S 1537 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO, I''
BUILDING DIVISION APPLICATION/IPERMIT PLUMBINO-MECHANICAL. � 1537
IIUILDING PROJECTIDENTIFICATION ..LL V
BUILD ADDRESS:Y _ SANITARY NO. APPLI NSUIB 1'll'AL DATE
pgRq MP � P �� CO CIY7R:S NAME: -� 4JLIC NO: Z
1f/��\T. N/C CONTROL.
�pHCI{I'IFCT/NGINEEH: LIC NO: DR'SS 2oAU N ElCONTACT. PHONE: prp - �� I 7 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Sr ElEl ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I harehy vmrm mat I ant rccnoed under provisions of chapter 9(commencing .JOB DESCRIPTION
Qts ZOwith Section 71NN1)ad Divisinnlol the Business and Professions Coda and myllccmels PERMIT ISSUANCERESIDENTIAL'
F W F in fu11 force and c �1 ❑SFUWI. ❑KITCHEN REMODEL.
r—Q License 't hic'N APPLIANCES-RFSIDEN'I'I Al. []ADDITION El PLUMPING RE-PIPE
Nz nam Commcort
4L ARC]111171 TS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F 5 ti PANELS MODIFICATION
zOwz iunda"n d an"lans shall na used vs Puhlicrwtm.
CZ -O Up 10200AMPS ]IN'I FRIOR NIiNREPAIR
License Potles.innul 201-1000AMPS IMPROVEMENT f1I SWIMMING POOLS
OWNER-BUILDER DECLARATION OVIiR IIx111AMP5 ❑BATA REMODFUkEPA1R [-]DEMOLITION
1 hereby nRrm Nm I run exempt from the Gmtrvemds License Law far Lha
t1 6 U following reason(Sanaa 91131 5,Business and Professions Code:Any city or county SIGNS IJ.FC'I'RICAL Q OI IILR
3 y which re9virvs a permh m construct.alter.Improve,demolish,or tapir any struclum
.F.�C� prior lots icsuanre,also requires the applicvm forsuch Permian fileasignedsmreatem SPECIAL CIRCUIT/MISC.
�yNthat he in licensed tonuanl In the pmvisimoofthe Commcmes License Law(Chapmro
W..a CO (cnnunencing with ScOinn7lM(B of Division 3ofthe Bminecsand Professions CuslOor TEMP.METER OR MOLE INST. COMMERCIAL:
a a C% that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
ad Section 7031.5 by any applicant for a permit subjects the applicantto a civil Penalty of IxDWHR DEVICES ❑TENANT' ❑FOOD SERVICE
.,o" not more than five hundred dollars 015110).
IMPROVEMENT
< � L»owner of the pmpeny,nr my employees with wages.Neirsole compenzmion, SWIMMING POOL ELEGTRIG
,p=-C will do the work.and the structure is not intended oroliered for sale(See7100.Business FR
we 3 m and Professions Cale:Ilse Contractor's License Low does not apply to an owner of
Olfl'Lf75-SWI'TCI{FS_FIXTURES
.. property who builds or improves flacon o,and who does such work himself aT through
his own employees,Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECrR SQ FT.
sale.If,howeve,the huildar,mimpmvement issold within one ya tremnliltnion,the SQ,FT.FTOOR FjA $/SQ.IT.
ownenbailder will have the burden of proving that he did not build or improve for put.
pose of sole.). TOTAL
❑ 1.ns owner nTtlte prnpeny,am exclusively contracting with licensed contractors to SPR 21 °®
construct the project(S
(,See 7044,Business wad Professions C def The Contractor's Li-
cemeLuwoesnotapplytoanownerofpropenywbohuildsorimprovesthermn,and QTY. PLUMBING PERMIT FEF. CI
who cantmets far suuh pmjocv'whh v eommvdops)Iicen.W pumuum m the Cnntrnner'e CITY F 1
License I,;,,. PERMIT'ISSUANCE Uf lrlJl-Cf71 IVVJ
❑ lam excustnder Be,,. .B&P C for his rcnwnt
Owner Date AUFER-BRAIN&VIXI'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby allirnt under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-inwre for Worker's Carman DRAINS-FLOOR,ROOF.AREA,COND. STORIES TY PE CONSTRUCTION
sa inn,us pmvidedl liar by Section 3700 of he Labor Code,for the performance of the
work for which this pandit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Semian
3700 of the Lahr Code,for the performance of Ne work for which this parfait is issued. GAS-IiA.SYSTEM-]INCA OUTLETS OCC.GROUP- APN
My War Co npenen"m mnca dPolic nu be a
Carrier. Policy NoJ.� s-tl2'2 GAS-IiA.SYSTEMOVEH4(F.A)
Clil"IIICATIi OIs Td%f:MI'TION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION_FEES _
(This>cminn need not F,ecomplerW iflbepemtil is forone hundreddollars 151(X11 GREASE*1'RAI'or less.) PIANCHF.CK FEE
I certify Run in the peUormonce ofthe work for which this Permit is mused,].shall SEWER-SANITARY-S'DORM F.A.200 FT.
