S 0398 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPERTINO ILDING-ELECTRICA L r m'No QO A
BUILDING DIVISION APPLICATION/PERM I'1' rLUNlnrac-b+h:cnnwcnl, 0398
I ,U,[NG PROJECT IOENTIFICA'rION
SANITARY NO. APPLICATIOESUBMITIAL IIUILUING ADDRESS:1 OWZONE: CON'HA OR'S NAM1f LIC NO: NIC CUN
ARC IT[CI'/IiNGIN1 ER: LIC NO: AD RESS: Y�y ( ✓f -.J ❑
���CJ6UlW FcwS�, S1
CONTACT• PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC FLECr PLUMB MUCH
❑ ❑ ❑ IO�C._1}
7,ffi.
ED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
ozz1 I am licensed under pnrvc on,of Chapter 9(commencingWOO lh Scmion 3ofthe Bmincccand Pndcssion,Ctde"clany lima,ix RESIDENTIAL:1'IiRMiT ISSUANCE��� nfidifa ❑SFUWL ❑KITCHEN REMODEL
ihic.NAPPLIANCES—RESIDENTIAL. ❑ADDITION ❑PLUM BING R E-PIPf!
gzDue. If'('I' ilearaclar ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECT'S DECLARATION PANELS
MODIFICATIONOZNZ I understand my plans shall W used m public record,
UP TO HXIAMPS [:1 INTERIOR ❑CHIMNEY REPAIR
W Licensed Prnlessional 200-1000AMPS IMPROVEMENT 0SWIMMING POOLS
,ee,ysXsa 7, OWNER-BUILDER DECLARATOVER❑NXI AMPS
ION ❑BATA RE ��#r0 DEMO ON
•+W C'� I hereby affirm that 1 am exempt from the Contractor's Liceme Law for the MM ?IJi w'
ax O a ow
V folling reason.(Section 7031,5,Business and Professions Cole Any city or mainly SIGNS ELECTRICAL ❑OTHER
W 3ILI- which reymrc,a permit rat construct,alter.improve,demnikh,or repair any structure
,I later bid i"amm,aho acclaims the upplicum far ouch permit,Dlc nvigned,mtananl !QTYPLUMSBINGPERMITE
I.GIHGDIT/MISC.
F,2} that he is licensed pmsuannomepn,vf.donsof the Contractors license l.aw(Chapter a COMMERCIAL.
al
mommcncingwith Seenim 70(0)ofDivia,m3ofthe Bminesnand Pru@,imm CWc)arITI?R OR POLE INS'1'.
6 ec e C that he is csempt therefrom and the basis fur the alleged eacmpliom.Any violation of ❑N17 BLDGIAOUITION ❑DF.MOLI'f10N
Section 7031.5 by any applicant far ro permit subjects the applicant a civil penalty of DEVICES ❑TENANT ❑FOOD SERVICE
not snore than five hundred dollar,(95(X0. IMPROVEMFNT
=O DLaa owner of the propenY�ormyemploymswitb xa6a"mtMiradecompenwlion, ING POOL ELECTRIC OTHER
will de rbc work and the structure is not intended oroOereJ fur sale(Sec.7011,Business
C F"o S—SWITCHES—FlXTURF_S
W nnA Prnl whoa,CWc:The se, hervoi Lind w Law dna,net apply man owner of
pnrpeny who builds or improves thereon,and who does such work himself mered igb
his own employee,,provided that such improvement,are not immadW nr aRemJ Ino NEW RESIDENT JAI.ELGCI'R S IT.
sale.If.howesta,the building or improvement is sold within..Yenrdcornplown.the _ SQ.FT.1'L(IOR ANIiA $ISQ.Irl'.toomm,builder will have the burden of proving that he did net build m improve for pur-
paw ofsfe). U'I'I,asowner of the impart,am exclusively contracting with licensed cunlramors m B�construct the project(Sec.]014,Business and Profe„iuns CWc:)The Contractor's Li- Y"c ve Law dons not apply to an owner of propcny who builds or improves thereon,and PLUMBING PERMIT E ID
wh"emmotel,for such pmjo f,waa a amtmaar(,)teemed pufmant,the Com ncou, �InX,Licene law. ISSUANCE (//tl�I am exempt under Sm. ,B&P C for this reason
—DRAIN&VENT—WATER IEA) NOwner Date
WORKERS COMPENSATION DECLARATION FLOW PR(H i?CI'.DEVICE h LUYty�.
