S 0113 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO III111.DIFG-ta.ECfRICAh rrxmrr rvo.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0113
BUILDINI:PH(1Jt:6T IDt:N'fIFICATION
SANITARY NO. A SI111MI"I'I'Ah DAI'li
RUILUING ADDRESS:
Orsir� k S'
OWNER'S NAME: PHONE: CONTRAR:S AME: hIC NO: NlC CONTROI,a
,r'C1♦ v 4Mc\.\ ., y46 - 1 1 Milk _.,T:III 6wd-
ARCI{IIECT/ENGINEER: LIC No ADDRESS: ,Aew�+a� 1 pr f(� - �.J�� ❑
COM'ACf: PHONE: U '1 O BUILDING PCRMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECTPLUMB h1T:CH
LICENSED CONTRAC IOR'S DECIARAHON QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(emmncncing
C IYZ with Seniors 7000)ofDivision3ofthe Bminesxand Professions Cdc.,nd mylicense is RESIDENTIAL
won full folies and n.� PERMIT ISSUANCE ❑SFDWI, C3KITCUEN REMODEL
i tier �u
� I) License Clues Y`-- b
ULlca..J' APPLIANCES-RESIDENTIAL. [I ADDITION ❑PLUMBING RE-PIPE
of Ute Ct6acC IV\sijj ❑MULN-UNIT ❑STRUCTURAL
ARCHITECT'S DIiCLARATI(lN PANELS MODIPICNHON
Z~O,�2Z I understand my planssoall be used an public recools OPTO 210 AMT'S
OZ—� ❑INTERIOR C]CHIMNEY REPAIR
Licenced Pmressitd 2111-IfXIU AMPS IMPROVEMENT E]SWIMMINGPOOLS
�, OWNER-BUILDER DECLARATION AVER 1000AMPS ❑BATH RIiM01lEURFTIN Ll DEMOLITION
C `c I hereby atTinn Thal I ant exempt Gam the Contract""'License Law f n the le OTHER
X d U following rcamn.(Section 7191.5,Business and Professions Gde:Any city n ummy SIGNS ELECTRICAL rT
6131+-ya which requires a permh m construct.alter,improve,demolish.m repair maty.Irvctnm AA
F u'OJ prion,,its issuance,a lm regmrcs the applicant for such Permit to file a signed statement SPECIALCIRCUITIN .C. !y Q
ythat he is licensed pursuant to the prvisions of the Commcmrs License Taw(Chapter9 COMMERCIAL:
❑W1-0i (commm�cing with Section 7000)of Division did he Business and Pmfesnnns CWdur 1EMP.MEfERt POLE1NST C1 NEW BLDG/ADDITION C1 DEMOLITION
L q e' that he Is exempt thembion and the basis far The nllcged exanpeon.Any violation of
W..y
Section 70?LS by any applicant fora permiLsuklccta the applicant m a civil penaltyof POWER DP CPS ❑TENANT' ❑FOODSERVICE
not marc than live hundred dollars(851X)1 IMPROVEMENT
Fs.4
owner of mime pmpcny.or my employers witM1 wages asTheirmlec,,mPtnsalion. SWIM NGPOOLELECTRIC OTHER
F- will do the work.and the nmaure is nm imm�deJmoRereJ lnrSdC(See.7014,Bicmc,,
KZ
and Professions Code:The ComoutorL
r License w Ines not apply to an owner of O LETS-SWITCIIFS-FI%'TURES
a'3 property who builds or improves thereon,and who does such work himself err though
hown employees,provide but web improvements are not Intended or o0kmd for IiW RESIDIiMTIN,ELECTR PI'.
is
g or improvement SG I'I'.I1O012 AREA SISQ�FL
sale.If,holder III have mit ,list he dol h onb build
or improve
the
wnerM1uilder will have Ne M1uNrn of proving that he did not build or improve fur
pur-pose of aided. TOTAL:
I,as owner of the propxrt t am exclusively contracting with licensed contractors 10
construct he project(See 7144,Rosiness and Professions Gde:)The Comrnetor's Li-
censeLaw does not apply tit an owner of property who builds or hnpmve%thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projeeu with a eornme orfs)Iicerwed purwant To the Contractors !
