S 1077 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO nun.DING-I:LEC'VRICAL PP MIT NO
BUILDING DIVISION APPI,ICATIONA'ERMI'P 1'LUMI4ING-MI!CHANICAI, 1077
BUILDING PROJECT IDEYDFICATION
BUILDING ADDRESS' SANITARY NO. APPLICATION SUBMITTAL DATI
7l0 5
OWNER'SNAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
Za e- NIC CONTROL#
11wAlj('JJ)TECIAiNGINIiIiR: LICNU: ADDRESS: ❑
, I-a e k s
CONTACT: PRONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) L ELECT PLUMB MECH
pC,,.,, 39S=9yco Nc �F
LICENSED CONTRACTORS DECLARATION QTY.iO�LETS-
ELECTRIC PERMIT FEE
I hereby affine that I am licensed mtdcr provision of chapter 9(commend„g JOB DESCRIPTION
QRZ with Section](XIU)of Division 3oOht Rustiness unJ Pndescinns CaM,unJ mylicatw i. R ID F TIAL:
W loO T ISSUANCE
Ftt�F in full forceand en act. FOWL ❑KITCHEN REMODEL
QUV Licence Class Liao NCES-RESIDENTIAL ADDOION ❑PLUMBING RIi PII'li
FZW Dme
C'ommcmr
onto. ❑MULTI-UNIT ❑STRUCTURAL
f,Dm ARCHITECT'S DECLARATION S MODIFICATION
O Z=Z I unJctsf nd my plans shall he used ax Public records HX)AMPS
[I INTERIOR C:1 CHIMNEY REPAIR
F-1.F7a Licensed Is le.sinnol XIAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION t(XXIAMPS ❑BATH REh10DEUR1iPAIR El DEMOLITION
C C Q 1 heohy affirm tom I am exempt from the Contractors Liceno,Law far the ❑rn.tJ�R
3 W following¢anon.(Section]OJT 5,13uxinesx and Professions Cnde'.Any city or county
ELECTRICAL '.a A -
,n which require%a Permit is construct,alter,improve,demolish,or repair any structure
(_LL ON st. pro r t '.. c 1. 4 theppl'wart hPe It fl i'W.ttemmat L CIRCUI VMISC.
E } that he licensed P ,t ra p f,hC t t ' L 1 (Channel 9
��QO
(commencing ithS t 70)(B fD t of the B . dP f:. Oak)or METER OR POIJ:INST 1P' L:
a d c C taut h se npt tnaal n and the best,far the alleged u. pr A Y loris t of li .DarIA ftin ❑DEMOLITION
WM" Secunn7031.5 by any applicant for a Permit artifacts the applicant nr a civil penalty of R DEVICES ��ny TENANT 4�td�{(/� FOODSERVICE
not msrethan five hundred doll..(5500). ' 11PR ;IENT
.2 ❑ I,as owner of the progeny.or my employees with wages as their sole compensution, MING POOL BLEC7fRIC r Cfll
N will Jo the work.and the structure is not imendeJnrnnered hao,le(Sea.]1W4,Brame,, ❑OTHER Id
L 3 w and pmfnsians Cede:The Crouse License law does net apply m an soon,of ETS-SWI TCHFS-FIXTURES
property who builds or improves thmcon.and who docscuch work himselfor through NEW RIiSIUENTIAh ELECTR SQ FT.
his own employees,provided that such improvement.,an,not intended ter offered for SQ lel'.FLOOR ARE SISQ-IT.
