S 1344 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-EL RUE RICA], PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1344
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
WNER'SNPME: PHONE: CONTRA 'OR'S NAME: LIC NO: - N/C CON'East.X
a C lU i
ARCHG'ECI'/ENGINEER: LIC NO: ADDRESS:
SY/0 h1 oi 64
CONTACT PHONEE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT L MECH
LICENSED CONTRACTOR'S DECLARATIONQTy ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO p
WOO with Suction TlXXlpd Division 3 oflhe Business anmmrs e.anPBHMI r ISSUANCE
d PressiCuddery lieresols RF ID .NTIAL:
NW invert f(,rlass e0ua. ❑SFDWL El KITCHEN REMODEL
CUE License Class Lic.p If
Q U API'LIANCIS-kIiSIDEN'TIAL [I ADDITION
F_ a,
PLUMBING
PIPE
H W Dale ❑MU:r-UNIT ❑STRUCTURA
ARCHOECT"S DECLARATION
F_p m
PANELS MODIFICATION
Z p 14 Z 1 undemmnd n,y Pl:ms shall be usuJ as public records
OZ140 UP TO 2e0 AMPS El INTERIOR [I CHIMNEY REPAIR
F�.F.W Licensed Professional 301-1000AMPS WPROVEMENT 0SWIMMING POOLS
ak .4OWNIER-BUILDER DECLARATION OVIiR HgOAMPS ATH REMODEUREPAIR El DEMOLITION
K Q I hereby if,.In.,I um exempt from the Connector,License law for the
aqqa55 6 U following reason.(Section 9031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
t++'3i ti which requires a Permit to construct,alter,improve.demolish,or repair any stmm
rre
N E,01Q prinnniH issuunce,uhn reynireslbc upplicnm for such perniu(,GleasigneJ smtement SPECIAL CIRCUIT/INISC.
$iMy; That he i,licensed pursuant to the previsions of the Conlmcmrs License Law(Chapter 9
00 lcommencm,with Section 7000)nl Division 3 of the Business and Pmfessinns Ced0e, TEMP METER OR POLE INS, COMMERCIAL
1++
11 y e C that he is exempt therefrom and the basis for she alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
Section 9031.5 by any applicant for a perronsubjens the applicant to a civil penalty of POWER DEVICES C1 TENANT ❑FOOD SERVICE
xzOnot more than live hundred dollars(§SaB. IMPROVEMENT
❑l,as owrrcr ofthe ampere,or my employees with wagesu+Wcirsole compenmtion, SWIMMING POOL ELECTRIC
g. will Jo the work,and the structure is not intended oroftared for sale(Sol.704,1.Business OTHER
Y a. and Professions Code:The Conusctors License Law does not apply to an owner of ou rLIETs-SW i kilt:S-17IVrUR[z.S
pospeuy wM10 builds or improves eluant,and who docs sorb
or himself or through
his own employees,provided that such improvements ate not fare.cd or enercd for NEW RESIDENTIAL ELI7CTR SQ FT.
sale.If.however the building nrimpervemem is sold within one year ofmmpleies'the SQ.FT.1100R AREA S/SQ.F1'.
ur-builderwill have the burden of proving that he did not halt nor improve for par- !1 p W � D
"tofxolef. 1�
❑Lax owner of the property,am exclusively con meting with licensed cmnracm0 m 44
TOTAL:
omuum the rosiest(Sec.9044,Business and Professions CTed.;. 11.C(,nlmetoLIt- ���
se Law does nm n open
apply,(,uwner of proy who builds or improves lherron,and QTY, PLUMBINrPE FEE O AS
who contracts for such projects with a commands)licensed auauantto the Counselors /
License law. PIiRMH ISSUANCEkr`'7e /RYA
1 (jr
❑ Ism exempt under Sec. ,R&1'C forthixreason
ALTER-TRAIN&VENT'- :R ) VA,
Owner Date (7�
WORKERS COMPENSATION DECLARATION BACKFLOW PROTECT,DEVICE �'\1 �—
Ihereby alina toiler penalty of perjury one of the tollowing decimations: d X
• I have and will maintain a Certificate of Coi or,self-imsum for Weekers Cooper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPIE CONS1'RUCTION
smiun,as pmvicial for by Smdon 391X)of the Labor Code,lar the pc,fonnonee of the
work for which this permit is issued. FIXTURES-PER TRAP
E]I have and will maintain Workers Comperandom Insurance,ua required by Section
370(1 of the Labor Cade,for the performance,of the work for which this permit is issued. GAS-EA.SYS FEM.I INC.4 OUT OCC.GROUP AIN
My Workers Compensation Insurance Cartier and Policy number art:
Cartier. Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTEINTERCEPTORCOMPENSATION INSURANCE OR DIVISION LEES
(This section need mol be cnmplctal ifthe permit is fortune hundred Jr,llurs(§I(p) GREASE'I'RAP
m it..) PLANCH[CK FEE
I artily thus in the acrhmnance of the work for which this pemnir is issued.I shall SEWER-SANITARY-STORM PA.200 FT.