License Law. 1112RMIT ISSUANCE •i
1 am exempt under Ser. ,B&P C for this reams
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Ilam
WORK17R'S COMPEN SKI ION DF,CLA RAT'ION RACK FLOW PROTECT.Up VICE• 0 A❑I have I hereby affirm under Penally of Mrjury one of the fallowing declamtion.s: r
ve and will maintain a Cenificau of Consent m self.inmm for Worker's Compen- DRAINS-1'LOOR,EDGE.ARBA.GOND. STORIES TVI'C CONSTRUCfI(lN
sarion,as pmvidd for by Section 37(X1 of the Labor Code.for performunce of the JUL 9
w rk for which this permit is issued. FIXTURES-PER TRAP 1
I have and will maintain Worker's Compem.unt Insurance,as required by Section
1Xl of he .rbos Calc.lot the ednnnumceol The work 4r which This pannit is lssud. GAS-EA.SYS'I 11M-I INC.4 OUTLETS OCC.GROUP h� APN
y Wnrk 's C}I� 'bonl ran •c: ' dPolicy aL i, GAS-EA.SYSTEM-OVERd(EA) CITY•u
Comer. 4 !+� ,Policy Nw:a1 V
CERTIFICATE ME PfION FROM WORKERS' GRFASI%INDUSTRL WASTE.INTERCEPTOR
COMVENSA'TION INSURANCE BUILDING DIVISION FEES
1Thissection need not he completed note permitis forte hundred do11ury(51 I E GREASE TRAP PLANCHECK FEE
less)
Ioyaythat inthe in anymannero a%i wmkfm whijM1 llmispermlli,ivwedlshdl SEWER-SANITARY-STORM EA.2191 PI'' ENERGY Igili
mol employ any petro in any manner m as m become subject to the Workers'Compen-
z .moon Luwsof Cdifomia,llate WATER HEATER WIVENTATLECTR GRADING FEE
Z Applicant
.N. NOTICE TO APPLICANT:If,after making this Ccnificmc of Exemption,you should NATER SYSTEMRRE\TING SOILS hili
s4 seeome subject 10 the Worker's CnmperosaM1un provision,of the Labor Gds,you must
forthwith comply with such provi.slons,,r this pend hall hcdccrosd m,tdod. WATER SERVICE
6 QPAID
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FK Dae Receipt Of
V O I hereby affirm that there is a construction lending agency for Ne performnmce of
U. t.o the work for which this panim is issued(See3197.Civ.C.) TOTAL:
O Lender's Name IOIAL:
� U Lender's Address BUIIDIN 1FEE
1 certify that 1 have read this application and state that the above information is
I: Vl coved.I agree to comply with all city and county ordinances andmam laws miming to QTY. MECHANICAL PERMIT FEE SEISMIC PCR.
U z huilding construction,and hereby amhodee rcpmsenmtives ofthis city to enter upon the
above-mentioned prnpeny fir inspection purposes PERMIT ISSUANCE ELECTRIC FIT 7.
(We)agree v+save.admarify and keep halides,the City of Cupertino against
Iiabililie,.judgmemhs,a..(,.ad expenses whichmay inany wayaccrae agnin.a said City ALTER OR ADD TO MITCH. PLUMBING ITR
in consequence of the granting of this permil.
A LiCANT UNDER ANDS ANU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(d)(TEND MECHANICALFEE
S1�fCEREGULAT . S. //)))
p ' �� AIR HANDLING UNIT(OVER I0,000 CF CONSTRUCTION TAX
.IIIYYYgwww11nllRlllamm of Ap ism Conaadpr Dem EXHAUST HOOD(W/DUCT) HOUSING'MITIGATION FEE
I{ASARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building mention store or handle hicallousmacnal HEATING UNIT TO I(XLIX10 U)
as defined The Code.Cupertino Municipal de,Chapter 9.12,and the Health and Safety HEATING UNIT LOVE LINn BTU)
Cdc, C3 YO,
25532(u)'I
❑Ye [:1 No VBN HLA'I'ION17 (SINGLE REMO) PAID
Unit, Rcccipt q
Will the applicant,,T future building accident use cquipnmmm devices which BOILER-C , P(3HP OR IM.00I BTU)
it harardnus air contaminants inants as defined by the Bay Area Air Quality Management TOTAL: a
District?
❑
Y� No
❑ BOIL -COMPIOVER 100,000BTII)
AIR CONDI'HONEN SSUANCE DATE
I have red lbe liarnrdous material,rcquiremcma under Choprer 695,,E the Cdi-
Emmia Health&Safety Gde.Sections t.not i 15 533 and nsi bili I undauand field doe NEW RESIDENTIAL MUCH. Sp,IT.
huilding Jots notds which have b tutunL that o is ua responsibility a C nifici end O he occupant
of the requimtrenn which most he met prion,,issuance of a Cenihcac of Occupancy.
Owner err umhorittd ager
UIde TOTAL: ISSUED 11
OFFICE