B 0113 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
RIIILDING DIVISION APPLICATIONMERMIT PLUMB ING-MEECHANICAL SOOOI 0113
BUILDING PROJECT IDENTIFICATION
BUILDING A DURESS: SANITARY NO. APPLICATION SUBMITTAL.DAT
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OWVQML HONG C NTRACT 'AMF,: 'W^ _ LIC "
r/�IV� �wfj kJ,I'• V N/C CON'1'R01.N
ARCHITECT/ENGINEER: LIC NO nD KESS: 11 ^^--��^^ ❑
Irv^
Fl� Pt NE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
by affirm that I am licenced under provisions of Chapter 9(commencing JOB D17SCRIPTION
Wd'ZMid of Di vision 3 of the Business and Professions Code.and my limit,ixX00 PERMIT ISSUANCE SIDE TI L:
atyFand dLcl -7OI q0,b SFDWL ❑KITCHEN R17MODEIQUUli1 Lich lO'LIIJ—V App1,IgNCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-1'IPEiy¢acunwCla
F-7o) ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUC'TURAL
Z O N z I understand my phre,hall he used es public me us MODIFICATION
OZ-a UP T02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F•y.,F'm Licensed prnfosdonal 201-11X0AMPS IMPROVEMENT SWIMMING POOLS
CLARATION
x ae C 6 1 hereby affirm mm Ilamle elmpt frDERom he Canvas ors License Law for the LIVER IOW AMPS ❑BATH REM DEI REPAIR DEMOLITION
X 3 4 U following reason.ISmium]031.5,Business and professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER Er 1,41/4
u] LL which requires a .it m conswn.almr,improve,dcaah,h m reps,any sloname
F"�•��
print o its issuance.also esquires the applicant for such penniuo file a signed summer, SPECIAL CIRCUIT/M ISC.
F, y that he is licensed pursuant o the provision,of the Commcmrs Licence Law(Chdpmr9
0�0 (commencing with Section Division 3 ofthe Business and Professions C( elm TEMP.METER OR POLE INST COMMERCIAL'
ii.kc e C thin he is esemp,hcmfmnt and the basis for the alleged exemption.Any siohdon of ❑NEW BLDG/ADDITION ❑DEMOLITION
_y Section 2031.5 by any applicant for a permit.abjecra he nppheant m a civil penaltyof POWER DEVICES El TENANT ❑FOOD SERVICE
not more than five hundred dollars(8500).FIMPROVEMENT Z< []I,ox owner ofthepropsny.nr my cmpinyesx with wagesnc lhcirxnle cnmpensalion, SWIMMING POOLIELECTRIC
L will do he work,and he sanctum is not intended or offered forsale(SeeJtW.Business El OTHER
3 w unit Professions Codc The Conweus's License Law docs not apply to an owner of OUTLETS-SW ITCHES-FIXTURES
property who builds or improves hereon,and who does such work himself or through
his own employees.pnrsided hal such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
.Is,If.however,the building or improvement is sold within one you ofcompleinn.the SQ.FL FLOOR AREA S/sQ.E-L
owner-builder will have he burden of proving that he did not Wild or improve for par-
Is alone).
