S 1619 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEµ,Hf NO.
BUILDIJT.&DIVISION APPLICATIONIPERMIT PLUMBING-NIECBANIGAL J 1619
BUILDING PROJECT IDENTIFICATION ...LLL
BUILDING ADDRESS: SANITAkY NO. APPL1 ATION SU MITTA DATE
o �l N � a 9
OWNS NAME: n CONTR L
+•' NIC CONTROL#
R HITECfIENGINEER: LIC NO: ADD'IXA ��I / ❑
orvTACT: & i PHO BUILDING PERMIT INFO
"v�`� ❑ Consultant Fees Paid by Applicant(Initial) BLDG E r PL MF.0
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby amrm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Metz th Section Illea)rfDtvlsionJ of the Business anA lhnfe-�innn Cnde,andm Interacts RESIDENTIAL:
foo wt PERMITISSUANCE D
tyu in full force and effect ❑SFDWL ❑KITCHEN REMODEL
IZUU Liceme Cl . tic.# APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
.Q a Date D. TS DEtar
CHITECFS DECLARA [I MULTI-UNIT L1 STRUCTURAL
z O y Z I undersand my plana shall be used as public records PANELS MODIFICATION
CZ4— LIP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
W Licensed Professional 201-IWAMPS IMPROVEMENT LJ SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I000AMPS BATH REMODEUREPAIR El DEMOLITION
C C'' Q 1 hereby affirm that 1 am exempt from the Contractor's Lineae Law forms, 1p'{
3 U rollowing reason.(Section 9031.5,B randw and Processions Cale:Any city or away SIGNS ELECI'RICAI. OTHER
al which q permit 1 construct. Ice improve,d n l h p any structure ��Q � 100
CW0� pri t t ' I y th ppl tf chP itt fl 'g d trement SPECIALCIRCUITIMISC. O' -
f fly'y shot he I,ancemed,mumn,b6c,nowistion,of the Carbachn,Len: La (Chaprer 9 ax�,
bommeningwith Section 700(o.fEb,ision3rftheBusneswndProfession,Code)nr TEMP MET ER OR POLE INST. COMMERCIAL:
CpiG�cB1 that he is exempt therefd,m ane the bods for thr alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
� m Section 9031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZ>' not..at than five hundred dollars A5010), IMPROVEMENT
qz Qpl,as owner of the propeny.or myempbyee,with,,•ages as theirsole mmpensmion, SWIMMING POOL ELECTRIC
y,FQ will do the work,and the standard,is not intended or uttered far sale(See.7044,Business ❑OTHER
YY11 m
and Profession,Code:The Connector's License Law doe,not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves thereon,end who does such work himsePar through
his own employees,provided that such improvements arc not Intended or offered for NEW RESIDENTIAL ELECTR IT.
sale If.however,the building or improvement is sold within one year of completion the SQ.FT.FLOOR AREA $/SQ.UL
owner-builder will have the burden of proving that he did not build or improve for par-
pn c of tale).
E] 1,as owner of the propeny,mn exclusively contacting with licenced amtecmn,m T f
rn,tr the Project(Sec.7044,Business and Professions Cadc)The Cnntmann', Li-
scLaw does not apply toanowner ofproperty who mulch,or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts ter such projects with n eammemos)licensed pursuant o Ne Contracmdc
Liceme Law. EGFAS-EA
ANCE
❑ I am exempt under Sec. ,B&P C for this reason
AIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION PROTECT DEVIC
I hereby a1Tmn under penalty of perjury one of the following declarations:
Ihaveand will maintain a Certificate of Consenuo self-insure for Worker's Camper- OOR,RODF,A 'A,COND. STORIES TYPE CONSTRUCTION
eo s Provided for by Section 37W of the Labor Cale,for the piti amnca of the t
for which this permit is Issued. PER TRAP
w 1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code,far th forma, r the work forwhich this permit is isaucdSTEM-I INC 40UTLETS OCC GROUP APN
MyWn a, C t teals rm.c mend Policy n� #¢I�PnV . YSTP.M-0VER4(EA)
CERTIFICATE OP EXEM 'ION FROM WORKERS' CktiASFJINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES_
(His xectionneedom be completal'dthe Naath,for one hundred dol Drs
($100) GREASETRAP
or less.)(His
FEE
I,arify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
rnmnpiny any Around,anymaarraf macro bornme,ubjecno the Wnrkem'Camped- ENERGY FEE
,Z svtion Laws of California.Date WATER HEATER WNENTIELECTR
p Applicant s - GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Hom,tinn,you should WATER SYSTEM/TREA'I'ING
a become subject m the Workers Compensation poisonous of the Labor Code,you must SOILS PHH
•,r W Q forthwith comply with seen provisions.,this permit shall be deee ed revoke l WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FT. PAID Date Receipt If
I hereby affirm that thesis a wnawetion lending agency far the peRormance o[
L) the work for which this permit I,issued(See.3097,C'm.C.)
(11 H Leader's Name TOTAL:
C V Lender',,Address TOTAL:
GI certify that 1 have read this application and sante that the above information is
BGILDINO HE
'4. tcorrect.l agree to comply with all city ad county mdirearesand state laws relating m
7o QTY. MECHANICAL PERMIT EEE
U G building condramone.and hereby umboul repmseaudive,of this city to enter upon the SEISM IC FEE
above mentioned property far inspedion Amp..a,. PERMIT ISSUANCE
(We) man.ave,indemnify and keep hmmles,the City of Cupenina against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any wayaccrue againstsaid City ALTER OR ADD TO MECH. U[BI[,6F E
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IQ(MO CFM) O C
Signature of Applia.nYCoat.tor Data EXHAUST HOOD(WIDUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicnm or[uwre building necupvm store nr handlehtiondnuematunad HEATING UNIT(TO 100,000 BTU) r�
as defined by the Cupertino Muni dn,Chaptw 9.12,nark the Health and Safety
Code,Second 25532(a)p HEATING UNIT(OVER 100Jpa BTU)
❑Yn o VENTILATION FAN(SINGLE RESID) PAID -
Dam Receipt#
Will the applicant or future locations
a equipment or yeah,which BOILER-COMP(31 IF OR Plains)BTU)
nit hazaous air contaminants as Jueby the d by the Bayy A Arca Air Quality Management BOILER
Istria) / BOILER-COMP(OVER 100,00)B'1'UJ
E]Yen L.In^!`
Alk CONDITIONER
I have read the hazardous materixls reyuirements under Chapter 695 of ds Cali- I ISSUANCE DATE
fdnia Health&Safety Code,Sections 25505,25533 and 255341 and mark that if the NEW RESIDENTIAL MECH. SQ.1• /� Z9 � SIJ' g
IN does, cu tly hove etennn0 that it is my resdessihiliny to city the cups
of the res tc r ich mush act pnono issuwce of t Ce
O ag n Uric TOTAL' ISSUEDBY:
OFFICE