S 1535 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pli IT NO
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL - 153;5
BUILDING.PROJECT IDF.N'1'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIUN SUBMITTAL.DATE
i o i r 3 Co l b Ave-• t-,•Liii q$
OWJKSNO
UAME: IS.V6 P;Ij'y �9yy C NTR it R:SNAME: ILL gtk39 N/C CONTROI.M
. ARCHITECTIENGINEER: LIC NO: ADDRESS: ❑ 1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
LICENSED nor I CONTRACTOR ndir P DECLARATION QTY ELECTRIC PERMIT FEE
I hereby(d efD nor I am rdic no under pnrvisinns of ChuMer 9(commencing JOB DE$CRIPPION
CgdZ with Section it
DivisinnJ nftha Bosinus and Pndcssions Cndu..nA mylicenu is RESIDENTIAL,
F�� full force and eon's PERMIT ISSUANCE —
m" nn ❑SFUWI. ❑KITCHIiN REMODEL
QZ W Date Class Coon APPLIANCES-
rFn6a Date-Contrecmr RESIDENTIAL COITION C3 PLUMBING RE-PIPE
T.PN ARCHITECPS DIiCLARAI'ION PANELS MULTI-UNIT ❑STRUCTURAL
Z O n 1 undemand my plans shall be uud as public records MODIFICATION
OZ-.0 UPTO 2INIAMPS ❑INTERIOR C3 CHIMNEY REPAIR
F��ul Licensed Pofessioml 201-InIq AMPS IMPROVEMENT C]SWIMMING POOLS
ad g OWNER-exempt.RDE he Com red pyER I(XIn AMPS ❑BATH REMODELIREPAUZ E�TIQN
�j a VII
a d OP
t¢ I hereby,(lion on 1 em exempts tan the*,,honors r:Ary L'Law for the
3 LL F following reason.(Section]OJI S,Business and I'ndes.vinm Code:Any city nr county SIGNS ELECTRICAL - El OTHER n
O y which requires a permit to construct,alter,impose,demolish,or repair any".mere
prisma its issuance,also requires lire applicant for such permit m file asipamontemvm SPECIALCIRCUIT/MISC.
f } that he is licetud pursuant to the previsions of the Canlracmfn License low(Chapter 9
Qp (, mndraingw,In See linn]nNnof Division Jnf the B.,inays.nd l'mft,ams Code)or TEMP.METER ORI .INSCOMMERCIAL:
Its6 c C Thal he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDI'I'[ON ❑DE:MOIATION
I m Section 7031.5 by any applicant fnr a permit subjects IIB applicant an a civil Ie nik,of POWER DEVICES ❑TENANT ❑FOOD SERVICE
nal more than five hundred dollars($500h,
IMPROVEMENT
Fs will
Lasowneroflhepopcdy.onnyet merneswithwngesaslhei(Sed.eompcn...... SWIMMING I'(O CT '
C E'Oo will Jothewons Coed, he Contractor's
Dots License ow,does nt apply it,an Business ❑OTHER
Lm and 1'nnl'es.vinm CnJc:The Cone.nur's License Luw,Aces not apply h,an owner of OUTLETS-SWITCH - TURPS
.. property who builds or improves tracer,and who does such work himself or though
his own cnnployces,provided that Such improvements are not intended or offered for NEW RESIDENTIAL EL SQ I.1
sale.If,howevelthe building or improvement isodd within nac,c.,.f competioglhe SQ.FL FLOOR AREA $/SQ.FT.
