S 1342 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY PE IT NO.
BUILDING-MECIIANICA 1342
CITY OF CUPERTINO p1.WIBING-MECIIANICAI.
BUILDING DIVISION APPLICATIONIPERNUT BUILDING PROJULT Inuist FICATWN
SANITARY NO. APPLICATION 5UBMI'ITAL DATE
BUILDING ADDRESS,
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lsV{lN�I ��%% NT
Q'� PHUNF�j/� 1� CORACTOR'S NAMELIC NO: NIC COM Lp
O RAS AVwG,xt�� 1�� MW
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ARCHUhCfIENGINEER: IC NO ADDRESS:
BUILDING PERMIT INFO
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUhyI MECH
E3 11 /c�Yj ❑
LICENSED CONI'RACTOR;S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIP'T'ION
1 hereby air...Nut I am licensed under porooln w of Chapter 9(commencing RESIDENTIAL:
OXZO with ScOns 7,,E)ofDivision 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE ❑SFDWI KITCHEN REMODEL
FF iicenail e Class deticd. APPLIANCES-RESIDENTIAL ❑ADDITION LUMBING RE-PIPE
GUU License Class Llc.0 ❑MULTI-UNIT ❑STRUCTURAL
F`�ul Dam Cnnwnor MODII'ICA'1'ION
6 ARCHITECTS DECLARATION PANELS
OoyZ I undcrstand my plans shall 6c used as public record, UPT0200AMPS [I INTERIOR C1 CHIMNEY REPAIR
FZ,F.uMu11 Licensed Professional201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Ca,4'J OWNER-BUILDER DECLARATION OVER RXICAMPS ❑BATH REMOUEVRIiPA1R 11ITTON
L
a Iz a� I hereby affrnt that I am exempt from the CO.(.,,,,,"License Law for the ❑OTHER
CiyS�dU following reason.(Section]131.5.Businessand Professions Code:Any city or county SIGNS ELECTRICAL
nl O y which requires a permit to construct.alter,improve,demolish,or repair any sanctum
�..
Sri ormit,ixwunca,also requires the applicam for such Permit In file n dgned,statement SPECIALCIRCUITIMISC. '
F,Wy� that lar,is licenxd pursuant sellae provisions nfNe Conoacmr's Lieen>c law lCM1aprer`1
COMMERCIAL
WCpO fcommencingwldr Scaion AMID).[Division)ofthe Business and ProfesslonsCode)or TF.MP.MEI'IiR OR POLE INST. [I NEW BLDG/ADDITION ❑DEMOLITION
L Xea q than he is exempt therefrom and the basis fur the alleged exemption.Any violation of TENANT ❑FOOD SERVICE
4LL` Section]BLS by any applicant for a permit suhjenx the applicant to a civil penalty of POWER DEVICES
W"y not mate than five hundred dollar,($500). IMPROVEMENT
CD ❑Lnd owner the property,onny employees with wage,as their or El SWIMMING POOLELEC'IRIC ❑OTHER
p., will dollar,work.and the structure is not intended or offered for sale(See7014.Business OUTLETS-SWITCIiFS-FIXTURES
IY is and I'mfe,oma,Gde:The Contractor's Limnse law does not apply t.un owner.f
property who builds or improves thereon,and who does such work himself or through NEW RESIDENTIAL ELF.CTR SQ E..
bis own employms,provided that such imprnvemems am not intended or offered for SQ.ET.FLOOR AREA FE
,.It.If.however,the building or improvement is sold within one year ofc.mpleti.m.the NAR A a� 0^ -
owner-Wilder will Linc the burden of proving that h
e did not build or improve for Son- 1 Q�
e of ble.L TOTAL:
sl,as owner of the prn,i ten exclusively emara,ring with licensed conrs.mrs o CI)'
oast the project(Soo.7144.Business and Professions Cale:)The Conauctor's Li- PLUM G PE FEE Y Ur LU
must,Law docs not appy to an owner of property who bund,m unproven,thereon.and QTY. C/')IIn'U
who,emarams for such pojecm with n...on.vogs)licensed pnrsunnt I,the ComocoO,
License law. PERMIT ISSUANCE?
