S 0032 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILDING-ELECTRICAL PERMITNO. _ ,., ^3,.,
BUILDING DIPLUMBING-MECHANICAL. _�'Lj`1VJ'L-
VISION APPLICATIONTERMITBUILDING PROJECT IDENTIFICATION -
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
23 lav&3 og r,,_9T
OW NA PH N CONTRACTOR'S NAME: LIC NO:
/� NIC CONTHOLp
7ARCHITEC'UHNOINHER:/ LIC NO: ADDRESS: ❑O�NTA`CT`: PHONE BUILDING PERMIT INFO
/S-�/' - /`,_-'4 /� 2-��_/�Y� Consultant Fees Pnid by Applicant(Initial) BO eL� PLUMB MECIiLICENSCD CONTRACTOR'S DECLARATION QTY.EAPPLTANCES
ELECTRIC PERMIT PEE JOB DESCRIPTION
I hereby o0inn Nal I am licensed under provisions of Chapter 9(commencing
with Section 7")of Division 7 ofthe Business and Professions Code,and mylicenscis RPRIDFNTIAL
SUANCEn full farce and effect. ❑SFDWL ❑KITCHEN REMODEL.License Class Lic.IT -RESIDENTIAL OADDRION ❑PLUMBING RE-PIPE
Date Contractor
rn Qy C1 MULTI-UNIT -)STRUCTURAL
F 7 y ARCHITECTS DECLARATION I undertand my plans shall be mobil as public.cord, MODIFICATION
OZp AMPS EIINTERIOR ❑CHIMNEY REPAIR
[•4 tMPS IMPROVEMENT (]SWIMMING POOLS
y JJ OWNER-BUILDER DECLARATION ATH REMODEUREPAIR DEMOLITION
OC �I OVER tIKK1AMP5
WQ 1 hereby MIT that 1 am exempt from the Contractor's License Law for me ❑OTHER
O2,U following reason.(Section 7011.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL.
3 LL which miatims a permit to csmstruct,site,,improve,demolish,or repair any start...
0 prior to its nemance,also centuries he applicant for such permit tile.signed statement SPECIAL CIRCUITIMISC.
f y that lie is licensed pursuant to the provisions of the Contractor'%License Low(Chapter 9 COMMERCIAL;
W�C�O Icnmmencing with Scctian 71100)of Division3 rfthe Business and EmfcsxmwCudo)m TE P.METERORPOLEINST.
C LL opN that he in exempt therefrom and the basis for the alleged uemplam.Any violation Of ❑NEW BLDG/ADDITION ❑DEMOLITION
Scotian 70715 by......he.,forape.it subjects the mplicantto a civil penally of POWER DEVICES EITENANT ❑FOODSERVICE
no,mare than Eve hundred dollars(S5110). IMPROVEMENT
❑ I,as ownerof the property.or my employees with wages es their tale compensminn, SWIMMING POOL ELECTRIC
F will du the work,and the xtm mon is not intended or offered for sale(Set.9M4.llusiness ❑OTHER
63m and Pmfib,amns Code:The Controa.rs License law does not apply m m owner of OUTLETS-SWITCHES-FIXTURES
popeny whit builds or improves thereon,and who does such work blmself or through 7
NEW RESIDENTIAL P.LECTR SQ FT.
his oxo employees,provided That such improvements are not intended m mfivmd for SQ.IT.FLOOR AREA SISQ.PT.
sale.If,however,the building or improvement is sold within one year of completion,the
owner-hoilder will have dee burden of proving duet he did nm build or improve for pur-
,,,a of sale.), TOTAL:
I,as owner of the property.am exclusively contracting with licensed contmemrs to
<onstrve,,a project f5ec.]044.Business nod Profession,Code:)The Commemr's p D
cerise Law does not apply to an owner of property who bonds or improves thereon,and QTY. PLUMBING PERMIT FEE r p� A
who mmmds forsueh projems with a contr.etor(s)licensed purw.m o the Cont,ecmrs
License law. PERMIT ISSUANCE
101 lam exec tun er ne. ,B&P C phis anon
ALTER-DRAIN oeVENT-WATER(EA) VALUATION
nor Date
WORKER'S COMPENSATION,DECh RATION BACK FLOW PR(YTECT.DEVICE Cj7Y Of• Vurt8VINO
I hereby aflicm under penalty of pe jury one Of the following declarations:
•IJ l have and will tmintalna Certificate mConeem o self-insure for Workers Co pen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRIJCTlO!
sation,as provided for by Section 7701 of me labor Code,for the performance Of the
work far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insumnce,m required by Section
17W Of the Labor Code,for the performance of the work for which this pert is issued. GAS-P..A.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insumnce canner and Policy number x:
Cameo Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FRES _
(ITiswnaon need nm be completed ifthepennit is forone hundred dollms(910a) GREASETRAP
or le,,.) PLANCIIGCK IEIi
I certify that in the performancc.frhe work forwhich this permit is issued,l shill SEWER-SANITARY-ST ORM EA.200 IT.
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FGF.
Z s.tion Laws of Calimmia.Date WATER HEATER WNENTA LECTR GRADING FEE
z Q Applicant )
NOTICE TO APPLICANT:If,after making this Certificate of Esentalms.You should WATER SYSTEM/TREATING SOILS ME
a; become subject to the Worker's Compensation Provisions Of the Labor Cole,you must
41I .. forthwith comply with such provisions or this permit shall be domed mvokW. WATER SERVICE
0. QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. Do. Receipt
U O p
I hereby affitat that there is a eausuucdon lending agency mome performance of
(~ the work for which this permit is issued(Sm.1097.Civ.C.)
TOTAL:
0 U Leaders Name
TOTAL:
lender s Address
1 certify that I have read this application and antro That the about information is BUILDING FEE
it N imaim l agree t.comply with all city and county Ordinances and state laws mlating to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
V Z building construction.and hereby amhorize representatives of this city to enter upon the
ab.ve-mentioned property for inspection purl —. PERMIT ISSUANCE ELECTRIC FEG
(We).gree m save,indemnify and keep harmless the City of Cuperiao.,at"
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH, PLUMBING FEE
in c.mequence Of the 6mntin,of this Permit.
APPLICANT UNDERSTANDS AN WILL MPLY WITH ALI,NON-POINT AIR HANDLING UNIT GO 10,100 CFM) MECHANICALFEE
SOURCE iU O S.
s y AIR HANDLING UNIT(OVER 10.01p)CEM) CONSI'RUCIONTAX
Si wren App aoVConuacim Data EXHAUSTHOOD(WIDUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wililhem,flOaor furore building mcupmt sore.,handle huzordous mute ml HEATING UNIT(TO Hal BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Deign and Safety HEATING UNIT(OVER I(NI,fNlll BTU)
Code,Scclmn 25572(.)1
' ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt Y
Will the applicam mfumm building mcvpvnt use eyuipmcm Or devices which BOILER-COMP UUP OR-. Ilk,"BTU)omit hazardous sir movica nams as defined by the Bay Area Air Quality Management TOTAL:
District' BOILER-COMP(OVER 100.000 BTU)
E]Yes ONO
I have read the hnurd.us materialsrequire mems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Hwhh&Safety CMc.e a lace]Shat,25577 and ns574.l understand that Haw NEW RESIDENTIAL MECH. SQ.FI'.
ofamnmum eanvm0yhave.mom,math ismyres ponsibilitymnotifytheoccupant '.
of the requimmemx which must be met prior m issumee of a Cerdficme of Occupancy.
0124
Owner or authorized agent Doc TasISSUED BY:
OFFICE