S 1940 (2) J APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUAu11NG-MBCI1nNICA1' 1940
BUI HNC PROJECT IIIEN'I'IF'ICATION'
IIUILUING ADDIt ESS: SANI'T'ARY NO. API-LIC
ION SUBMITTAL DNI 1;
�a 7
_ F OWN/y'H'��$//ryry��AME. PHONE: C( RACGQR'SAAMEy �p(j
(Vf NIC CONTItOLk
ARCHITECTIENGINEER: LIC NO'. I ADDRESS: ❑
CONTACT. p PHONE BUILDING PERMIT INFO
'OO tL (J� q(T ^�^,(Y�Q ❑ Consntlant Fecs Paid by Applicant(Initial) BLDG f;1_F PLUMB MECH
LICENSED CONTRACTT OR'S DECLARATION QTY ELECTRIC PERMIT FEE "
1 hcrehy antro the I am Imemed under praduiom al Chaplet 9 b'ommtanng JOB DESCRIP'T'ION
WaFmOQZa
IiltMl'I'ISSlANCl
RESIDENTIAL'
F in 1ucand dkcl7_i 230 ❑SFUWL
❑KITCHEN EL
U1- iccnwClass Licp [-]ADDITION PLUMBING RE-PIPE
ZW I.DamCGrttraan � p rp APPLIANCES—RESIDFN1Ah
AHCIIIT ❑MUITI-UNIT ❑STRUCfURN,
Z.O'n un
Z 1 JccsmnJ rimy Pl:nts,hull a h use useDECLARAr10N d as public records PANELS
MODIFICATION OZ4O Oil"F020)AMPS [I INTERIOR ❑CHIMEY REPAIR
Limned Phwlcssioal 201-1Xp AMT'S IMPROVEMENT SWIMMING POOLS
OWNER-RU1LDER DECLARATION
p.C Q I hereby affirm that I am exempt from the Cnmmnnr's License Law,lin rhe OVI7R I000ANPS ❑OTHfik
REMODF.1/kEPAIR DEMOLITION
ic 3 C U foll,,wing reason.(Section 7011.5.Btsine and Pndesio is Code Any coy ur county SIGNS MEC'IRICAL
W c h which rryuire,a Ecrmil nr cema recL,,Ler,improve,dent l r repair any stmererc
Q pit oeh,,it,issuance,aleareyuire,dual,ph,latI..f such pennitm file u-signed,mmmcul SPHCIAI.CIRCUITIMISC.
thn he is licensed p.,uam to'be provisions at the Contractor's License Law(Chaplet Y
WC, (cnmmcreing will Section 91m00),dDivision JoOme Bminms and l'rofcniom,Code)or TEMP.ME TER OR POLE INST. COMMERCIAL'
a a e W thin he is exempt therefrom and the basis lin[tic alleged exemption.Any violation of E3 NEW BLDG/ADDITION ❑DEMOLITION
X-H Section 7031.5 by any applicant for a permit.subject,the applicant in a civil penally of POWER DEVICES ❑TENANT' ❑FOOD SERVICE
SpBol more Than levo hundred dollar,(8500). IMPROVEMENT
❑ 1,ascwner of the property.or my employees with wages as their sole compensation. SWIM M ING POOL ELECTRIC ❑OTHER
N tui II dothewol k.andlb—nonemm is nm llllcndcd..roti tired Bn'sale(See7144,B-ines,
63 w and Prodo,ioms Code:The Contractors License law does not apply to an went!of OUTLET'S—SWITCHES—FIXTURES
puyteny who builds or improves thereon.and who Jae snob work himself sur through
his own empinyeex,provided that such improvement%are not intended or offered for NEW RESIDENTIAL ELECTR SQ 14.
sale.If.however,the building or inhproseaent is sold within one year nfmnhpltti..m lM1t SQ.Pr.FLOOR ARBA SSQ.Irl'.
