S 1397 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUU.DING-ELECTRICAL I'E 1'I'NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBROJECTEDENTIFIC 1397
ISUIi.DINI:PROJECT IDENTIFICATION
BUI I G DRESS, SANITARY NO. APPLICAHON SUBMITTAL DATI
IS, via '�3 q g
OWNS :S NAME PIION'' CONI'RACIOR'S NAME: LIC NO:
NIC CONTROLN
IMF il'FECTdov'I 3R. Qr^O / gDBF_SS: ❑ [�
CO ACC PHONE: BUILDING PERMIT INFO
l� ❑ Consultant Fees Paid by Applicant(Initial) BL IiLECT lPLLUMBB MECH
LICENSE.DCONTRACTORS wisimsDECLARATION Cmp QTY 13LF.CfRIC PERMIT FEE
I herchy a1Rmt that I oro licensed under provisions of Chapter 9(commencing JOB DBSCRII'TION
DMZ with Semin.7000)of Division 3efthe Rosiness and Pmfessions Cede,and mylicense is RESIDENTIAL
WOO PERMIT'ISSUANCE
PDIFW'U inhall eartaand cltbct. WI. C1 KITCHEN RE-DIEL
' License Clens Lic.p
U APPLIANCES—RIESIUHNTIAI. ADDITION [:1 PLUMBING RE-PIPE:
F Z W Dene Can tDEC
,n6 MULTI-UNIT ❑$TRUCfURAI,
As shall BOTS DECLARATION PANELS
F MODIFICATION
Z O,- 1 understand my plans shall Be used as public records
OZ—O Oil'1'021XIAMPS I L1 INTERIOR ❑CHIMNEY REPAIR
Licensed Panic...onal 201-11100AMPS IMPROVEMENT 0SWIMMING POOLS
S X,� OWNVR-BUII.UI3R DECLARATIONOVER IINXIAMIM1 ❑HATH RF:MODIi1JR17PAIR ❑DEMOLITION
WG�y C C4 I herchy efOrm m
hat I um exempt loom the Contractor's License Waw for the
i O y U following ratson.Ne,lu n 9031.5,Husiness and Professions Cala:Any airy or tonntY SIGNS 131,ECI'NICN, ❑OTHER
W 3 W i- which p quires a permit m construct,Inter,improve,danamish,or repair any slmeture
.W.06 pri�rmits issuance,oleo requires the upplicam for arch permit to fleesigneJ statement SPECIAI.CIRCIII'PIMISC.
y",s. thmheislicensed,armmltothepnrvLoonsoftheC.nvactor'sLicensefearlChaptcr9
QO (commencing wish Section 9fXN0 of Dlvialun3 efthc Business and Pmfessions Code)or TEMP.M If HER OR POLE INST. COMMERCIAL,
6 p o C
qualm is exempt therefrom and the basis fm the alleged exemption.Any violation of DGI.a6Ul a ❑DEMOLITION
iC u.
Section 7031.5 hyanylpplicnnt furl,conn subjects theapplicant ma civil Penalty of MIWER DIiVICILS T `$ Q C3 TOO])SERVICE
Wzy wt more Nan five hundred dollars lSSIXO. IMyp,Mli
Ol,as owner nfine progeny,or my empinyces with wages as their sole compensai.n, SWIMMING IKIOI.[Lf:Ci'NIC LUNO
F- willel the work,and lheshucme is but imendedm.fifred narrate(St .9DH,Business
u�4 m and Rnfessions Calc'Dtc Convenors License Law Joel not apply to an owner or OUTLETS—SWITCHES—FIXTURES
6 3 properly who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FF.
sale.If.howervee the building.,improve....issold within one yen.(completion.the SQ.FTFLOORA EA 1/SQ.FT.