nn,employ any person in any manner soy I me subject m the Workers'Co.,.- ENERGY MEOzsvti(,n law, Culilnmia Upq �'t/10//1/6 WATER HEATER WNIiNTELECTR
--...(� Applicant LL ! GRADING IrEli
H NOTICE TO APDL AMIk If,alcor tg Of, visions o of Exemption,you should WA'f1ER SVSTIEM/TREATING
a ;
become subject to it Worker's Compensation pervasions of the Labor Gde,you must SOILS PF:Ii
{A forthwith comply with such provisions or this pemrit shall he deemed revoked. WATER SIikVICE
CONSTRUCTION LENDING AGENCY NF.W RLSIDE N r1Al.PLMU. SQ.FT. PAID
CU I hereby affirm that there is a construction lendingagency for the performance of Dam iptp
the work for which Nis permit is issued(Sec.3099.Civ.C.) .TOTAL
OLenders Name TOTAL:
U Lenders Address
Ly, 1 certify that 1 have real this application and sole that the abwc inferruf n is BUILDING FGF,
correct.)ug. ,,comply withall city and cauntyardinance,and state laws ofding 'I Q'PY. MECHANICAL PERMIT FEF,
V z building rourambron,and hereby indicates,streseninive,of Ibis city m th
cuts,upon e SEISMIC PEE
ahuve-mentioned propeny for impecti en puHrmes. PERMIT ISSUANCE
(We)ague to save,indemnify and keep Tombless,the City of Cupertino against IA,ECfBIC Fl;
Iiibilnies,judgnrcntn costs and expenses which may in any way same ugainvl said City ALTER OR ADD'[0 M I!CI I, PLUM RING FEE
r,evarn coot he gruntingofthi,permit.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO UT0O0CFM) MECEIANICA14F E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 11,1100 CFM) CONSTRUCIDO
�ian taXX �,(�Q/ 3l n g
S,pmaw fAp canVConaachn f 11bou EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr(mere building mccup.nl surrour handle haradous material I IEA'rING UNIT(TO 100,00()BTU)
as defined by the Capsular,Municipal Code.Chapter 9.12.and the health and Safety
C(,da Suction 25532(.)9 HEATING UNIT(OVER 100.0flat BTU)
❑Yes [D No VENTILATION FAN(SINGLE RESIDE PAID
Dam Rcccipt X
Will the applicant or future building occupant use refrained,or devices which BOILER-COMP(3HP OR 100,(M1U BTU)
emit Tormentors air contaminants as defined by the Bay Area Air Quality Maragenmmt TOTAL:
Dishier? BOILER-COMP(OVER 100.100 BTU)
❑Yes ❑Nn
Ih:we mad the hazmdeas materials,cquiremems under Chapter 6,95 of the Cali- AI R CONDITIONER ISSUANCE,DATE
forms Health&Safety Code,Seamus 25505,25533 and 25534.1 underxmnd that if the NEW ii DENI'IAL PIECE I. SQ.FT.
building does not currently have a moan,that it is my responsibility to notify the lccui ant
of Ne,requirements which must bo met prior to issuance of a Certificate of Oecupmrry.
Owner or nutharimd agent Dace TOTAL: ISSUED BY:
OFFICE