29828 i' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMITNO. ^/� /�/�/�
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL. L V4 VX L 8
I BUILDING PROJECT IDIWI7RICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
` �y I �
OWNE 'S AME; PII N COe CTOR:S NAME: IC e
NAC CO TROLX
AR ITECf/ENG LIC NO: ADDRIiS ' ❑
T c+l,
CONTACT: PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant Qnllial) BLDG Ii1.ECT PLU B MECH
❑ ❑ ❑
LICENSEDCONTRACTOR'SDECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ef0rm that 1 am licensed under provisions.f Chapter 9(commencing 106 DESCRIPT
�D 00 with Scuion]O(p)of Divisi.nl.f Ne Business and Pro1'exsions Crak,andm license is RESIDENTIAL:
1 ��4�O full(nice and If�u y PERMIT ISSUANCL
,ij m Cl..,,,
❑A DWL ❑KITCHENREMODEL
F6UV License s LIO.X
yQL Dme� Commnor AI'PLIANCFS-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
L-�py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT '❑STRUCTURAL.
zp n Z 1 unJersNnd my pions shall be usW as public rtcnrds MODIFICATION
0Z—p UP 10 2M AMPS
Licensed Professional ❑INTIiR10R ❑CHIMNEY REPAIR
ey$$yf•l OWNER-BUILDER DECLARATION 201-IWUAMPS IMPROVEMENT
of R beach,1 hhy sTrn that 1 am exempt front ramo
the Contrs License Law for the OVER INSAMPS _ ❑BATH REMODEUREPAIR ElDF.MOLI'FION
OWVb. following reason.(Section 0031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
i LLO which reclaims a permit m construct,alter.improve,demolish,or repair any structureT�I 0 :)-
prior to its issuance,also requires the applicant for such permit to dile aligned statement SPECIAL CIRCUIT/MISC. I /R_
'�y thmheislicensedpursuanuoNePmvisinvoftheComncmr'sLicenseLaw(Chapner9
gp0y (commencing with Section 70100)of Division 3 of the Business and PrMcssions Code)(it TEMP.Ni PULE INST. COMMERCIAL:
4 Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION [I DEMOLITION
4•
section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEV ICIig
on
unre Nan live hundred dollars($500). TIiNA FOOD SERVICE
Ic�Qn0Lvsownerofthe pmpcny,ormyemployees with wages vsdocasnlecompsmalion, SWIMMING POOL ELECTRIC VEMENT
t3$ will do the work,and the structure is not intended interfered basalt(Sec. Business ❑OT .R
en
and Professions Code:The Contractors License Law Js not apply to an owner of OUTLETS-SW11'CN
ES-FIXTURES
_GG property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements um not intended or offered for NEW RESIDENTIAL ELCCTR SQ Pf.
aide.If.however.Ne bmidingwimpmvemem issoid widair,meyeartifrompletion,the SQ.FL FLOOR AREA $/SQ.ET.
aowner-builder will have the burden of proving the,hedid not build orimprovefor pm-
pos,ofsale.),
CI I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the prajeel(Sec.7644,Business and Profession,Cale)The Contrm:mr's I.i-
seLaw does act apply toanowner ofpropenywho builds orimproves mimon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjecta with a cmttmemr 0licensed pursuant to the Conbnemrs
License taw. PERMIT ISSUANCE
❑I sm exempt under Sec. ,H&P C far this reason
Owner Date ALTER-DRAIN&VENT-WATER(1'A) VAL11.KiON
WORKER'S COMPENSATION DECLARATION BACK FLOW PRIlTEC'L DEVICE �1 V
1 hereby affirm under penalty of perjury one of the fallowing declarsame, O(/
.❑I have and will maintain a Certificate of Corciato selbinsure for Wwkees Compen. DRAINS-FLOOR.ROUE ARRA,GOND.