ownerhuilder will have the burden of proving That he did not hutld or improve for pus- O r
pose of sale.). 2"Z
O I,as owns of the property,a xclusively converting with licensed contractors m T
om swet the project See,7044,Business and professions Cale:)The Comment's Li-
ccmc Law does not apply to an owner of property who builds or improves themon,anJ PLUMBING PERMIT FEE
who eontractx for such prujccts with s contractot(s)licensed pursuant.me Commuters
License Law. PERMIT ISSUANCE
Olu tempt n a B&P .for in sae
ACfER—DRAIN&VENT—WATER(EA) VALUATION
Dene ��
1 e WORKER'S COMPENSATION CLARATION BACK FLOW PROTECT.DEVICE ^/—
�
I herchy affirm under penalty of perjury one of the following declarations: ^ f�l
E have and will heimain u Certificate of Consent to self-insure for Worker's Coal DRAINS—FLOOR.ROOF A RHA,COND. STORIES TYPE CONSTRUCTLOls
nation,ua provided for In,Section ThX).1 the Labor Cale,for the p (koro mer of the
weak for which this Iennii is issued. FIX'I ORES—PER TRAP
❑ I have and will maintain Workers Conapensa'mn Insurance,as required by Section
3700nf theLunn,Cale,for iheperlimnuncenfthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.40UTLE'F0 FICC,GROUP APN
My Workers Cumpensntion mous cewrte rand Pola,mmibcrare
Carrier: policy No: GAS—HA.SYS'I EM-OVER 4(EAI
CERTII0CArC OF EXEMPTION FROM WORKERS' CRHASPIINDI15TR1.WASTE IN'IERCEPFOR
COMPENSAI'[ON INSURANCE 1111JIIIQ�IXVISION ITFS
(Thissali.mmirst a he completed ifflepe.I,is furore hundred dollars(SIM) GRF.ASETRAP
.r less.) PLANCHEC
Iecnify0mtinlhe Perlinowarrofthewmkfnr whichtbispemti...issued,loml SEWER—SANI'T'ARY—STORM F.A.210 PT.
not employ any person in any manner so as to become subject to the Wohers'Compal ENERGY FEE
O Z silos Laws of California Dorn WATER HEATER WIVFN IELECFR GRADING FEE
z 0 Applicant
y NOTICE,TO APPLICANT.IL after making this Cenificae of Exemption,you should WATER SYSTIM/PREATING
a ; become subject to the Wnrkers Compensation previsions of the Labor Cade,you must SOILS FEE
Wforthwith comply with such provisi.ne or this permit shall Is,deemed revoked. WATER SERVICE
a'
a z CONSTRUCTION ES
TION LENDING AGENCY NEW RPDPIAL PLMH. SQ.FT. PAID
Dam ettipt p
L)0 Ihvrcby anion that there iseconstruction lending agency for the performance of
H the work fm which this .it is issued(See.3097,Co.C.)
QLewers Name TOTAL:
L) Lenders Address
�+ CBULLRING FEF, f
E.a 1 certify shot I hove rear this application unJ same then the abuse information is
rA correct.i agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
IJ ,Z building construction,and hereby atdhonm representatives.ritak iy menmrupor the SEISMIC FEE
above-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)agree us save,Indemnity and keep harmless the City m Cupenmo against ELECTRIC FIE
Iiabilltics,judgments,coats and expenses which may in any way aceme againstsaid City ALTER OR ADD TO MECH, PLUMBING 'F.E
in asequence of the granting of this permit. X.
APPLICANT UNDERSTANDS AND W PILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNI"I'(TO 10,000 CFM) MECHANICAL :F.
SOURCE Rlifyiee�`L/ "lam✓ C! I "l9/�
S.
AIR HANDLING UNIT(OVER IB,IXXI CPM) CONS'FRDCI'l(lN3
SlgnummotA tcom/Coutmnor EXHAUSFHOOD(WIDUCT) HOUSINGMI'1'IGAI I( FEE
HAZARDOUS MATERIALS DISCLOSURE
I the applicant or future building occupant store or handle hanmdnus material HEATING ONI'P'GO 100,000 BTU)
as defncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 HEiADNG UNIT HWER 100,000 BTU)
O Yes F7 No PAID
VENTILATION FAN(SINGER RL•SID) part Nviceipt p
Will the apgllcum nr human bu0ding Vcupant use equipment nr devices which ROILL'R—EOMI',111'OR 100,(1011 BTU)
it hosannas air conundrums as dclined by the Bay Area Air Quality Management TOTAL:
istnat7 BOILER—COMP(OVER 100,010 RTO)
Oyes ON.
I have mad the hamadaus internal,requirement,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomla Health&Safety Calc,Sections 25505,25533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
huilding docs had currently have a moral.aha it is my us insurability to notify the oeculsom
of the tequirercnt,which mast M mel,dor to issuance of a Ccnifcam of Occupancy
Ownermauth.needagem Data A ISSUED BY: r
/ OFFICE