S 1892 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL. 1'F:SIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1892
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
�oI i 50 l Z\
ffTAC�
PHONE: ONTRACTOR'S NAME LI NO
•NI 2 �J NIC CONTROL#
. NO: ADIIRESX- PHONE: �(�'ZVI 4S HUILDING PERMIT INFO
A -V7 952-�fL3 Consultant Fees Paid by Applicant(Initial) BLDG ,CECT PLUMB MECH
. ELECTRIC
LICENSED CONTRACTORS DECLARATION QTY ❑
Z1 berehy ammo that 1 am licensed under previsions of chapter 9(commending PERMIT FEF.
JOB DESCRIPTION
Section 9000)of Division 3 ofthe Business and Profes.aons Code,anJ my license is
FSO with in full force and effect. PERM]'1'ISSUANCE RESIDENTIALQ UV,License Class -Lice ElSFDWL [I KITCHEN REMODEL.
FZW Dale Contractor APPLIANCES-RESIDENTIAL.
[]ADDITION El PLUMBING RE-PIPE
ARC]HTECT'S DECLARATION
O Z ti Z 1 undersand my plans shall be used as public records PANELS ❑MULTI-UNIT ❑STRUCff1RAL
MODIFICATION
UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
F I"' 1-�censed Professional
J 201-IIXIBAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARA9'ION
y LV Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER I000AMPS ❑BATH REMODEL/REPAIR DEMOLITION
FC a lL V following reason.(Section 9031.5,Business and'profeeions Code:Any city or county
W LL F which requires a permit m construct,niter,ire SIGNS ELECTRICAL ❑OTHER
F(ri O prove,demolish,or repair any nmcalb,
m priori t s also q 're th Aplin tf suchp mitt fl tg ed smtmamt SPECIAL CIRCUIT/MISC.
y+ that he I alp rsuann th p ns fM C mfador's Llc L w(Cheptcr9
d� (comm mgsv lh Sectio ]IMNI) fD"cimn9 ftheB nossa dP fe','ons Crxlc)or
❑❑A O TEMP.METER OR POLE INS'f. COMMERCIAL-
'
b
a
r
he ire exempt'therefrom and tM1e basis for the alleged exemption,Any violation of �NEW BLDG/ADDITION ❑DEMOLITION
W on See
rs l]trJlSbypny vPPlicam bnnpermit suhjeets the appllcummedvil pcemiyof POWER DEVICES '
pq„ >„ not more_ati five hundred dollars($5(NI). El TENANT FOODSERVICE
2S0 ❑I,a fawner of the tropI car my empbyeec with wages as theirsole notion, SWIMMING POOL.ELECTRIC IMPROVEMENT
4 F will do the work,and nc�_swcunrc is not intended orofYered for.cale(SecAM4,Uusiness ❑OTHER
a and Professions CWe:The Gmtracmrs Liccnm Luw tires not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeny he build or improves thereon,and who Aoes such work himul(or through
his own employees,imendul nisi.tach impmvemuns v¢not imendeA or offered for NEW RESIDENTIAL ELECTR SQ FT.
rale.If,however,the building or improvement is sold within one year of completion,the
refabuilder will have the burden oimprove 5 .FT FLOOR AREA f proving that he did not build or ifor par- Q $/SQ'EL
�rrvaam.), n
❑I,as owner of the propeny,am n el,sely communing with lirmIsed contractors to TOTAL: 4
eoastmet the project ISc,.](44,Busineau and Prefessionc Code:)The Contractors Li__
court,Law does'mot apply to an owner of Property who builds or improves rhetoric,and QTY. PLUMBING PERMIT FEE JUL ��
who contracts for such projects with a amtrannr(s)licensed pursuant to the Co tar'v F96 �
License Law.
