S 0724 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE51T NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 0724
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'T'ARY NO. AI'PLICA'1'ION SUBMITTAL DATE
A HONE: NIRA O 'S NA LIC NO
NIC CONTR( .x
A C TE /; ANEE IC O: ADDRE S:
CONTACT: PHONE: BUILDING PERMIT INEO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICCNRED COMsed under
p DECLARATION QTY ELECTRIC PERMIT FEE -
Iherehyaof that lam licensed BJunderprovisionsof Chapter 9(commencing JOB DESCRIPTION
�C with Seorceang0)of Uivisinn7of the Business and Prnfessinns Calc,and my license is - 'RESIDENTIAL:
W f,
in a Class d eRat PERMIT ISSUANCE
�UZU License Class Liap ❑SFDWL ❑KITCHEN REMODEL
6e. Dam Contractor. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF-PIPIT
I„py ARCHITECTS DECLARATION El MULTI-UNIT 11 STRUCTURAL
O R 917K. I understand my plans shall he used as public records PANELS
JJ MODIFICATION
UP T02W AMPS ❑INTERIOR [3 CHIMNEY REPAIR
l-G�,N-�44�4]]] Licensed Pmfcssmnal 201.100DAMP$
edOw,i4�. OWNER- IMPROVEMENT ❑SWIMMING POOLS
c << BUILDER DECLARATION OVER 1W0 AMPS El RFMODEVREP R ❑
1 hereby.(Sinn the 1 1. exempt from the fesmm�s Co License Law for the � N Q{�Fii�K f
X a 6 F
whifollch
renes a permit to o s.S,Businessimprandove.
Professions Code:Any city or county SIGNS ELECfRICAI. ❑(7fHER IS•!�-`4�jS��
LL 0.WO which requires a permit re construct,aline improve,h Permit t or repair any structure
kph pat heisscense pandrreto theres Novisio so Me ConpenninLfile aicense ned aw(Cha mem SPECIAL CIRCUIT/MISC.
}Q Lhaheiscingwiit pSectio 7 the provisions of Ne Comracmrend Prof Isw(Chapter9
(commencing with Section 70N10)of Division 3 of the aged exe and on.Any.violation Code)or
O O TEMP.METER OR I'(JLE'NST. COMMERCIAL:
6 a oy Rte he is esempt Nemfrom and the Per fns Ne alleged esemant to Any lnaty of ❑NEW BLDG/ADDITION ❑DEMOLITION
-01 amethanst 101 by any hundred
doll fora permit subjects the applicanuoacivil penalty of POWER DEVICES
t mare than fiveOldie Property.
dationyeml ❑TENANT ❑FOOD SERVICE:
9p ❑ Lothe owner k.and Property,or is
sempbyeed creameesa Nei(wec 044,Bmti.n, SWIMMING POOL ELECTRIC IMPROVEMENT j
will dothework,and the he cture Cooisnots Livens Livee dost apply to
Business ❑OTHER
6 and Professions Code:The Cnmmemor License Luo does not apply s if r through
OUTLETS-SWITCIfFS-FIXTURES
hpropertyis own who builds or improves theca n,and who nts such ware himself f through
his awn employees,e provided that such improvements within am nm immnoW or offered for NF.W RESIDLNTIAf.ELELTR SQ FT.
sale.q h.we,will h ve th brolg or mpmvemem is ed hedt Wild r of or improve
completion, Q.FC FLOOR AREA $ISQ.FT.
wmofv ildcr will have the burden of proving the he did not build or improve for purr- N p 'O
pose of salaJ. �`I
❑I,ss owner of Ne property.am exclusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.7044,Business and 14ofessiom Cole:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUM BING PERMIT FE �I 09
whoconvacu forsuchpmjcaswithaconmctoHs)liccnsedpumumt3othe Commemrs -
License Law, PERMIT ISSUANCE.
❑ loro exempt under Sec, a &P C for this reason QVN
canerORKER'S ALTER-DRAIN&VENT-W E (VALUATION
WCOMI'ENSAT'bN UECLA 'ION BACK FLOW PROTECT.DP.VICE
•I Ihendwaffirmunder penalty of perjuryone ofthe owing Worker ions: C/
EI priondilrll b S on3700cate of the Labor
Cod fthe Worker'sce of n.the DRAINS-FLOOR,ROOF,AREA,COND.
satian,m provided Inn by Section 3]IYJ of the Lasrr CWe,I'or the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensmom Insurance,as inquired by Section
3700 ofthe Labra CWe,for the Pedbrmance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRI,WASTE.INTERCEPTOR
(This section need nm,he completed if the permit is Tonne hundred dollars NINE BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
Loy my peri.hat in Neperfmmorrmance ofthew rg for ectamewhicethio perthe W,isissuCoTshallr- SEWI7R-SANITARY-STORM EA.2W FU
not employ any peamn in any manner so ant m become subject m the WnrkerM1 Cooper- ENERGY FEE
Z O Osw
Laws of Calinma.Dam
Applicant
WATER HEATER WVENTELELTR
GRADING FEE
NOTICE TObj APPLICANT:eWork r'after Compensation
This Cisions of ofExemption,Laborde,you muld
st WATER SYSTEMQKHATING
a 7 become subject to the Workers Compensation pmvisions of the ishan Cade,you mast SOILS FEG
W forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE
d
U0 CONSmis a c0NLPNnlNGAGFNCy NEW RESIDENTIAL PLMB. SQ.PT. PAID
(�O I hereby Inch thi that is toned
lending agency for performance of Dols keceiptp
D. Fthe work for which this permit is issucJ(Sec.369],Civ,CJ
V Lenders Name
O TOTAL:
Lenders Address TOTAL:
0. I certify the,'have read Nis apphemin.and state that the.have aromatic.is BUILDING FEF 717-7
Wcorrect.I agree to comply with all city county ordinances and suite laws telatingro QTY. MECHANICAL PERMIT
7 FEE
V ;i building construction,and hereby aahmixe m""wrtedws of Niscity to emerupon the SEISMIC FEF.
ahave-mentioned popery for inspection puryoses. it.9D
PERMIT ISSUANCE
(We)agree,o save,indemnify.ad keep harmless Ne City of Cupenino.gains, ELECTRIC FEE
Iiahillties,judgments,csrstundexpenses which may in anywayacerue ogmml said City ALT'FR OR ADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 16000 CFM)
SOURCE R'GULATIONS, a MECIIANICALFEi
AIR HANDLING UNIT(OVER 10,00CFM) CONSTRUCTION TAX
"SigrealmaidApInEtimuCmdontor FDm EXHAUST HOOD(WIDUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCL URE
Will the applicant or future building rccupam some or handle haamdous mammal HEATING UNIT(M 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? HEATING UNIT(OVER 100,0110 BTU)
❑Yes No
VENTILATION FAN(SINGLE RESID) PAID
Date Receipt# r
Will the air costa or dumas building occupant use u Air Qu or devices which BOILER-COMP 1311P OR 10e"RTU)
Trait humrdnus air contaminants as defined by the Buy Arca Air Quality Management
District? TOTAL:
11 Yes F1 No BOILER-COMP(OVER 100,0010,BTU)
I have read the havrdous m.mialsAIR CONDITIONER ISSUANCE DATE
requimncna under Chapter 6.95 of this,Cai-
fomia Health&Safety Cale,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does..currently have a mount,that it is my responsibility to notify Nn rccupam
of Ne vquimmenls which most b,met prim t.issuance of a Ceni6cat.mf Oeeup.nry.
Owner or aafionaW agent Dae TOTAL: ISSUED BY:
OFFICE