S 1573 (2) -- APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL � 1573
BUILDING PROJECTIDENT'IF'ICATION
RUILDINGADDRESS: � // SANITARY NO. APPLICATION SUBMU7AL DATE
t b 3 A10 W UE- 2$q(6
OWNER'S NAME: Pill N'' CO ACT)R'S NAME: LIC NO: NIC CONTROL#
_
�
/��ARCI II'1'IiCI'IFNGINEER: LIC NO'. I ADDRESS: 4 5(5. /,v x'�/ PTCv El
ow
PHONE: UUILDINC PERMIT INPU
❑ COnsaltant Fees Paid by Applicant(Initial) IfG FLECT` P UMB ;c
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE IL
I hereby affirm Nal 1 an licensed under pmvicions of Chapter 9(commencing JOB DESCRIPTION
Dlxz with Section Division 3ofthe Businessond Professions Cade,and my liana is RESIDENTIAL'
FUS full force and effect. PERMIT ISSUANCE
WOO to ❑SPUWL HEN REMODEL
<UU License Class Li,# APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z W Date Comment,
t <a ❑MULTI-UNIT [I STRUCTURAL
ARCHITECTS DCCIARAf10N
p.,7 y PANELS MODIFICATION
z p s-^ understand my Flair,shall he used as public recordspz—� uPTO 200 AMPS [I INTERIOR ❑CHIMNfiY REPAIR
F� N Licensed l'rofc"innal 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDHR DFCLARA'I'ION OVER HXN)AMPS ❑BA'1'It REMODEUREPAIR ❑DEMOLITION
I hereby affirm that I am exempt from tire Contractor's License L4w far the
�•OWU ❑(YI'HIiN
3 2 fnllnwing rcvson.(Section]0315,Rumness and I'ndcssinns Ctdc:Any city or..Only SIGNS ELECTRICAL
y¢ which requires a permn m connmet,tire'itnpnwc demolish,of repair any strucmm
I�_yCC)
.4 #unarm its lssutdart.also requires the applicant l)nsuch permit to files omard stammer, SPECIAL CIRCUIT/MISC.
} that he is liceined pursuant the ptnvisions of the Contractor's License Law(Chapter9 01
WC9 0 (commencing with Section 7Mgof Diviwon3 ofthe Businessand Professions Coda of TEMP.METER OR POLE INST. -
a e ooGG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLITION
Section 703 IS by any applicant for apembi subjects the applicant to a civil penalty of POWER DEVICES nTENA ❑FOOD SERVICE
FSGn mom than five hundred dollars($500). VEMENT
❑1,¢.nwnendtM1c property.or myemptoyeowith wages as theirsole compensation, SWIMMING POOL ELECTRIC
F will Jo the wort,and the structure in not intended or offered for sale Sec.70,44.Husiness HER
3 and Professions Cade:The Cummmols License Law fres not apply to or.-,no,of OUTLETS-SWITCHES-FC('1'U RES
property who build,or improves Immin,and who drex such work himself rr throuff
his own employers,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
g or improvement year p S FI',.FL40RAREA VSQ.lel'.
ownri-hownvan1l have he ties Iho iidnone form le hon,the �# /A4 hhM1M1
p"er-bulWer will have the banderol proving that he did rat mild or improve for par.
