S 0714 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P v IT NO. 71
BUILDING DIVISION APPI,ICATION/PF,RMIT PLUh/RINs1-MECHANICAL O 1 1
BUILDING PROJECT HHUELIF'1CA1'ION
ItITCDING ADDRESS: / SANITARY NQ APPLI2ATION SUBMITTAL DATE
O /Y///!R'S P/ —�a C CfOFU ME: .IC NO
�O NIC CON'1'ROLM
*RCENC,1.NEER: - C O: /S D a zl�/ ❑
2� 161,PHONE: Bl11LDING PF:RMIT'INFO
Consultant FeesPaid by Applicant(Initial) BLDG BLECT PL B MECH
TRACNICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Cazwith Section]OOBof Uivi.io 3ofthr Business.nd Pmfcssimts Coha.mdory lean i. RESIDENTIAL
{�p O PGRMI'I'ISSDANCE
1-W full force and effect. ❑SFDWL ❑KI'fCIIh:N REMODIiI.
6OU Ldcense [1. APPLIANCES—RESIDENTIAL. ❑ADDITION C:1 PLUMBING RE-PIPE
yy W Date
Contractor
In<4 El MULTI ❑STRUCTURAL.
ARCHITECTS DECLARATION
F. Z I continuum my plans Shull be used as public record. PANELS MODIFICATION
C2-C UPT02MAMPS C1 INTERIOR [I CHIMNEY REPAIR
F.zi ' Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ATH REMODFUREPAIR 11 DEMOLITION
y 4' I hereby affirm that I am exanpt from the Contractor's literate Law for not
4 UF following reason.(Section 7031.5.Business and Truncations Code:Any city Or county SIGNS ELECTRICAL F1 OTHER
F�40 Na which requires a permit to construct.utter,improve,demolish,or repair any structure
J prior to its issuance,also requires the applicant for such permit to File a signed statement I SPECIAL CIRCUIT/MISC.
;!�} that he is Licensed pursuant to the previsions of the COntmerm's License Law(Chapter 9
apo (commencing with Saxtion'1000)nf Division 3of the B.,anessand Professions Cele)m TIME NIL ITR OR FULL;1 NST. COMMERCIAL:
4 M C that he is exempt therefrom and the basis for the alleged exemption.Any suction of [D NEW BLDG/ADDITION C1 DEMOLITION
{LSection]031.5by any applicant fora permit subjects the applicant to u civil penally of POWER DEVICES El TENANT ❑FOOD SERVICE
�. w not more than live hundred dollarsWish. IMPROVEMENT
O Ol,as owner mf the property,or my employees with wages as their sole compensation. SWIM M I NG POOL ELECI RIC
will do the work,and the somme,is not inrendedor offered for sale(Sec.]044,Business OTHER
W op
and Professions Cele:The Contractor's License law does not apply m an Owner of / OUTLETS—SWITCIIfS-19XTURfS
4 3 property who builds or improves thereon,oetl who docs sods work himself or dtmugh
his own employees,Provided that such improvements am not intended to marred for NEW RESIDENTIAL ELIhm SQ PI'.
sale.If,however,the building or improvement is sold xiihinom yarridemo,lain..the Q.IT.FLOOR AREA EISQ.FI'.
er-builder will have the burden of proving that he did not haild or improve lot pur-
pose of sola.). TD3'A1.:
❑1,as owner of the prnpery,am exclusively contracting with licensed contractors to
construct the project(Sat.]BM,Business and Professions Code:)The Contractors Ib Ifs
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such prefects with o cnntmem(s)licensed pursuenno the Commerce. DECLicense Law. PERMIT ISSUANCE D -8 11,121)
I am exempt under Sec. .B&P C for ins rcnaon
AACKt—DRAIN PROTECT.