cation,as provided far by Scetion 9900 of the Imes Codo.far the performance of rho STORIES TYPE CONS1'RUCf10N
work far which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance.its required by Section
3700.1'the Labor Code,for the Ecrfnrmarecof the work for whiA,his pemsil is issued GAS-FA.SYSTEM-I INC.40UTLE'1'S OCC.GROUP APN
My Worker
Cnrlar: C�g1cCLEic' h
•��cort� ld/ GAS-EA.SYSTEM-OVER 4(LA)PoicyN
CAPE
OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GRBASFJINDUS'IRI,WASTE INTERCEPTOR
(This section need not be completed if the pcoait is formic hundred doll.,151 W) BUILDING DIVISION FF!IS
w less.) GRLASE TRAP PLANCHI3CK FEE
I verify that in the performamceofth...ik for wh id,this permit is issued,l shal l SEWER-SANITARY-STORM G.200FT.
not employ any person in any manic s v m r t cynbjen io the Workeri Compen- ENERGY FF.F.
z ,anion Laws of Calif. Uric le--
Q WA'1'13R❑1!A'fER WIVCNT/CLEC'fR
O Applicant k-AJ GRADING FEE
to NOTICETO APP ICAN31L e r makmg this Certificate of Csemption,yon should WpTCR SYSTEM/1'REATING
a hcwme subJccnn th.W ker's Canrpenmtlnn prnvlslons of the Lnlsnr Cato,you mustSOILS PER -
faMwiNcomplywimsuchprovidn%.amispeoniuhall bcakermlrevoAcd. WATER SERVICE
CONSRUCT10N LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.LT. PAID
I.J kfor which
ismal i isamn(See i0lending agency forthe perfonnunce of ( Date Receiptp �
D.U La work for which Ihie permit i,issued(Sec.J09],Co.C.)
0 C.1 Lenders Name sh'a s �b TOTAL:
Lenders Address - TOTAL:
CLI1 certify that I have rend Nix application and cram thnnM1e above information is BUILDING MEC �`2
VI cormct.l agree to comply with all city and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT PI7E
U,Z building construction,and hereby authorim representatives of this city to aver upon the CIs MW EER w•
above mentioned property for inspection purposes. PERMIT ISSUANCC ````
(We)igre,to save,indemnify and keep harmlessthe Ciiyof Cupeninongainst s%7CCTRIC FEE .
liabilities,judgments,costs and expenses which may in any way accrue 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 NOY POINT AIR IANDLING UNIT(TO 10.000 CFM)
SOURCE R/Fy/�,LATIONS.
dt / J CMECHANICALFEE
� AIR IIANDLINGUNIT(OVER 10.000CFM) CONSTRUCTION TAX
Sig rt A c i mrowmr Ir Dam EXHAUST HOOD(W/DUCI7 ' HOUSING MITIGA'T'ION PCE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Invitations material HEATING UNIT(TO 100,000 BTU) a
as defined by Ne Cupertino Municipal Code.Chapter 9.12,tied the Health and Safety AP
Code,Section 25532(a)^ HF.A'I'[NO UNfr(OVER 104.000 BTU) MA
❑Yes FNo VEN'I'I LAI ION PANS INGLE RESID) PAID
f.IiY . Vsin Ls Q�sl R.;PIX
Will the applicant or future building occupant y A equipment or Marta which
emit rlet?rdous air contaminants as defined by the Bay Amu Air Quality Management BOILI3R-COMP(3FlPOR 100,00OBTU)
District]
TOTAL,
❑Yes "IN. BOILER-COMP(OVER 100,000 BTU) ,
I have read the harsNsmx materials requirements under Chapter 6,95 M the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 255115,255]1 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not emren0y have a tenant,that it is my reaptmsibilay m ratify the occupant
of the rtquiremeno which mon 4 and prior ur issuance of a CetiOcete of Occuponcy.
Owner or autheriexd agent Date TOTAL: ISSUI:D BY:
OFFICE