S 0324 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. I'CRh11T NO.
BUILDING DIVISION APPLICATION E MIT PLUMBING-.SIECIIANIC$1. S 0324
BUILDING PROJECT IDENTIFICATION
BUILDING ADD ESS: ;SANITA]RYNo APPI.ICATIONSUIiNil1'FAI.QAIF.j//! g 'OWNIER'S NAME I'HUNI3: CON'TRACTORS NAME: LIC N¢ CON'IRoil p
RCH
EJ
110" I'IE /ENGINEER: LIC NO'. ADDRESS:
CONGACT, PHONE BUILDING PERMIT INFO
❑ Consultant Fifes Paid by Applicant(Initial) BLDG ELECT PLL ml,iH MECD
LICENSED CONTRACTOR'S DECLARATION Q y ELECTRIC PERMIT FEF:
I hereby o firot'h:n 1 ant licensed under pmvisions of Chapter 9(commencing JOU DESCRIPTION
QaZ with Section 7000)of 3Ofthe Business and Pmfcxain is Rdo,amd my license is RESIDENTIAL
WOO w I'IiRMI1lSSUANCE
in I'ul l force and effccl. ❑SFDWL El KITCHEN IthMODliI.
aUU Litemw Class Loc.to APPLIANCES-RCSIDENIIAL ❑ADDITION ❑PLUMBING RE PIPE
!-.Z W DareCurnmemr
yam []MULTI-UNIT ❑$TRUCTURAh
ARCHITECTS DECLARATION PAN131S
f-HZ l understand my plans shall be used as public mcurds MODIFICATIONOZZ�G UPTO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Mofcssional 2014000AMPS IMPROVEMENT C)SWIMMING POCHS
may$;
OWNER-BUILDER DECLARATIONOVER I"AMPS C3 BATH RBNIODEI/NCP IR ❑DIiMD1.ITIGN
yC a 1 hereby affirm the I am cumpf from the Comoros',Liccn.ae Law for the
X 3 L U following reason.(Section 11131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHCN
which require.,.pnrnit lit cons.....aIle,improve demolish,m repair any saunas,
f"'LL0 prinrlors ivsuunce,also requires the applicant for such permit mlilenrignedamemem SPECIALCIRCUIT/MISC.
WyThal he is licensed pursuant n the provisions of the Conlrecmr's License Law(Chapter 9
CSO (commencing with Section 10X(1)of Division 3 of the Business and Professions Code)or TEMP M ErER OR POLE INST. COMMERCIAL:
Q.60�' that he is exempt therefrom and the Iasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑UEMOLI"PION
�y Section 1031.5 by any applicant for a pearout subjects the applicant in a civil penally of POWER DEVICES ❑TENANT FOOD SERVICE
Out more than five handled dollars($500), IMPROVEMENT
ASO ❑1,asownero'Ne papery,or my employee,with wages as their solecumplarmlion. SWIMMING POOL ELECTRIC ❑OTHER
(- will do the work.and Ne structure is not intended or Offered for will Pim.VMi,Business
L 3 m
and Pastessions Code:The Contracmr's License Law does
nm apply m an iswmcr of ON LEIS-SWITCHES-PIX'il S
property who builds or impraven thnem,and who dues such work himself Ot through
his town employ«s,provided that such improvements am not intended Or offered for NEW RESIDENTIAL EU(C113
SQ.19'.FLOOR AREA $ISQ PI'.
sale. lacvc,th'tooddingnrinip wnnem.,wdwithmoneychr of wmplaion.Ibe
ILtw
er-builder will have the burden of proving that he did not[could or improve m for pur-
sT L'
llas towcoupon,er of the couponuevit.,ney violation,with licensed contractors to A
p .