�15t I hereby affirm under penalty of perjury one of the following declarations: e
r ave and will maintain Certificate of m.w
of CnnselGinsum for Waders Carolina- DRAINS—IT.00R.ROOF.ARIDA,COND. STORIESTYI'E CONSTRUCTION
iAlmn,as provided far by Section 3703of the Labor CWa,far that peffrn cram of the
went for which this permit is issued. FIXTURES—PEN'1'HAP
❑1 have and will maintain Worker's Compcmation Insurance,as reyuircJ by Section GAS—Els.SYSTEM I INCA OUTLETS OCC.GROUP APN
.170)of the Labor Code.for the performance color,work for which this permit is issued
My Worker's Compensation Insurance currier and Policy number am: GAS—1?A.SYSTENTOVER 4 B?A)
Conies Palley No,:
CERTIFICATE QI'12XEMM[ON FROM WORKERS' GREASIUINDUS'FRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
or less.)fUnisseedon need not be complend iDhc permit iv fmune hundred dollars Staff GREASETRAI'
PLANCHECK ITER
I certify that inthe perfnrmurrce of the work far which this permit izi,meJ,l shall SEWER—SANITARY—STORM IDA.200 PI'' ENERGY FF,Ii
nm Iny anY Y m' mer w as m eco 5 ti c IIIn the Woden'Compen-
nn in an m
O z on haws nf( Jnrnia.any
m L WATER HEATER W/VF.NTIiLIiCfR GRADING FEE
Applicum `
.N. k,ma, bj,APV?. ANT.If,slier mal n this CmiOcote of ExcNption,you should WATER tiYSTEh1/I'HPiV'ING SOLI ti PIiE
M1ccome subjca es the Waders Compen,am n provisions of the Latin Cede,you must
forthwith comply with such provi,iona or thispermit shall he deemed revoked. WATER SERVICE
WQ
d
CONSTRUCTION I.FNDING AG17NCY NEW RESIDENTIAL PI.MB. SQ.IT PAID
,U zDa¢ Receipt#
L) 0 k far
rwhichrhi that isacomtmcti30leading agency be the Performance of
the work for which this pemtit is issued(Sec.JfN].Civ.C.) TOTAL:
O (•" lander,Name 'DTAL:
r Leader'.,AJdm.vs BUILDING FEE
C I minify that I have read this application and state that the above information is
r�. y cartt l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V buildingconswdlan.and he i,ynmharim npm%cntativen ofthiscity to eructation the
ahove.mentioned property for inspection polls' FERMI I'ISSUANCIi Fl.VC'I'RIC hili
(We)agree ns mve.indemnify and keep h.lc,,the City of Cupertino against
habilitics,judgments,costs and expenses which may in any way accrue against mid City ALTER OR ADD TO MECH. PLUMBING FIDE
in consequence of the granting of this permit.
APPLE(, I'UNUHRSB' NDSAND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,0N)CFM) MECHANICAL Iy1E
SOD EGULAI'I
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature ApplicmW ntramm Doc EXHAUST II(IQD IW/DUCI'1 HOUSING MI'I'IGAHON hlili
HAZARIX) MATERIALS DISCLOSURE
Wlltber,dwaneor future bulldingrcaupuntstain"r handle k.aNausmanrial HEATING UNIT To 100.00()BTU)
as defined by the Cupec m Municipal Cede.Chapter 9,12,and the health sad Safety REM[No UNIT(OVER INN NX)BTU)
Code,Section 25532(d'I
❑Yes It No VWI BAI'ION FAN(SINGLE RESIDE PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP OHP OR IN).(=BTU)
: emit h...Mon, to enntamivar,as defined by the Boy Arca Air Quality Management TOIAI
District? BOILER—COMMOVER I(X).(NX)BTU)
❑Yes �Nn
AIR CONDITIONER ISSUANCE DATE
blue ted that hneuMaue innledal,rcyuimnn mi undar Chapter 6.95 of the Cali-
fomiaHcxWt&Safety CWaeca(cou 25505.is my benJrsibil 1unrtuity d Joel iveref lbs NEW RIiSIDEN'I'IAI.M1iEC11, SQ.17L
buildingdratnmavcurrently have b,netpthat o isufccula ernusramifytheoccupant
i of the mquiremenu which must be ma prior m iswance of a Cenificu¢of Occupancy.
Owner or amhomN age,
Date 'rOTA1,: ISSUED BY:
OFFICE