sale.E,howcve,,ma ladding o,improvement is sold wi11 it one yea,aI mmplction.theQ
wne,builder will have the],volar of proving that he did nm build or improve for pur- ^
posy m'sleJ. A
L as owner of me property,um exclusively contracting with licensed contractors to V
mstmct tht pmjmt(Sec.70,44,Bunimxc and Professions Core.)'I'he Cnnnarra's Li
-
xLawdoeanat apply to an owner of progeny who builds or improve%thereon.and QTY. PLUMBING PERMIT FEE
who cc atmets for such Projects with a contracmr1%)licensed pursuant b the Contractors
License law. PERMIT LS ANCE
❑ I am exempt under Sec, .B.@ P C ter this resmn
A -DRAIN&V -WATER(EA) VALUATION
Owner Date
WORKER'SCOM PENSATIUN DECLARATION PLO :CT.IJIiV ICE
1 hereby allirm under penalty at Perjury one of IiJlnwing Acdurnuonn:
E3 I havevvJ will mainmin aCenifcateof Cenot tosel6insum for Wader's Comptn- DRAINS-FLUOR. .AREA.COND. STORIES TYPLCUNSTRUCflO
scion.vs provided for by Section 37M of the Labor Code,for the performance of the
work for which this Pemtil is issued. I'IXIURES- TRAP
I have and will maintain Worker',Compenmtion 1-111111111v.a'r faired by Section
3700ofthe lather Code,forthe performed ofthe work havihichhtnis permit;,issued. GAS-EA.SYSTEM-1 C.4DUTLFTS OCC.GROUT' APN
CMy omcrrkf��npQcnsaYY0wYp4�I'murder nlly No.:olicy mm.he^ GAS-EA.SYSTEM OVERi(EA)
'Tr'"'�e cEERTIFI11CAfE�,NNO1//�//EXEMPI'ION FROM SWORKERS' GREASIIINDUS IRI.WASTE INTERCE0R
COMPENSATION INSURANCE 19BUILT 'GDT SIONFF'S
(This section need nothe completed if Ne Permit is for one hundred dollarz(5100) GREASE TRAP
or leas.) I'LANCHECK PEE
/
lecoify that inds, ,Ionnmmcoftne work for which this Fee rntit laurel,I%hall SEWER-SANITARY-STORM EA.200FT.
not employ any person In any manneron as to become subject m the Workers Compete ENERGY PEI;
,Z ,mien Laws of California.Data WATER HEATER WA EN HELEC R
ZApplicant GRADING I]:
NOI SCE TO APPLICANT H div,making this Cenilicum of
lhcmpunn,you should WATER SYSTEM/TREATING
become subject to me Workers Compensation provision o1'the Labor Gale,you must SOILS FEE
�'. forthwith comply with such provisions or this permit shall he deemed revoked. WATER.S[RVICE
a
CONSTRUC'I'ION LENDING AGENCY NEW RESIUF,N'l]AL PLMIf. SQ PC PAID
V O Inereny acorn mat mt,e isaennamnn,n leneins aganey nor tet peHormamaar 1- Reaerpta
U the wad(or which this permit is issued(Sec.3097.Civ.C.1
TOTALlenders Name
,r Lenders Address
O. I certify that 1 have read this upplicmion and date the,tba above information is BUILDING lilt
.F. N correct,l agree to comply with all city and county ordinances and state laws adding I. TY MECHANICALPFRMIT FEE SEISMIC El:
V z huilding esnstmninn.and hereby authorize represanmtiven of this city to enwrupm the '
ti eluwo-mcnd ad property for inxl¢cdon pumas,,,. PERMIT ISSUANCE ELECTRI'ITB
(We)agree to save,indemnify vad keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any wayaccme agaimtsaid City ALTER OR ADD TO MECH. PLUMB], ,FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILI,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,000CFM) MITCHAM I.FEE ittitt
SOURCF,REGULATIONS.
NR HANDLING UNIT(OVER IO,OW CPM) CONSTRUCT )N TAS
Signamreol'AFEliamtlllearet Dmc EXHAUSTHOOD(WIDUM) HOUSING MITI'ATIUN FEE
HN'.A$ S MATERIAL ti DISCLOSURE
Williheapplicant' mumbuilding occupant store or handle hrardous material HEATING UNIT UPO 101000 BTU)
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(al't HEATING UNIT(OVER 100,r)(M B'IT)
El Yea ❑No VENTILATION FAN(SINGLE RESID) PAID
Ua¢ Recciptp
Will the applicant or future building occupant w¢equipment or devices which BOILER OHP OR❑X1,000 BTU)
mit hmardo t,air conmnarem n e,defined by the Hay Arca Air Quulhy Management 'TR'I'AL
U,111WO BOILER-COME(OVER I(X).(Xk BTU)
❑Yes C]No
I have read the hazunlou%materials re is ander Chapter 095 of me Cali- AIR CONIJITIONER 1$SUANCk DATE
15533 a
litmia Health 85I demo Gv1v.Sections t.that is
and 25534.1 understand anifY the
mut if the NEW RI'SIDENTIAI.MECH. SQ.FT.
buildingd«cnuteuemnth host atenant,that it is my ecof-Ceitya,notifycc Occupancy.
Ownerof the rc(uimmenfc which most he mer prior to issuvntt of a Cenificme of(kcupancy.
Owner or motion"agent Date ISSUED H
OFFICE