construct the prof«t(Sec.70eW.Business and Professions COdef The Connotation's Li- pp
«tow law does tool epplymmOwner of papery who milds or improves thereon.and QTY. PLUMBING PERMIT FEF: �Y
who contracts for such pmjecls with a erne acmrts)licensed pumuantto the Conuecmr s
License Law, PERMIT ISSUANCE f
❑ 1 am exempt under Sec. .B&P C for this mann `
AI TBR-DRAIN&VEN'T-WA'I ER(EA) VALUATION
Owner Date ss,
• WOR KER'S COM PENSAI'ION DECLARAFION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the lAlnwing dcdurahons
[have and will maintain a Cenillcam of Consent tot wit'mvuml'Or Wnt,eds Cmnwn- DRAINS-FLOOR,ROOF AREA,CORD. SIORIBS TYPE CUNS'1'RI,IC'DON
sminn,as provided for by Scctum 3](q of Ne Labor Rede,lits the performance of the
work for which this permit is iswed. FIXTURES-PER TRAP
FI I have and will maintain Workcris Compensation Inwame,as required by Section
3100 of the halos Code,an the performance ofthe work fest which this permit is iswed. GAS-EA.SYSTEM-1 INC.4 OUTLISTS (TCC.GROUP AI'N
My Wmker'sCmn'm1mKm inseoncecarierand Policynurks"ou: GAS-FA.SYSTEM-OVER 4 TSA)
Carrier: Policy No,
CERTIFICATE OP EXEMPTION FROM WOR K ERN GRP.ASFANDUSTRL WAST It I NI ERCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION IEES
(Tblssectian need can becmoecled iffbepemtin isl'nrrmchendreddollars($I(X)) GREA$E'TRAP
PIANCHECK hi
in,Ica,.) li
I lenity him lnthc penclumoc.offic wo o for whichthis wrom,is issued.I shah SEWER-SANITARY-S"F(IRM EA.Zia)fT.
Out employ any person in any nlE subjectthe Wrnm
colors Coper. ENERGY THE
Z notion laws of California.Date WATER HEATER W/VENT/Ii1.liCfR GRADING PER
Z Applicant
= NOTICE TO APPLICANT:IL after making this Ccnifirme Of Esemption,ynu should EfIH
WATER SYSTM1iATING
> became subject Int the Worker's Compenmeon pmvisinm of the Entire Cecil.your must SOILS Flil?
W a.. 6trhwith comply with such Provisions in,chis permit shall M themed revoked. WATER SERVICE
CONS'1'RECTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.1"T PAID
I c teceipt 4
U O I hereby affirm that there is n consmetion lendingngcncy i Or the performance of
[iF the work for is lch this permit is issued(See3097,Civ.C.) TOTAL:
O Larder's Native TOTAL
U Lcnder's Address
OUILDIN 'li
I certify that I have read this application and state that the eh eve information is
rLJrn carrot,l agree to comply with all city and county Ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE SEISMIC IT
Z building conswction,and hereby aulhame,representatives of this city to enter aponthc
alamementioned pmpcny fur inspection purpous. I PERMIT ISSUANCE ELECTRIC FEE
(We)agree to wise,indemnify and keep harmless the City of Cupertino against
Iiabilities.judgmems.costs and expeahs which may in anyway income against said City ALTER ORADDTOMECH. PLUMBING FEE
. asequence of the...toning Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'TO 10,(X1)CFM) MECHANICAI ;EE
SOURCE REGULATIONS.
l AIH HANDLING UNIT(OVER R1.(XX)CFM) CONSTRUCT )N'TAX
Sa�of Applicant) onttucasr ate EXHAUST HOOD(W/DUCI') HOUSING NIITIGGI' NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant Once Or handle haaallous material HEATI NO UNIT(TO I NON)BTU)
as defined by the C.N.mo Municipal Code.Chapter 9.12,mal the Health and Safey HI3Al'ING UNIT(OVER IIX4NMI BTU)
Cad..Section 25532(ap
El Yell ❑No VENTILATION FAN(SINGLB RESID) PAID
[)ala lice f F
Will the epplicum err future Ladling occupant use emanalm or devil.,which BOILHR-COMP(31IP OR IIXI,gNI B'FU)
'unit ha'eordeu,air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Discric? BOILER-COMP(VER II WOO IIT'Ll)
]Yes ❑No
l have cocaine Wausau,materials rtquitemcros an Chapter 695 of Ne Cali AIR CONDITIONER ISSUANCE DATE
hum.fita Health&Safety Cosk,tieaions 25505,25533 and 25514.I umkmtand the Hobe NEW RESIDENTIAL MCCIL SQ.FF.
building does nd currently have o tenant.that it is my nespmribility to Wily the clinical
of the rruirements which must W met prior t0 issuance of a Cenificme of(kcupamy.
Owner err authorized agent Date TOTAL: ISSUEU BY:
OFFICE