S 0825 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL° PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. _ Q 0825 n 5
BUILDING PROJECT IDENTIFICATION J e L
BUILDING ADDRESS: � - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'
-r-c;,. I l q3(B--I03Q3 V� LJ$$4,-( Q�cz E X (p-s....- R N/C, CONTROL.#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: T�`�`r_� ❑
(Osrb Tlo./L.o��fA'L
CONTACT: - PHONE: BUILDING PERMIT INFO
�.A<tcQe� x+35 [:] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY.. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION ".
M9Z with Section]000)of Di1i1ion3efthe Business and Professions Code,and my license is '-
Y RESIDENTIAL:
0O PERMIT ISSUANCE
�rinfall force andefteET_Z� (O�sTi�o s ❑SFDWI. ❑KITCHEN REMODEL
�UU License Cl us GG Lic.N
P Z W Dua -t r'1�"'�� Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
Z p 7'4 I understand my plans shall be used as public records ,PANELS MODIFICATION
OZ-, UPT02MAMPS. F1 INTERIOR ❑CHIMNEY REPAIR
Licensed Professional - 201-1000AMPS - IMPROVEMENT []SWIMMINGPOOLS -
OWNER-BUILDER DECLARATION OVER 1000 AMPS
0 El BATH REMODEUREPAIR DEMOLITION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
iqqiS5 y U following reason.(Section 9031.5,Business and Professions Code,Any city or county SIGNS ELECTRICAL ❑OTHER
ti++LL O F' which requires a permit to construct,alter,improve,demolish,or repair any structure
iCC...� an-ons Issuance,almotanires theapplicam for such pennon.fileauenedemenont SPECIAL CIRCUEDMISC.
i } that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
CCS QQO (commencing with Section 7")of Division 3.fthe Business and Profemidns Code)or TEMP.METEROR POLEINST. COMMERCIAL'
6 e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
aW Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
rn ❑TENANT [_1 FOOD SERVICE
t more then Five dolma($5011).
F Z Y IMPROVEMENT
Q ,i Lo the work.the Property, myemntended with wages rsalei(Sec.compensation, SWIMMING POOL ELECTRIC
and Jathewons and the structureCoatis oat.License Laoffew
ed doesorsalepply la anon, F OTHER
m and Professions Cmle:The Conahereo License Luo does not apply m if owner of OUTLETS-SWITCHES-Fl%TURES
property who builds or improves thereon,and who awes such work himself or through
his own however.
the pmvidW that such menti is sold are not intended m offered for NEW RESIDENTIAL ELECTR SQ FT.sale.If.however.lhe building or improvement is sold within one year of compldion.the - Q.Pf.FLOOR ARBA LSQ.Ff.
cowner-builder will have the burden of proving that he did not build or improve for pur-
pose of at)e.L -
❑I,aser of the property,am exclusively contracting with licensed contractors to
..truer thepmject(Sec.71144,Business and ProfirWivn Code:)The Ciarnmetn a Li- '
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PL B P 1
who contracts for such projects with a conwetor(s)licensed pursuant to the Contractors 4 ]1
License Law. ERMIT IS E
F7Iameomptunder Sea ,B&PCmrthisaason
Owner Date DR VEN WATER( VALUATION
WORKER'S COMPENSATION DECLARATION CK FLOW I
I hereby affirm under penalty of perjury one of the following declarations:
IF-IIhave anJ will maintain aCertificme of Cnnsenn.self-i...rzmr Worker's Cmdaq- PRORL ,AREA ON_6. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the _ r
` work for which this permit is issued. FIXTURES-PERT - y
—�
and will maintain Worker's Compensation Insurance,as required by Section t 33700w the haMr Cede,for the Performance of the work for which this permit is issued. CAS-EA.SYSTE I NC.4DUTLIBTS® 2 OCC.GROUP APN
My Worker'nLgmpen it Insurance carver and Policy num le re �_020 2' GAS-EA.SYSTE -OVER4(GA)
Caller.Lt--{{77flaltCC''�~�� Policy NcW—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUST FVTE INTERCEPTOR
BUILDING DIVISION FEES
(This sect1.n need not bec.rmplemdlTthepermit is income handed tlallers l$I WJ GREASE TRAP
or less.)(This
PEE
I certify that in the perfarmaneeofthe work forwhlchthls Permit is Issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
net employ any person in any manner sn an to become subject to the Workers'Compen- ENERGY PEE
cation Laws of California.Date WATER HEATER WNENT/ELECTR
Applicant i GRADING FEE
'Cn NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE -
I1J forthwith comply with such provisions or permit shall be deemed revbkcd. WATER SERVICE
0. Q
U O
CONSTRUCTION LENDINCAGENCY NEW RESIDENTIAL PCMB. SQ.FT PAID Date R Neipt#
1 hereby affirm that it is i s co (See.on lending agency for the performance of
W ti Laderk for which this permit is issued(Sec.3097.Cis.C.)
F Iznders Name TOTAL:
LUkI Lenders Address TOTAL: Vk
I reality that 1 have rend this application and state that the above information is BUILDING PF.
lad correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building eonsheal.m,aad hereby authorize repowen...ocxofthis city to eaternponthe SEISMIC FH
above-mentioned Limped,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTR
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City' ALTER OR ADD TO MECH.
in cons of the granting of this permit. PLUMBIN E
APPLI e t NDERSTAN S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iq(gh1 CFM) MECHANICAL' E
SOUR ATf S.
1 2 A AI R HANDLING UNI'r(OVER 10,WO CFM) CONSTRUCf]O Ato X
Signat fan, ntmate 7J EXHAUST HOOD(W/DUCq
HAZARUOUS MATERIALS DISCLOSURE HOUSING MITIGA N FEEIt oant or future building.ecapant store or handle weadoux material HEATING UNIT(TO 100,000 BT U)
peino Municipal Code,Chapter 9.12,and the Health and Safety ` HP.ATING UNIT(OVER I(%lKlll BTU)
E01_
EI No _ VENTILATION FAN(SINGLE RP,SID) PAID
Dom Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air ernmiummus as defined by the Bay Are ,
Arco Air Quality Mamagemet TAC:
District?
❑Yes El No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE ATE
fomia Health&Safety Code.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
building does not currently have a tenant,that it is my resecnsdality to notify the.ccupam / /-'2. /
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent - Date 0TAL ISSUED BY: ` Z
OFFICE