B 0240 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �/1 A
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.r(a, O L�T O
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECTBING- IDENTIFICATION
50001 IRKL!
BUILDING PROJECT LD4:NTIFICATIUN
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL.DA]I
\'1.35 r. "7 -/67
OWNER'S NAME. PHONE CONTRA 'S NAME LIC NO: SIC CONTROL.
A RC H YGICLENGINEER: LIC NO: ADDRES. s J � ❑
CONTACT: PHONE: BUILDING PERMIT INFO
1 1 (51 O) —g3'7 ^`-r 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE PLUM MECH
LICENSED CONTRACrOR'S DECLARATION U` lT/ QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
N
1 hereby affirm Nut I am licensed under Provisions of Chapter 9l commencing
G a Z with Sell an 7(M)afDi1i1i n I affix Badness and Professions Cale,and my license is RFBF-IB$DFNTIAL:
+I 1 O O PERMIT ISSUANCE
F iicene Cls and eB t. ❑SFDWL [I KITCHEN REMODEL
a 4' License Class Lic.p
at-IJ APPLIANCES-RESIDENTIAL []ADDITION C3 PLUMBING RE-PIPE
H ac W Date - - Contractor
roan ❑MULTI-UNIT ❑STRUCTURAL
4.Dm ARCHITECTS DECLARATION PANELS
z nr IunJenanJ my plans ehull Be ustJ as public rsords UP T020f1AMPS MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
<�Iqq'41 Licen+eJ Profesxionel 201-1000AMPS IMPROVEMENT SWIMMING POOLS
CYZ�a OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RFMODEVREPAIR ❑DEMOLITION
a a a 1 hereby affirm Not 1 am exempt from the Contractor's License Law far the Ja�-r a- 1'K�{t✓f CO_I-�,re»+.
$e 3 a U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
Yl LL O which requires o permit w construct,aha improve,demali la,or lanai,any amount
F�y.J prior,.its issuance,also requires the upphrum for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Wpp } Nm he is licensed pursuant to Ne provisions ofthe Contractors License Law(Chi
aoo (commencing with Section 70001 of Division 3 ofthe Business and Profeisicns Code)or TEMP.METER OR POLE INST COMMERCIAL,
6 q a that he is exempt therefrom and the basis for me alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
{tXl Y• See..7031.5byeayupplicunt far.penotnobje,mihe applicormitrivil perath,of POWER DEVICES 0TENANT ❑FOOD SERVICE
I,-
ZpN„ no,marethan five hundred dollurs($500L IMPROVEMENT
aQ ❑tins owner of the progeny.or my cmployeos with wagwmtheirsole compensation, SWIMMINGI'WLELECI'RIC
will do the work,and Ne nrumure onto adended muffered fur stile(See.7fH4.Business []OTHER
0 :2 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-PIXTUR S
property who huilde or improvas thereon, it who does such work dreadful through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENFI AL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within.neywr of camploionthe - SQ.FT.FLUOR AREA $ISQFT.
.
owner-builder will have the burden of proving Nat he did no,build or Improve for imr,
aof sale.)..
F71,as owner of the property,am exclusively contracting with licensed contractors in TOTAL:
construct the project(Sec.7044,Business and Professions Cocci Ino Conuacanr's Li-
cemeLtwdoesnotuPPlymanowner nfpropeny who builds or improves thereon,unit QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contracmKO licensed pursuant t.the Contrucmes
License Law. PERMIT ISSUANCE
1 um exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECF.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workera Cooper- DRAINS-FLOOR,ROOT,AREA,GOND. STORIESrf p ' Ely' CONSTRUCf101
,
safe as p.video for by Section 34fk1.f the Latin Code, P A e,far Ne perforce of the U
work for which Nis permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Cale,for the performance lithe work for which this Permit is issued. GAS-EA.SYSTEM-[INC.4 OUTLETS OCC. Is D APN
My Worker's Com,meadoa Insurance curticr and P.licy number are:
Cartier. Pulicy N., GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSFRL WASTE INTERCEPTOR G
COMPENSATION INSURANCE BUILD IVIRIUN FP,F_S _
(This section need no be completed ifthe permit is for one hundred dollars PS 100) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the Performance ofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any nen s.0 to hec object to the WnrkmK Cornpor. ENERGY FEE
Z nation Laws. 1' _Iy WATER HEATER W/VENT/ELECTR
z0O Applicant,
—c GRADINGFEE
NOTICE TO APPLICANT Ifs,afier making am f Exemption,you should WATER SYSTEMITREATIN,
atNy SOILS FEF.
famine subject y the Wich s tails r his pmvisions of the labor Code,you mon
{LI
forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE
Pi z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FIT PAID
L)0 I hereby affirm that in u construction lending agency fm,he performance of Data Be i M
f" the work for which this permit is issued(Sec,3097,Civ,C.)
0 U Lender's Name T AL:
Lender's AJJresa TOTAL:
�.t W� BUILDING FEF.
sandyLL 1sandy that have rcaJ misapplication and state hat above infomwtion is
rA correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEF,
Litz building construction.and hereby authaux representatives of this city to emeruPon the SEISMIC FEC
mono mentioned property for inspection purposes. P, Ml'I'ISSUANCE
ee
(We)agr ,.save.indemnify and keep harmless the City of Cupenin,against ELECTRIC FIER
liabilities.judgmets,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
PLUMBING PEE. aq
in consequence of thegranting of Nis permit.
APPLICANT UNDERSTANDS AND WIL1,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(3U IILOtq CPM) MECHANICAL 'F.
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCfI TAX
Signature.(AMlicanUContmctor Data EXHAUST HOOD(W/DUCT) HOUSING MI CATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamNoes morrial HEATING UNIT(TO I BE."BTU)
as defined by,he Cupertino Municipal Cale,Chapter 9.12,end the Health and Safety
Cale,Section 25532nd? HEATING UNIT(OVER 100,000 BTU)
❑Yes �N. VENTILATION FAN(SINGLE RESID) PAID
_ late Receipts
rte' E3II the applicant or future building.ccuponl use equipment m devices which
emit lmardous acontaminants as defined by the Bay Area Air Quality Management Ll
OR 100.000 BTU) TOTALTOTA
Dlnno'I BOILER-COMP(OVER I W."BTU)
❑Yes kIN.
1 have mad elm formrdous mvtemas requirements under Chapmr 6.95 of the Coli- AIR CONDITIONER ISSUANCE DAATEyq
forms Health&Safety Code,Sections 25505,25533 and 25511.I undersmM than if the NEW RESIDENTIAL MECH. SQ.EU � ��W -q O
Wilding does no currency have a tenant that iti.s my responsibility to nmify th<occupant lVV I
of me re,drtments which must be,met prim to issuance of a Certifivere of Occupamy. O
Owne,manthoroadagard - Dare TOTAV ISSUED BY:
OFFICE