C]1,is owner of he pmperty,am exclusively contracting with licensed crmdors m
tmTOTAL
nowt, he pmjca(Sea 7044,Business and Profession,Ctde:)The Convectors Li-
censelrwdoes nor apply it)not owner of progeny who builds orneuroses hereon.and QTY. PLUMBINGPERMIT FEE
who contracts for such projects with o contranor(s)licensed Pursuant to the Conuacmrs
License law. PERMIT ISSUANCE
I am exmnp,under Sm. .B&Is C for this reason
Owner Daly ALTER-DRAIN&VENT-WATER H;A)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I bemby affirm under penally of perjury one of the following i cclamt ions:
❑I have and will maintain aCmificateof Consent mself-insure for Workers Cont DRAINS-FLOOR,ROOF.AREA,COND. STORIES 'TYPE CONSTRUCTIC
smion,as provided for by Section 3700 til' Labor LOr Code,for the performance of the
k for which this permit is issued. FIXTURES-PER TRAP
I�I
have and will maintain Worker's Compensation Insurance,its turmoil by Section
] mf rbc Luton Cods,fonhs performance ol,he work for which,hic pcnni,is issued GAS-IEA.SYS I'EM-I INC.4 OU"1'LE'IS OCC.GROUP APN
My WarCo pcnsmion lnsu K .artier and Policy
Currie, Policy No.: lYV •I-7 GAS-IIA.SY TlkklB GRC'fC2VT
ERTI CATS OF I3XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJIND T
rA WAST : EPI'O
Cs section need not he completed ifihe perooks formic hundred dol tan Sl dtp II BUILDING DIVISION FElS
or less.,DtiGRF.ASET'RA v ►1[� 1'LANCHIECK FEE
I curb fy that in the perfonnunn of he work lar which hN RY
is permit is issued,Ishall SEWER-SA -tQ 1 IT.EAL20
no,employ any person in any manner m ax to become subject m the Workers'Cnmpen- 17NERGY FEE
0Z s.,am taws o!Caldr n,Pau WATER HF,AT NENTTLECTR
Z O Applicant t GRADING FEE
h NUTICE TO APPLICANT:If,after making his CeniGcute of Exemption,you should WATER SYS rEZgli TING
f•' {�' become subject vt he Worknts Compensation previsions of the Labor Code,you must SOILS FTIi
Wforthwith comply withouch provisions.,,his peman shall he deemed invoked WATER SERVI - -
a �
U z CONSTRUCTION LENDING AGENCY NEW RESIUEN'I IAL PLMB. SQ.FI'. PAID
L)Q 1kI.,by which rat that there ixacil(See 30 lending agency for the performance of O:tic NeceiptN
LIJ n the woek toe which This permit is ixsucJ(See.iB9],Civ.C.)
U Lenders Name TUTAL:
r W Lender's Address TOTAL:
F
I certify that l have read this application and state that the ahovc information is BUILDING FEE,N correct.l agree to comply with all city and county ordinances and state laws mlating to QTY. MECHANICAL PERMIT FEE
U ,Z building cmnetmctimn.and hereby amhmrlee represemmivcx of this city to enter upon the S19SMIC 194E
inose-mentioned property for lmpemlou proposes. PERMIT'ISSUANCE yy
(Wes)agree ro save,indemnify and keep hamdess the City of Cupertino against Jr ELECTRIC FEE
Iiflad,iee,lud,rimm,coo,and expcnsce whichmny in any way accmu nguindsnid Cry ALTER OR ADD'TO MECH.
consequencein mi
of the gran ding of this pert. PLUMBING FIJI
APPLICANT UNDERSTANDS AND WILT-COMPLY WI'I'If ALL NON-POINT AIR HANDLING UNIT(TO IQ(00CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AER HANDLING UNIT(OVER I0,000 CPM) CONS"I RUCTION TAX
Signimmul'Applicant/Contmctor Date (EXHAUST HOOD W/DUCT) HOUSING hill'IGA'1'ION FEE
I IAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store of handle ha>ardous material HEATING UNIT 00100,000 B'I'U)
as deli tied by the Cupeni no Municipal Cade.Chapter 9.12,and he Health and Safety
Code,Section 25532or" 1 IMATING UNIT(OVER I WdHO BI U)
El Yes q(Nn -
VEN'1'ILA NON PAN f51NGLE RFSIU) PAID
Will he applicant to furore Wilding occupDole Receipt k
mmmmininuantaceequipmentordeviceswhich BOILER-COMP QHP OR 10100 B TO)
�mi,h �lntu air cm � ms as delined by the Nay Arca Air Quality Management
District? lll...��'No (TOILER-CDMP(QVER 100,801 BTU) 1 L:
❑Yes ry,
1 have mad the hazvdous materials AIR CONDITIONER ISSUANCE DATE
re.25533 ms under Chapter b.95 i t the Cali-
Hit &Safety Code.Section,25505,,,my and 25531.I unletnartd that if doe NEW RESIDENTIAL M ECH. SQ.14. S/7
huitdingdoesnm matly haven¢mm,,hal it is myrenponvibilitymnntify the,cusum ( SL
fh which as, ofmr,missuance ofaCenilicateoff/��c-s-Pay.
ll'�rtmc te a' I - ��/erome rG
OO uhmmMagcnt D TOTAL: _1 ISSUED BY.
OFFICE