o,I'ale). TOTAL:
I, o owner Ofthe property,nm exeluslvely contactor,wish licensed comments to A RI n
monist the project(Sec.7044,Business and 11 nebs.oms Cade:)Thi,Commcmr's Li- APR y 8 �NS,n
cense Low does not apply m an owner of property who builds or improves ihereon,and QTY. PLUMBING PERMIT FEE ANS
,n
contracts for such projects with a contortions)licensed pursuant tothe Convenor's /
License Law. PERMIT ISSUANCE Ur Vur
E]I am certain under see. .B&P C for his mason � Cet(!llpV
ALTER—DRAIN&VENT—WAFER(PA) VALUATION
Da
Qwnet te 2�d
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirmunder penalty perjury one Ofthe following declarations:
❑ Cla
Ihavc andwillfon by Se Certificateio7of the vern Labor Cuts,
self-insum forthe Performance
Of the
DRAINS—FLOOR,RWF.AREA,COND. STORIES T PE CONS'TRUCfION
smirch as hick thi for mi Section 3]00 of the labor Cshle,for the performance of,hc
work I,,,which this maintain
is issue]. PIX'TURFS—PER TRAP
have tact will maimaln Worker's Cnmp:nmtinn Insurance,as requited by Section
3AIOnfthe Luis adgfor�6+perfortnunc 01 the work for wIt. 11 pemml i>uei GAS—F,A.SYSTEM-I INC.40(1TI.IdfS OCC.GROUP
AIN
My Worker'sC nsauo macer ]Policy, r
Y
Carrier: _policy No.o a GAS—EA.SYSTEM"OVER 4(FA)#
/ CERTIFICATE Or IIEMPI'ION FROM WORKERS' GHEASFIINDUSTRL WASTE.INT' "E OR
COMPENSATION INSURANCE. RU 'VISION EEIi$
Cmis section need not be completed Him,perosit is intone hundred dollars(SIM) CR TR P
or less.) PLANCIIHCK M
Loy any tPer int he vitany mnnerof as to
this the W rkers i suConnd- SE —SA T ORM EA.21X H'.
nm employ any person in any manner w us m M1ecume subject to the Workers Compen- ENERGY 19iC
Z
sminn laws of California.Date WAT HEATER WNENT/ELECT GRADING F
z Q Applicata
N NOTICE 10 APPLICANT:If,after ou er making this Certificate of Exemption,yshould WATEN SYSTEM/fREA LNG
I-' bemmc suhjecnO the Worker's Compensation It ckions of the Labor Code,yru mus, SOILS FEE
La$1 forthwith comply with such provisions or this#crinin shall the deemed revoked. WATER SERVICE
U
z
QaCONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAID Z 1forestalmtha„hem I,a cimnutction landing agency for the perfortnonceof Dute ReceiP
L) T
the work far which this permit is issued(Sea 3097,Co.C.)
1•T" Lender's Name TOTAL:
0 [U Lender's Address TOTAL: BUILDING FF,F
(•-' y 1 certify that I have read,his application and state that the above information is
N romttLl cmc to comply wi"Wl city and county ordinances and state laws refining mto QTY, MECHANICAL PERMIT FEE
V z M1iilJing. atrnction,mdhemby euthorizerepreoentn,ives ofthis city enteruprn the SEISMICFEE
'—t above-mem ed pope for inspection#trioses. PERMIT ISSUANCE.
( .) rte to ,indemnify rod keep harmless the Ciry of Cupcnino nguinst ELECTRIC
IiuM1ilitiesqWSTANDS
and expenses which may in any way accru/L�111
inns' City ALTER OR ADD TO MECH.
nsequing of this Permit. PLUMBING
AP'ILICAAND WILL.COMPLY WITH A _OIQ3' AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL FEE
SOl1RCh: I Q /J }'� ��—WWW AIR HANDLING UNIT(OVER 10,IXX)CFM) CONSTRUCTION TAX
Sl,mlmcaTApp11 tlCmdmelor Dte EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tbcapplican,or future buildmgoccupam store nr handlehamNos mined,l HEATING UNIT(TO 1004000 H'PH)
us defined by,he Cupertino Municipal Code,Chapter 9.12,and me Health and Safety
Come,Section 25532(a)] HEATING UNIT(OVER 100000 BTU)
E]Yes FNo VENTILATION FAN(SINGLE RESID) PAID
Date Raei M
Will the applicant or furore building y the B use equipment or devices which
va
emit Immortals air contaminants as tkhned bby,he Bay Area Air Quality Managemcm BOILER—COMP(3HPOR Iq),IX01 BTU7 TOTAL:
District, BOILER—COMP(OVER 100,000 B'TO)
E]yea El No
I have mad the hazmdons materials regcracntents under Chapter 6.95 Of the Cali. AIR CONDITIONER ISSUANCEPAXF.
fomla Ilcalth&Safety Code,Sections 25505,25533 and 25534.I understand that it the NHW RESIDENTIAL MECH. SQ.PT.
building Jars net cumxmly haver lemen,,,hal it is my rc,rym,ibility to notify the mSuperl
of,hu mp0mouride which must be me,prior to,iwunrcc of o Crinficate of Occupancy.
Owner nr authorized agent Dam TOTAL: IS5UIiU BY:
OFFICE