned.Islnll SitWLH-SANI'I'ARV SI(1HM EA.200 Frnal ply ypa. n" y an�, ,,ba nnc subtest to II W krd Cnapen, ENERGY FEE
za
suna LuIws of CUlitoola.Dna WAI'17R HEA!FR IN VEN UELECI'R GRADIN '
zO Applicnnl
r-I V) NOTICE TO APPLICANT:If,afmr nwking this C10illcalc of Excngs0on,yon sImmo WATER SYS'FEMO`REA'1'INC,
[-� bearmc rnhFul ,,me Worker's C.nn tion frac Luhor Coda I SOILS PE
1 p[nau Plnvieinn1 n you non
forthwith comply wits such Pnrvisinn.v or his perinil xhull Fu Aan¢d revoked. WAI'EN SERVICE
WW
fir
CONSIRUC'IION LENDING AGlIan, NIiW RIiSIDIiNTIAI,P'LMB, SQ.FT. PAID
I hemhy vfEsenlnw mere isunnnswninn lending uben<y tin the perlircmnncc of D� a Recciptp
U O me work f(r which this Perfat s m Sec.3097.Cis.C.)
OF LcnJere Nume isi m 'DOTAL:
L) Lenders Address
'I'(Il'A1.:
r 1 I certify that I huv read lis applicminn and amac mm the vbovc information is RU ILDING EE
nFih corzcct lagrecm comply with all city and countyoxuan s bull4ata laws«llingm QTY. MECHANICAL PERMIT FEE SEISMIC ik
U building conslmction,and hereby audarisc representativesof this city it)enlerugm the
above-mentioned property for inspection tarlovs VERM11'ISSUANCE ELECTRIC FEIi
(We)ugc,to s' indea rmless the Cayof Cl, an.ugalnst
liabilities 1,,c -x os hichmin anyway accrucvgabaa said City ALTERORADDTOMECPL PLUMBINGF-E
unconse cenft gr ung finis per nit.
APPIC TUN 4 L CO D'LY WITH ALL NON-1 INT AIR HANDLING UNIT(T(l 10.0X1CFMI MECHANICAL FEE
SOURC EG I(NS.
_ AIH IIANDLING UNI'I'(OVER 10.000 CFM) CONSTRUCTION TAX
Si pp licrntsComnixt. ate EXHAUST HOOD(W/UUCT) HOUSING MITIGATION E
HAYARDOUS MATERIALS DISCLOSURE
Will thcapplicant ar fumrc buildingacupamsurto nrhmdlc hwunor,rimuml HEATING UNIT(TO 101.000 RTU)
as defined by the Cupertino Municipa-1 1CpJe.Chapter 9,11,and the Health and Safety
Code.Section 25532(.)? /{ n N HEAPING UNIT(OVER 101,0X%1 BIO)
]Yes rN VENTILATION PAN(SINGLE RESPD) PAID Dat[ Re -iptN
1,11the applicant or future building nwcupant use oximpmem a devices which BOILER-COMI'(3H1'OR 101.003 BTU)
lot emit his Mous air comaminanl'as thebyby the Bay Arca Air Quality Management 'TOTAL:
District? '(5L^�l.`' hrl� BOILER-COMP'(OVER IW.gp BTU)
❑Yes o
I have rthe by d mccomes under Chapter 6.95ofdw Cali- APR CONDITIONT:R ISSUANCE DATE
far .Health&Safe t a�Se[IRm ''505, 5533 and 255.W.1 understand that if the NEW RESIDENTIAL MECIL SQ.ET.
huilding dsws s' v Mnant,IIha'skyrezpmsihilily Inn Wily the«eUI'vnl
oflM mquitn nts is m 4 ce ofa Ccnificam Aa
cy.
Owner or gent en notes TOTAL: ISSUED BY:
OFFICE