everner-builder will have etc burden of proving that he did not build ar improve for put- a
:Kpre. nf.saiser 1
aiser,of the properly,,B exclusively con]mnlng wird:)'Bard anatcmrs i- ` P
momma the prajem apply
]OSS,Business and Professions Cml JThe Contmemn,Li- �S /I
nmoLaw dcesnmapplymts with
aoncretins who
sedporimpro the
Conmentractors
License
QTY. PLUMBING PERMIT FEE
who enntmers for such projects with n concretions)licensed pursuant m the Cnnwmors
License Law. PERMIT ISSUANCE APR
q l
❑ Iron ex pt under See. ,B&PC finrincrimn n 1R 2 r
114 Dale ALTIiR-DRAIN&VENT-WATER EA) VALl1AT ON
WOHKF.H'S COMPENSATION OECLARATION BACK FLOW PROIT ..DEVICE CITY Uh
I hal uRrm under penalty of perjury one mite following declnmlions:
' M Ihave anal will maintain a Certificate ofConsem to self-insure for Workers Campton- DRAINS-FLOOR,RODE,AREA.CONE). STORIES TYPE CONSTRUCTION
..tion,as provide,]for Is,Section one of he Labor Code,rnr rhe perforinsaid of fire
work for which]his permit is issued. FIXTURES-PER TRAP
ElI have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe LaborCodc,fomhe performance ofthe work forwhich lhispermit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS IXC GROUP APN
My Worker's Compensation Insurance carver and Policy number arc:
Cartier. Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' Oil
COMPENSATION INSURANCE GREASFJINDUSTRI.WASTE INTERCEPTOR
BUILDING ISION I'IiLS
(Thi,mclina need nm be crnnplemd if the period is l'nnu chu beddollarvlS1W) GREASE'TRAI' —
or est.) PLANCHGCK FEL �r
Icedifydne in the Petbmnlnce of the work l orwhich this perinifis issued,IshAl SEWER-SANITARY-STORM EA.2x1 ET,
not employ any Person in any manner m u to become subject to the Workers'Camper- ENERGY FEE
2.e cation Law,of Cul ifmnia.Dam WATER HEATER WNENI'/ELECfR
am GRADING
(.r y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTRF.ATING
become s rbjnt m the Workers Compenmean provisions time Labtm Cde,you round SOILS ISE
W G fnthwlN emnply with such provisions nr this pcnnd,hull he dcemd revoked WATER SERVICE
aQ
CONSTRUCTION LEN DING AGENCY NEW HESIUENI'IAL PLMH. $Q.FC PAID
L)0 I 4. if,,
af0nn that isaronsweti30 len ding tgrncy for the performance of DI Raceiptp
the work fnr which this pem]il is issued(Sm.3119],Civ.CJ
0 F' Lends's Name TOTAL:
O L) Lcndus'x AJdm,, TOTAL:
1'�.. 0. 1 certify that 1 have read this application end sore that the curve information is BUILDING C �1
F.I N correl.I.,me ns comply with all city and county mdinancev and stare lawn reining to Q-py, MECHANICAL PERMIT FEE
U building coosounion.tnllimebyauthorau
e arpremmive,oflc,snymemermad the SEISMICI :G
Ol IAO
alcove-mmaianed prnpety fnr inspection purry,n a. PERMIT ISSUANCE
(We)agree In save,indemnify and keep hatless the City of Cupertino against ELECTRO FEE
Iiubilitie.s.judgmenls.costs and expenses which may in any way acme against said City ALTER OR ADDTO MECH.
in consequence of the granting of this permit. PLUMBIN
APPLICANT UN OERSTANDS AND WILT.COMPLY WI'I'II ALL NON-POINT AIR HANDLING UNIT(TO 10,00 CFM) Ly?2ukr2�
SO' ERF.GH MECHANICAL FF.E
/ Oq AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCI'ION'TAX
S' nature of ApplicuntlConnuctorV Dale EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will rhe applicam or fwum building isho,ont store it,handle huallom,material IDEATING UNIT TO 100,1X1(1 BTU)
as defined by the Comedian,Municipal Code,Chapter 9.12,and the health and Safety
Cale,Section 25532(x)? HEATING UNIT(OVER INLMIO BTU)
[-1 Yes ❑Na VENTILATION FAN(SINGLE RPSID) PAID -
Will thea applicant or future building i use equipment or devices which Dam Receipt M
pp gbytheBBOILER-COME OHP OR IW.000 BTU)
emit haraNnus air comaminunrs as Jefind by the Bay Arca Air Quality Management T(YI'AI
UlstnaP
0Yn C]No BOIL17R-COMP(OVER handrail BTU)
I have mad the htzmdous intervals requirenstax Mer Chapin,&95of the Cali- AIR CONDITIONER ISSUANCE DATE
foal.Health&Safety Core,Seclione 25511.5,25533 nor 25534.1 undenwnd that if the NEW RESIDENTIAL MECIL SQ.FI'.
building does ren currently have a Iewnk that it is my responsibility to unify the occupant
of the requirements which must he net prior to ismanco din Cenilicam of Occupancy.
Owner or anhnnerd agent Date ISSUED BY:
OFFICE