S 0076 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING.ELECTRICAL. /� PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGPROJECT
IDENTIFICATION
4ao�, #e
BUILDING PROJECT'IDh'.NTIPICATIDN ��7Y )
BUILDINGADDRESS: SANITARY NO. EAPPLICATION SUBMITTAL DATE
1 uaa S ) Ave.O;ERS NNAME: PHONE: CONTRACPRSIA �,r �rI/ LIC NO: / NIC NTROL#
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ARCHI�MitlCNGINEER: LIC NO: ADDRESS: 3 "S-� ❑
91 3 Fr �
CONTACT: PHONE: BUILDING PERMIT INFO
e ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLIiCT PI M MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby ahmt That 1 tan licensed under provisions of Chapter 9(commencing
DMZ ith Seainn 911(X17 afOivisinn3nfthe Nosiness and Professions Cade indmylicenseis RESIDENTIAL
y�OO w PERMIT ISSUANCE
Fp�1y F- m full farce and effete.C3 U/ 7 1 ❑SFDWL � ❑ CHEN REMODEL
GUU Lacense las L Lie0 / APPLIANCES-RESIDENTIAL ❑ADDITION L MBING RE-PIPE
ly Dam Conwcmr_ ///222ILL_
�n w ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLAMATION
p., m PANEIJS MODIFICATION
Z O 1 understand my plans shell be used as public records
zcnK UPTO200AMPS [I INTERIOR El CHIMNEY REPAIR
F-�1t:W Licensed Professional 201-tMAMPS IMPROVEMENT ❑SWIMMING POOLS
O W U 1 hereby aW on OWNER-BUILDERa am cxap mmTCLARA`RON [I BATH the Contractor's License Law for he OVER IOW AMPS ❑OTHER C•MODEIIREPAIR ❑DEMOLITION
dF. following rcuson(Soman 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL
{�'3 C N which requires a permit to constmet,when improve,demolish,or repair any structure
F.�+0n prior to its issuance,also requites he applicant forsuch permit to file a signed statement SPECIAL CIRCUITMISC.
My that he is licensed pursuant to the provisions of the ContrecoraLicenseLaw(Chapter 9
pJ'a� (commencing with Section 7")of Division 3 of the Business and Professions Cale)or TEMP.METER OR POLE INST COMMERCIAL
_
6 q e C thin he is exempt therefrom and the basis fm Ne alleged exemption.Any violation of ❑NEW BLDGIADDFIION ❑DEMOLITION
LiLC 4. Section 7031.5 by any applicam fora permit mbjeas the applicam to o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1„ 5 not more hon live hundred dollars(ESW). IMPROVEMENT
❑Las owner of the property,nr my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
willdahe work rdhe structure is not intended or offered furwle(See 7044.Business El OTHER
and Professions Code:The Constance,License Law dcex not apply m an covin(of OU'1'LI7S,_SWITCHES- . T ES
property who builds or improves thereon,and who does such work himself or though
his own employees,provided hat such improvements am not intended m offered for NEW RESIDENTIAL ELECSQ FT.
sale.IL however,the building or improvement is sold within one your oftomplatiom,Ia SQ.FT.FLUOR AREA &SQ.FT.
ownertwilder will have the burden of proving that he did not build or improve for pur- PAID
"b a/i ID
poseafsalc.). 1� V
❑1.as owner of he property,our exclusively contracting with licensed contractors to -
construct he pmject(Sec.]044,Business and Professions Cade:)The Contmcmr's Li- ���, n
c se Law does not apply to an owner of property who builds or improves hereon.and QTY. PLUMBING PERMIT EM
who cormacts for such projects with a contrachads)licensed pursuant To the Contractor's V
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. .B&P C for his reason Y Ur UUfI
ALTER-DRAIN&VENT-WATER(EA) VA UA9'ION
Owner Dam
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby a0irm under penalty of perjury one of the following declarations:
❑Ihave end will moinmine Certi0cac of Cnmcm to edf-insure for Workers Compete DRAINS-FLOOR.RWF,AREA,COND. STORIES TYPE CONSTRUCTIOI
satins,as provided for by Section 3900 of the L ahor Code,for he performance of the
work for which this permit is issued, FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance.as requited by Section
19004 the LaMn Cale,forthe performance mile work for which this Permit is Issued. GAS-F.A.SYSTEM-1 INC.4 OUTLETS OCO GROUP APN
My Workers Fro nsag Ensu .abler and Policy qu��{
Cameo n > Policy Nn:11 •� o— GASB-EA.SYSTEM-OVER 4(F:A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GNEAS[IINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed lithe Permit is foresee hundred dollars($10so ORFASE TRAP
PLANCHLCK FE
or less.)
FEE
I cemfythat in he pertnrmanceofthe work for whichthis pemdl is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person many manner ser as to become subject to Ube Workers'Compes- ENERGY FEE
z ration Laws of California.Dae WATER HEA'L'ER WNETUDULECTR
z Q Applicant 1 - GRADING FEE
r.y 7 NOTICE TO APPLICANT:IL infer making his Certifiente of Exomption,you should WATER SYSTEMORPATING SOILS FLE
(~ became subject in he Worker's Compensation provisions of he Labor Code,you most�i . forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
[SI Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ,FL PAID
'7 'x I herehyalllrm drat them is a construction leadingagency forthe pnf.me,of One Rtp
e eiP
I'" The work for which this permit is issued(Sec.309"/,Civ.C.) TOTAL:
O U Lender's Name I
Lender,Address BUILDING FEE
C 1 eci ify that I have read this application and one That the above information is
ti Nor
correct.l al o comply with all city and county ordinances and stem laws relating to QTY. MECHANICAL PERMIT FEE
7 SEISMIC FEE
V s7 Wildingconsuucliom,and humbly authorise repmsenmtives of Thistuy men¢r upon the
above-mentioned Property for inspection Imposts. PERMIT ISSUANCE ELECTRIC FE
(We)agree a save,indemnify and keep harmless The City of Cupertino against As
liabilities judgments,grits Ad expenses wti h may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING E
inAenc , c,.ftbk,e ANDS Ay /TLL COMPLY WITH ALL N N- DINT AIR IIANDLING UNIT(TO 10,000 CFM) MFCHAN AL PEE
SAIRIIANDLING UNIT(OVER IO,IXpCFM) CONST Cf1ON TA%
Stract Dam EXHAUST HOOD(WMUCD HOUSE GMITIGATION PEE
RDOUS MATE DISCLOSURE
Willtheap,licanlmfuturelwildingo upam stem or handle hazardous nu¢riul HEATING UNIT DO 10411!X1 BTU)
es defined by The Cupertino Municipal Cede,Chapter 9.12,and the Health and Safay
Cede.Section 25532(x)? HEATING UNIT(OVER 110,000 BTU)
E]Yes Nn VENTILATION PAN(SINGLE RFSID) PAID Dam Receipt#
Will the applicant or future building Notation use equipment or devices which BOILER-COMPORPOR 100.000 BTU)
tan hazardous air countermand,as defined by the Bay Amo Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100.000 BTU7
E]Yes CMa
I have teed he or materials menta uMet Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
fmnia Heath&Saf tions 533 anJ 534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdcesno y Bate t,Tis nn, sibilitym notifyh upam
ve Ore st be t aCertificateo a cy.
Owner a onacJ ogeet TOTAL: ISSUED BY:
OFFICE