DEVICWAI E
(EA) tYsr VALUATION
Owner Data lUty}�({/J%hKVyr%( M I liyU
WORKER'S COMPENSATION of
DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declaratWaskeux Co
❑Ihave and will forbyneCion 37m of the
abor Code,sumfer Workds Comp em DRAINS—IlOOR,RWryARFA,CORD. STORIES 'I'YPECONSTRUCTION
section,rc provided for by Section)]fX1 of the Labor Code,for the performance of the
w rk for which this permit is issued, FIXTURES—PER TRAP
1 have and will mni main Workers Compensation Insurance,us required by Sed on
3701 of the Labor Code,for the Extortionate or the work for which this permit is issued. GAS—HA.SYSTEM.I INCA OUT LETS OCC,GROUP APN
CMy ameo 'Con tion . nett FnId Policy m rNni�.n29 S/ GAS—FA.SYSTEM OVER
Policy
IrUI KATE FEXEMFf10N FROM WORKERS' GRESF/INDUSTRLWASITINTERCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION 17?EC
This mat inn need not be cnmplemd ifthe perdu is for one hundred dollars lS ILIO) GREASETRAP
nr 1.0I'IANCHECK PEIi
I comity that in the perfunnanco ofthe work forwhith dols permit is issued,l shall SEWER—SANITARY—STORM LM.2011 FT.
not employ any person in any manner so as to become suhjecun the Workers'Compen. IiNERGY FEE
action Laws of Califnmia.Date WATER HEATER W/VENTIELECfR
Applicant GRADING FEE
NOTICE TO APPLICANT.If,of it making this Cenificum of Eaempnio t,you should WATER SYSTEM/IRP.ATING SOILS FEE
(~ become subject in the Workers Compensation previsions of the Labor Code,you must
Wforthwith comply with such provisions or this permit shall he deemed revoked. WATIiR SERVICE
at 0
CONSTRUCTION LENDING AGENCY NI7W RESIDENTIAL PLMR. SQ.PC PAID
V Q Iherehy affirm that there i.eacunstmetinn lendin6 agency for the performance of Um R ciptk
(, the work for which this permit is issued(Sec.7(19],Civ.C.) TOTAL:
OL) I-mdeea Name
L7J Lendees Address TOTAL:
Rs 1 certify that I have real this application and state that the abuse infurmatinn i. BUILDING FEE �a
VJ caveat.I agree mcomply withull cityand county ordinances and saute Laws retatingto QTY. MECHANICAL PERMIT FEE
V building construction,and hereby amhorim representatives of flit city mentor npora due SEISMIC PEE
ahmve-mentioned property for imqucom.purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEV.
liabilities.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PLUMBING ftiE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 16.000 CFM)
MECHANICAL ITE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0NI0 CFMI CONSTRUCrION'I'AX
Slgnamre of ApplicaeContractor Data EXHAUST HOOD IW/IIUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building weapons store or handle hamNous material HEATING UNIT fro 100AM BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 25592(.)? HEATING UNIT(OVER 100.000 BTU)
❑Ycx No VEN'1'I[.AI ION FAN(SINGI.11 RESID) PAID
Dom Receipt p
Will the upplicam or fu are building occupant use equipment or devices which BOILCR—COMP(7HP ON IBq.fNlfl BTU)emit Iteration air contaminants as defined by the Bay Area Air Quality Managentem TfpTL:
District? BOILER—COME(OVER I(A000 BTU)
[]Yet
I have readthe huxambsstomdal,mminmenk under Cmpmr6.95ofthe C.H. AIRCONDITIONER ISSUANCE DATE
fomie Health&Safety Coda,Sections 25505,25537 and 25574.1 understand that if the NEW RESIDENTIAL MECH. SQ,Irl'.
building does urn currently have.kraal,that it is my reslxmsihiliq In notify the eo:cnpunt
of the mquiremcnte which must he met prior to issuance of o Certificate of Occupancy.
Owner ser mNoritud agem Dam TOTAL: ISSUED B e
OFFICE