not manna so any person in any mannso as m become subject the Workers'Compen- ENERGY FEE
OZ satin,Lawsof California.Doc WATER HEATER WNENT/ELECTR HEADING FFE
Z Q Applicant
tr fn NOTICE TO APPLICANT.If,after making this Certificate of Exetnplinn,you should WAT FR SYS TEMfI BEATING
Ws"" become subject to the Workers Compensation isihof the Labor Code,you must SOILS PEE
tiforthwithwiforthwithcomply with such pnrvisinns(it thiss peoremtit shall be okemeA revoked. WAl1iN SIiHVICF.
a
UZ CONSTRUCTION LENDING AGENCY NEW ItIiSIDFNTIAI,PCMB. SQ.FT. PAID Duw Re /PIN
C.1 I hmehy:dlir o dial them is v constdetion lending agrncy for the parfordtmcmd
me work fur which this crof Is issued(Scc.3097,Civ.C)
Lends,Nim TOTAL:
L) Isnder'.v Addre,, 'I'O'I'AL
[.,. I certify that I have reed this application and state that the have information is BUILDING FEE
hcomet.)agree Iemnply wire ell city unJ county ordinances tmA slam laws rclvtingm QTY. MECHANICAL PERMIT FEE
U z huilJing cnmwcrinn,and hereby authorise rcpresemaives of this city memm�mun Ne SEISMIC FEIi
ato)ve-mentioned pmpeny lisr inspection purposes. PERMIT ISSUANCE
(We)race In save.Indemnify and keep hmmlcss the City of Caperton against IilX.C'FRIC IT
Iiahiliiies,judgmenu.coslsundexpcnsexwhichinayin any way aceme against said City ALTER ORADD TO MECH.
in censequenceof Ne grumm,of his permit. PLUMBING—F.F.
F,F,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO MAJOCPM)
OURCF.RF LATIONS. MECHANICAL
AIR HANDLING UNIT(OVER]0,000 CFM) CONSTRUCIIONTA
Signsdr 'r Inntmdc Dam EXHAUSTHOOD(W/DUCT) HOUSINGMLTIGATION E
1{AZA t� 5 MATERIALS DISCLOSURE
Will the applicamo building occupum score or hanJle hvnrduus material tI1iA1'ING UNIT lT0100,gO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,sad the Health and Safety
Code.Section 25532(x)'! HEATING UNIT(OVER 100.1100 WITH
E]Yes ❑No V17N'DLA'1'ION PAN(SINGLE RESID) PAID ])ate Reset
killf
Will the applicant or future building occupant use equipment or devices which
emit heaardou.c air eemmarrms as defined by the Bay Area Air Quality Management BOIhCR-COMP THP OR 100,000 BTU)
TOTAL:
District?
C]Yes ❑No MOILER-COMP(OVER 100.000 BTU)
I haven, ]the It adou.mamdel,toqulnnene,under Chapter 6,93oflhe Cub- AIR CONDITIONER ISSUANCE DATE
mmla Heald)&Safety Coale,Serious 2.5505,25533 and 25534.1 understand that it he NEW RESIDENTIAL MECH. SQ.IF.
mildingdocsrun rnredly have.tem t dthan it,,my respnnsib,itym on iry nmoanpain
of the mquientents which nous be ntal prior to issnnncc of a Can invow of Oecupmay.
Owner or umlanued agent Doc TOTAL ISSUED BY: q�E
OFFICE