� er-h older will have the burden of proving Wat he did nol bol,or improve fo pur-
a,e"Italic.z
❑ 1,as owner til(tic
e property,ren cxeln%ivcly cnntmetng with licensed eamracmhs o IDEAL
m"rael the project(Sec.T1 .Buxine-and Professions Cak:)'Me Contractors Li
( ems law does not apply to an o%tier of Pmpvny who bwldsor improves t hereon.and QTY. PLUMBING PERMIT F E
who contracts for such project with a contraam(%)licensed pursuant o the Contractors
License I.aw. PERMIT'ISSUANCE
O l am exempt under Sec. B int P C lot this reason
A I.TFR—DRAIN k V ENI'—WA'I ER(IIA) VALUAI ION
Owner Date
WOR CUR'S COMPENSATION DECLARATION BACK PLOW PROHiCT.DEVICE
I hcrehy ufOmt under penalty ol'perjury Inc of the lidlowing declaration,
e,Ccu O a
❑ Ihovc andwill foo by
17MAComcts...Cde,lurelin Workers Comp'he DRAINS—FLOOR.ROOF,AREA,GOND. STORIES 1'VPIi CONS'FRUCI'ION
sati,,v.:r provided,thi Ire' ci Sschiot 371X)6rl thu Lahor endo,Bn thu Ixrfomtunce n(thc
work(sur%tech this purmil is iswtd. FIXTURES—1'IiR TRAP
p 1 have and will maintain Wader's Compcm,euion In%umn o.as«qui,ed by Section
3700.1 the Whin Codelin the lcdorar nee of the work for whi,timis peroul is issued GAS—HA.SYS"FEM-I INC.4 DO FLET5 'D A OCC.GROUP APS
My Woder s Cnmpemmiom Imnrance earlier and Policy number are:
Cancer: Policy No.: GAS—EA.SYSTEM-OVER 4(LVA)
CERI'IFIG\TF.OP EXEMPTION FROM WORKERS ❑RI3A51%INUIISTRI,WAS'I'IiIN'I'ERCFI'POHI
CO MPIiNS AIION I NSURANCIi BUILDING DIVISI FEIS
(1lmissechion need not be completed a lls,sector is fortune hundred dollars(510) GREJSHTRAP
oilless.) PLANCHECK PEH
�^ Icenify that in be perfn..ant ofthe work for which this permit islaued.l shall S12W'ER—SANITARY—STORM FA.201 FIL ENENGVI'EE
mar employ any person in any marines( �'�fsuhjcenntbeWoekcriConhpen-
O .z salon Lm"'fC.Itiv.IlS�t/�/ •—e+ WATERIIEATERW/VE.V'TXLRCTk
z C) Applicant GRADING FEE
NOIICETOAI'PLICAN'I' Il,vl mg lht. ihcam..f Excnclumn,ycu should WATER SYSI ENlTIREATING
become subject us the W'od.erx Com - f the Labor Gale, r SOILS F131i
> ) pen%tion provisions n You
Wfontwith comply with noul.Pr' 6%mt o,d is p ono dull he domed mmkeJ. mu WA'T'ER SERVICE
Q v
oz CONS IRUMION LENDING AGENCY NEW RESIIIENNAL PI.MB, SQ,PI PAID a Receipt It
U 0 1 Imeby.allinm than there is a cunstrvcrion lending agency for the performance of
F"' the work for which this perm h is issued(Sec.UMP,Civ.C.)
0U I.cnder'e Name TOTAL:
,rLenders Addre, TOTAL:
y I certify that I have read this application and alms that line above intortnauon I% BUILDING '.E
c nest.l agree hocnalAy with all city and county ordinances and state laws elating u) QTY. MECHANICAL PERM IT FEE
U z holdin,,mtmetinn,and bet,hyawh....crepro.cunwe,of this city mcmmrhpnm the SEISMIC F:13
Co
move mentioned property for inspection purames. PERMIT ISSUANCE
1 We)ngrce ,,save,indemmify:md keep tunnies,rhe Cay of C.,lon again" ELECTRIC :P,
Iiabiloics.judgmmnm,cosesandexpemes which may many way accmc against smd Coy ALTER OR ADD TO MECII.
in nscyuetce of rhe granting of rix permil. PLUMBING B'G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
MECHANICAL 'EE
SOUHCIi k1iGULA'1'IONS.
AIR HANDLING ON]((OVER 10.0X)CFM) CONSTRUCT ION TAX
Signature TAppficntlCnttmctor Dom EXI IAUS'P GOOD I WIDU4r) HOUSING MITIG61'ION FEE.
HAZARDOUS MAI'12RIAIL DISCLOSURE
Will the applicant or future building occurymh store or handle haemo¢material HFINFING ON]'r(11)RX),ONI BTI)
as defined by Ire Cupertino Municipal Cole.Chapter 9.12,and the Heath and Safety
Crdq Section 2559860'! BEATING UNIT(OVER 100.000 BTU)
es No.� � VFNTILAI'ION FAN(SINGLE RESID) PAID pals RctciplM
Will the aTILIo t nr foull budding ocmpamt use ap6ip6ncolor dewire,which BOILER—COMP CHP OR 100,0X)BTU)
mit hamrJous air contaminant as defined blithe Iia,Arta Air Quality Management TOT
District!
11
❑Ye, (]Nn BOILER—CONP(OVER IIN),(NN)HTU]
1 have rtud the hamfdom nmteri.1,let under Chapter 6,95 of tc Cali- AIR CON DI"I IONER ISSUANCE DATE
yuirtmcn p
forma Imahh.R Safety Cade,SLntiwns 25505.25533 and 25534.1 underd,r tat if the NEW RFSIDEN'IIAL MECIL SQ.FT.
building Jwesma currently have u mnaml.Ilan it i,olyce,tio-ulil,u,notify the wccupcm ^ 3 Q r
of the requirements which must be mel poor m ismmme of a Certific:to of occupancy.
Ownerm authorized agent Dam TOTAL: ISSD1::D BY: k—Inn IQ
OFFICE