S 2009 (2) APP t
LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF,SIT NO.. �] (�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. PES
GOOD
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO APPLICATION SUBMITTAL DAT
115-96 CF-O hP— sPlz+nlG G7 CCJP i I No, Gl-`I�► r��
OWNER'SNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CON'TROL N
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE:
' BUILDING PE IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG CLEM. PLUMB MUCH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby effinn that I tars licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QaZ with cation
in fell Porte ana l [oivlsinn3ofthe Businessand Pm[ecsinns Code,and my licenseis RESIDENTIAL'
fa-i d dficeReG. PERMIT ISSUANCE
6 u u License Class Liv.it t ❑SFDW L ❑KITCHEN REMODEL
Naw Date Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
[, ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z8.2 y PANELS
Z 1 understand my plans shall be used as public records MODIFICATION
O Z..Q UP TO 2M AMPS
r:4,~.W Licensed Professional . 0INTERIOR ❑CHIMNEY REPAIR
�k�.•....111 OWNER-BUILDER DECLARATION 201-IMOAMPS IMPROVEMENT Ll SWIMMING POOLS
C C 6 I hereby affirm that I am exempt from the Car l.,,rr'a License Law for Om OVER INTO AMPS Ll BATH RBMODEL/REPAIR ❑DEMOLITION
X6 O w U falling son.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OLD ER
W 3 ax Nowreawhich requires a permit to construct,alter.,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to File a.vigned statement SPECIAL CIRCUIT/MISC.
y�ymWm that he is licensed pursuant to the Enormous of the Contractor's License Law(Chapter 9
RIg00 (commencing with Section 9000)ofDivision 3 of the Breimesemmi Professions Code)or I EMP.METER OR POLE INST. A R IAL'
n. ca that he is exempt therefrom and the basin for the alleged exemption.Any violation air ❑NEW BLDG/ADDITION ❑DEMOLITION
x 0.
Senora 1031.5 by any applicant for a permit subjects the applicant n a civil penalty of POWER DEVICES
Izl^rn ❑TENANT ❑FOOD SERVICE
t mom than five hundred dollars(5500).
I,us owner ofihe n,urm In ees with wu IMPROVEMENT
G ❑ prose y yetis y ed formic(See 7044pensation, SWIMMING POOL F;LIiCr0.IC
and dothewotk,andthe he Corelsnoml License
Law dos or apply In 44,Business o ❑OTHGR
m and Professions Code:The Contrador's License Lnw docs not apply to an ownG of OUTLETS-SWITCHES-FIX'f ORES
C� pmpeny 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 RESIDENTIA ELEC. SQ ET
sale.If,however,the building or impruvemmot sadd within one yeurnfbomplGlon,the SQ.FT FLUOR AREA $/SQ.ET
er-builder will have the burden ofpmving that he did not build or improve for put-
poseofssle.).
❑I,as owner of the pmpeny,am exclusively contracting with licensed contractors In T TAL' D
construct are project(See.704,U Business and Professions Cade:)TheCon termirs Li-
eneeLaw does act applytoair owner ofpmpenywho amidxmimproves thereon,and QTY, PLUM C ERMIT FEE
who nmaact for such project with a contractor(,)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C forthis tcoson
ALTER-DRAIN&VENT-WAIF
Date IO
VALUATN
Owner
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following reductions:
❑ I have and will maintaina Cenifcateof Conseatto,self-insurefor Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES '1'YPU CONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the psrAormearr of the
work for which this permit is issued. FIXTURES-PER TRAP
L have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the Labor Code,for the performance of the work for which On s permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC. APN
My Worker's Compensation Insurance carrier and Pnl icy number are: . .
Carrier: Policy No: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASEIINDUSIRL WASTE INTERCEPTOR
(This section need not be completed iRhe permit is forms,hundred dollars(5100) ,`BUILDING tlIY1S1ON PEld;
or less,) GREASEq'RAP
PLANCHECK PGE
Loy any that person in
perforanymanance nerofthework for subject
M1tin wornit the Wicissued,Lshall'Camber- SEWER-SANITARY-STORM UA.21x1 Pi'.
t employ any person in tiny manner so as to become subject m the Workecc'Camber- - ENERGY PGG
OQ Ie m s - al' ,pwe WATER HEATER W/VENBUELECTR
G GRADING FEE
y NOTICE TO Her making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a become smbjec to the orkces Compensation provisions of the Labor Code,you most SOILS FEE
{ra forthwith comply with such provlsmnsnr this pemllt shall be deemed booked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FI'. PAID
UO k forwhichthi that there is ac cal Snctionlending agency(tar the performance o[ Date 0.eeciptM
W U the work(tart which this pennon is issued(Sec.3099,Civ.CJ
O Lender's Name TOTAL:
LU$J Lenders Address 'TOTAL.
1 sonify that I have cad this y and court and state that the above cos existing Is p LDING FEE k
rs Z building I ogre,to comply with all city and county ordinances and state laws relating e QTY. MECHANICAL PERMIT (EEPx
U �/. above-menttamdiomand hereby authorize representatives ofthiscity mcolor upon the SEISMIC P,P,
abmveme e)ug d property for inspection keepces.
(We)agree to rove,indemnify and keep bmmlevn lM1e City of Cupertino against PERMIT ISSUANCE
-liabilities,judgments,costs and expenses which mayinany way aceteeagainueaid City ALTER ORADD TO MUCH.
in consequence of the granting of this Permit E'LUMBING UE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT
SOURCE REGULATIONS. (OV 10,000 CFM) sTME�T Is ICALFEE
AIR HANDLING UNIT(OVER 10,00()CPM)
CONSTRUCTION TAX
Signatureof Applicaura Cmdartmr Date EXHAUST HOOD(W/DIJCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING ON]P(To 100,(x)0 BTU)
as defined by the Cupertino Municipal Gyle,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yen 7N
' 'VENTILATION FAN(SINGLE READ) _ PAID -
,� Will thea locant nr fuwre bulldin" uu nt use, t or Devices which Date Receipt N
PP bm a
BOILER-COMP(3HP OR IW,IXIO BTU)
emit hazardous oh Gmtammant as defineddby the Bay AreaAir Air Quality ManagementTOTAL.
Di.atrict?
' ❑Yes No HOLLER-COMP(OVER 108000 HTU)
I have reed the hamadmlt material,requirement under Chapter 6.95 at the Cali- AIR CONDITIONER -
ISSUANCE DAT'
+ forma Healthgdoes no Safety Code,Satins 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MUCH. SQ.FE p
building requiremenor nts
rrentlywhich have be met p triafor o is ua responsibility to notify Occupancy.occupant ^'(
of the requirements which must MmG prior to issuance ofoConditioner Oesupaney.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE