S 0261 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S.000l [vim 1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'T'ARY NO. APPLICAT ON SUBMI ITAL DATE
10-13-o 0 �vE �1�/�s
OWNER'S NANi PHONE: Co NAME: LIC NO:
L_!l )-n S-3210 N/C CONTROL#
A TECT/ENGINVVEFR, ^ �r4 y ADDRESS: ona `_ ❑ ��BS
CONTACT: `"OVA I�L�NpI�VS'.Y `.VPHJHOONNEE: S BllILDING PERMIT INFO
P�/ 640—/N� 3-2Y— g0� ❑
Consultant Fees Paid by Applicant(Initial) BLDG ELECT Pl.0 7
LICENSED CONTRACTOR'S DECLARATION / QTY. ELECTRIC PERMIT FEE LrWi./ WI']If/
1 hereby aiBrm that I am licensed under provisions el'Chapter 9(commencing JOB DESCRIPTION
WOZ with Section7000)nfDivisionSofNe Business and Professions Gde,and my license is RESIDENTIAL
F�0 in full force and effec �y�_/Q�� PERMIT ISSUANCE #� [I SCOWL ❑KITCHEN REMODEL
0Uz License Cles. Lic.# O APPLIANCES-RESIDENTIAL
yZH Dort Contra L ❑ADDITION [I PLUMBING RE-PIPE
Z OD an ARCHITECTPANELS S DECLARATION ❑MULTIUNIT ❑STRUCTURAL
y� I understimd my plans shall be used as public records MODIFICATION
OZ`-a UPT02MAMPS � [I INTERIOR El CHIMNEY REPAIR
F4tBI Licensed Professional 2111-IIlIX1AMP5 IMPROVEMENT
"1 OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
aW�
1 hereby affirm that I am exempt from the Contractor's License w for the OVER IIXIBAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
'IPS,O M O following reason.(Section]03 L5,Business and Pmfesslons Code Any ty or county SIGNS ELECTRICAL ❑OTHER
s� O y which requires a permit m cnnsmml,almo improve,demolish,or re n any structure
prionrlls issuance, requiresthe eppllcnnl for eteM1 pemtiuo El a�igned stulement SPECIAL CIRCUIT/MISC. �1
�Cthat M1a is licensed pursuant provisions of the Conlracmre so Law(Chaprtr9
uu11
(commencing with Sealers]000)of Divisinn3 ofihe Bovines. ntl Professions Cadet ar TEMP.METER OR POLE INSyI CAMMERCIAL,
Wm he is exempt therefrom and the basis for the alleged cannon.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W"^N Section]03L5byany applicautforapermitcuhjecest applicant to a civil penalty of POWER DEVICES
not mere than five hundred dollars($500). ❑T NT ❑FOODSERVICE
FXD ❑1,as owner of the progeny,or my entployeesw wagesmth,ir,mav ,w.,mf.m SWIMMING POOL ELECTRIC ROVEMENT
P., will do the work,and the sweture is not imende ocoHercd for sale(Sec.Taft,Business HER
�W�'m and Profesxions Code:The Convacmr's Li ase Lew does not apply to an owner of OUTLETS-SWITCHES-FIXTURES O39
progeny who builds or improves Theron rid who does such work himself or through
his awn employees,provided that su improvements arc not Intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building or int meet is sold within one yeorofcompletiao.the SQ.R.FLOOR AREA $/SQ,FT
ner-builder will have the bur of proving that he did not build of improve for par,
pee1,aso owner
TOTAL:
❑1,as owner of tu
ct pro ny,am excessively comessions with licensed ultra clam m f O
construct
IM1e project( c.]044,Nosiness and Professions Cotic:7 The Contmmrr.Li-
ss Law does ern ply to an owner of properry who build or improves thereon,and QTY, BING P.RMIT FEE
who oonwcmfir uch projects with a mmmemRs)licensed pursuant to the Contraemrs
License Law. PERMIT ISSUAN -
❑ lame pt under Sec. ,B&P C for Otis mason
1
time ALTER-DRAIN E -WATER(EA) VALUATION
Own
WORKER'S COMPENSATION DECLARATION PACK PLOW PROTECT,DEVICE Air✓)
,.• Thereby affirm under penalty of perjury one of the following dedaratinns: I+VV
I have and will maintain a Cenificate of Consent to self-insure for Worker's Cimpen- DRAINS-FlAOR,ROOF,AREA.COND.
sation,as provided for by Section 3700 of the Labor Cute,for the performance of the STORIES 'TYPE CONSTRUCTION
m
walk for which this permit is issued. FIXTURES-PER TRAP 07O
E]I have and will maiota.Worker's Compensation Insurance,as required by Section G.
3700ofthe Labor Cotle,rorthe farommeaaenfthe work for which lhlspermitis I...ed. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Wnr ''Coepensmio Bt n nandmrand Policy .'B�j ((ll
Comer: nC[Mbn• Policy Nd: 'a' �+�F�If3� GAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATE,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thisseatien need not be completed Hire permit is fpe or handl eH s ]III) GREASETRAP nr less.) PLANCHECK FEE #
Toy any thein the
pedormnncenfthe workf c this the W=it SEWER-SANITARY-STORM EA.200 FT.
no,employ any person in any manner sn as some suhjea m the Workers'Compen- p ENERGY PEE O
QZi salion Laws of Calborne.Date WATER HEATERW/VENT/ELECTRP yy
O A licant GRADING FEE
y NOTICE TO APP :If,after making this Connote,of Exemption,you should WATER SYSTEM/TREATING
a ? became s n the Worker's Ce ufamamon p mound,of the Labor Code,you s SOILS FEE
W Q
on comply with such provisions nr this permit shall be deemed revoked WATER SERVICE
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAI,PLMB. SQ.FT. \t IIX\J PAID
Iherchy affirm that there is a Ooze ion lending age or the pu,ormance of ^Date c pt#
the work for which this permit is issued(Sec.309].Civ VI
O U Lender's Name TOTAL 3&0
Lenders Address TOTAL:
I certify that 1 have read this a amino and sem that the above ivfnmmtlon isl�_Lcf
BUILDING PEH D Q
w+V] correct.l agree ou'reply with a y and county ordinances and amts laws relating m QTY, MECHANICAL PERMIT FEE
U building canstmction,.ntl yauth".'a represem.tives of this citymenmr upon the SEISMIC FBF.
ahnvn-mentioned Pm for inspection purposes. r PERMIT ISSf1ANCF. ELECTRIC FEE !U
(Wc)a r v save,indoneilY vntl keep haneass Ne City of Cupeninc against pp-••��
liabilities,' memse emts unJ expenxes whicM1 may in any way acerae against said City I ALTER OR ADD TO MECH. LJ PLUMBING FEE 0
no
cel the Granting of this pern�it.
in col ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00,71 CPM) CONSTRUCTION TAX
Signature of A,pIir.nt/C.nmwt., Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will theappllcnnl or future hailing occupant stere edtedle hazardous material HEATING UNIT OU 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)] HEATING UNIT(OVER 110,I100 BTU)
Yes VBMI'ILATION PAN(SINGLERESID) PAID
Date Receipt R
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR 100,000 BTU)
mil hazardous air contmnitmnts esdefined by the Bay Arca Air Quality Management
District'!
E:]Yes BOILER-COMP(OVER IINI,INNI BTU)
I have read the hazardous materials rcyuirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE q
Brain Health&Safety Cede.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL SUCH. SQ.Ur
building dors note neat,the it is my respnnsihilitym notify the occupant of dere env which me��ntl Issuance ofa Cenifit�nf���mp
Owner or authorized agenttOwner or authorized agent Date TOTAL: ISSUED BY: h10
OFFICE