❑ I am exempt under Sec. ,B&P C far din,eaeea PERMIT ISSUANCE IT
Owner Dnte AL'PHR-DRAIN&VENT-WATER(EA) • I" YATION
• WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of ujury one of the following Jednmtions:
❑Ihavc end will mvimain eCmnifinnc of Cnneemmself-insure[or Workcr's Compen- URNN$-FLOOR.BOOP,ARE ,GOND.
radon,i s provided fully Ser ion 37(X1 of the Lubar Code,for the perfofmvnee of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will aga Curt Worker'sr{Casurf ensaion Insurance,m required by Section
M Worthe
abel ode to the pctlo�cartie�und Polity l irl hichon,permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUP APN
/ Carticc VPolicy No.:�����Q�, CAS-EA.SYSTF.M-OVER4(F,A) ,
CEI I ICA9E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE �� CREASFJINDIISTRL WASTE INTGRCF.PTOR
(Thissxtian need nor benimplomd if the pumit is foronchundrW dollars($I tlD) BUILDING DIVISIbN EBBS
or lees.) ORBASF,TRAP
I certify ohm in the pufmrmvvcc ofihc work forwNch this PLANCHECK PEE
permit is icsoed,lahvll SP.WER-SANITARY-STORM EA.2W FT
not employ any person iu any mater so as m becomn suhjm to the Workers'Compen-
z ENERGY PEE
O sation Laws of Cat fornix.Uac WATER HEATER W/VENT/ELECTR
z Applicant GRADING FEE
I F-t ti NOTICE TO APPLICANT:If,attar making this Cenilicme of Exemption,you should WgTER SYSTEM/1'REATING '
-s bccomc comp m the Workers Compensation provisions of the lanbor Code,you run
6Wai Q
forthwith comp with such provisions or permit shall be deemed revoked SOILS FEEWATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMP. SQ,Ff. PAID -
U0 IhcmbyvflUrmthvnhereisaconsbucrionlendingaguey fonheperfonmrm cut Date Ree pie
W the work for which this permit is issued(Sec.3097,Civ.C.)
O U Lenders Name TOTAL:
Lender's Address
Eby a 1 certify that 1 have read oboe application and state m
te that the aMve inforation is TOTAL.L)
Z? BUILDING FEE
Z7correct l agree to comply with all city and county ordinances anisate laws relatingm QTY, MECHANICAL PERMIT a building commaction,and hereby authorize representatives ofrhis city toenerupon the FEE SEISMIC FEE
above-momioned propeny for inspection pnrpoxes. PERMIT ISSUANCE
(We)agree In save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE r
liabilities,adgmen ,cost.and ex swhich my non I
rinse uenceof tense yi yway accme againntsaid Ciry ALTER OR ADDTO MECH.
y PEST ng S r AND
WILL
PLUMBING FE
AP RCERELWANT UN ERST, Dfi AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(I 010,000 CESH
SC RCE RE L TION,.
MECIIANICA LEE .-
AIRHANDLING UNIT(OVER Io,deffCFM) CONS RUC ON TAX
Signature of ppli�m/C m, r Doc EXHAUST HOOD(W/DUCP)
HA' OUS MATERIALS DISCLOSURE HOUSING M TIGATION FEE
Will the applicant or future building occupant.store orhandle hazardous material HEATING UNI I(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Code,Section 25532(x)9 HEATING UNIT(OVF,R O(L000 BTU)
E]Yea []No
VENTILATION FAN(SINGLE RESID) PAID ._
Will the vppliwnt or furore building ixcupvm use eyuipment or devices which Date Receip
unit hazardous air contaminants as defined by the Bay Area Air Quolity Management BOILER-COMP(3HP OR 10(,000 BTU)
Disvicir TO
L:
❑Yes No. BOILER-COME(OVER 100,000 BTU)
(
Laurin
have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
min Health&Safety Code,Sections 25505,25533 and 25534.1 undersand rim if the ISSUANCE DATE
Call-
building does not urrently have o tenant,that it it my responsibility to notify the occupant NEW RESIDENTIAL MECH. SQ.Pf.
of rhe requlreme is which must be mer prior m Issuance of a Certificate of O,rapm,
Owneroraunamrcd agent Dare TOTAL: '
ISSUED BY:
OFFICE