lamexcmptuodm Sec. - ,B&I-Cfordooresson
_ ALIER-DRAIN&VENT- 1'E' FA) VALUATION
ner
• 1 w1 I n.A!� Dam
W R iR'SC MPLNSATIO DECLARATIOI BACK FLOW PROTECT.DEVICE
Ila 'eh'Inirm under pemRy of perjury f the following declmfirol: TYPECONSTRUCTIC
1-1 In. and will mamminn Cenifemeof C.nunun self-insure for Workers Compen- DRNNS-FLOOR,ROOF.AREA.CONE), STORIES
anion,a,,provided for by Section 37W of the Labor Code,for the performance of the FIXTURES-PER'1'RAP
work for which Shia permit is issued,
0 1 have and will maimein Wnrkei s Compensation Inmmmce,as resulted by seelon, APN
3700.f the Labor Code,for the pinfarnanceofthe work for which this ponan is issued. GAS-EA.SYSTP.M-I INCA OUTLETS OCC.GROUP
My Worker's Compensation Insurance carrier and policy number arc: GAS-EA.SYST Fid-OVER 40'
Carrier: Policy Na:
cEltrIFICATE 01:EXEMPTION FROM WORKERS' GRE.ASI%INDUSI'RL WAS TE IN I'ERC17MR BUILDING DIV1510NS FBPS
COMPENSATION INSURANCE
(Thissecti.n need not be completed iflhe permit is hoonclunred dollars($100) C VP PLANCHECK ITE
Ic..)
Toy anytpersnthe any manner
the become
which this the Wrkco,uComshall SEWER- NITARY-S'FORM EA.200 FT. ENERGY FEE
not employ any pardon in any manner x u>m become suhjecno the Wnrkcn.'Compen-
' z satins LawsaCallBmnia.Dam 18R IS HATER W/VEN'f/ELCCfR GRADING FEE
7�7 C) Applicant
a h NOTICE TO APPLICANT:If,after making this CeniEree of ExcntSunni,you should WATER SYSTF.MRRFATING SOILS FEE
E-'Wbecame subject to the Worker's Compensation pmvisiom of the labor Code,you motor ti forthwith comply with such provisions or this pemsit shall be doomed revoked. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENT SAL PI.MB. SQ,PI'. pare Rcmiptk
L) I herehyaRrm dmnhere is a construction lending agency for the performance of
W the work for which this permit Is issued(See 3097,Civ.CJ r
O U Lenders Name TOl'AL:
WLender's Address BUILDING FEE
CL 1 unify that I hive real Sir's applindion and stem Ihw the shove n,ism is FEE
it fn correct.I agree to comply with all city and county ordina round stele laws rclatingm QTY. MECHANICAL PERMIT SEISMIC FEB
f�7 building construction,and hereby authorize represemati nes of this city to enter upon the
A rumvo-meminned property Ibr Ina'sna.n p.,P.xc P17RMTT ISSUANCE
ELECTRIC FBB
(We)agree re save,indemnify end keep harmless the City of CLpenino against
,a Stdties,judgmm�u,costs and,expenad whichmay many way ncemc against said City AITER OR AUDIO MECH. PLUMBING FEE
.nseyuence of the grunting.f this Permit.
APPL ,ANT UNDERSTANDS AND IB.CO7V2MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFMI MECHANICAL FEE
SOUR E REGULATIO" s
3 �(/ �� AIR HANDLING UNIT SO ER II),fXID CFM) CONS'1'RUCI'[ON TAX
gnu ecuf Appllemo/Commetin Dine F%HAUSTHOOD(W/DUCE) HOUSINGMI'NGATI NFEF.
HA9ARDOUS MATERIALS DISCLOSURE.
Will the applicam nr furore building oocurymr sore rrbanJle harallom material HE
UNIT(TO 1011,000 PTU)
as defined by the Cupertino Municipal Code,Ch ten,9.12,and dm Henllh and Su(ny HEATING UNIT'(OVER tourist BTU)
Code,Section 25532mu? `� PAID -
Ye, D[No VVWILATION FAN(SINGLE RESID) pare Rmoipt
Will the applicant or�fum�m building cap.'use cquipmcm ordwices which BOILER-COMP Onto OR IW,(1(ad BTU) TOTAL'.
;•ronin huxaMous air conraminanu ns defined by the Pay Area Air Quality Management
Drano? ROILER-COMP(OV F.R 100,0011 BTU)
❑Yes No
AIR CONDITIONER ISSUANCE DATE
I hove mad the hmu OII wrial reyuirelmems under Chapter 695 of the Cali-
fomia ItraRb&Safety Code,Sections 255115,25533 end 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.Em
building does not eurre dy huv,W souse hm'n is tyrespnmihilay 1.nmify the acupunt
ofthereyuir, Lich moor me issuance or.Cenius`7` pT
Ownere out nzcd,gem
`( Llme TOTAL: ISSUED RY:
OFFICE