S 1542 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Migir NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL v 1542
BUILDING PROJECT IDENTIF'IC'ATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
OWNER'SNAMFR.,1 Q. PHONic f RACIOR'S NAM H: '/LIC leo:
• _I'1�1 a+-`"-'•'�— 99& —� l/C �lak/ -)-g 90.5 N/G CONTROL If
q
ARCHITEC A NGINEER: LIC NII: �R S. ^ A �� ❑
IO/lir_ 4 z2
CONTACT: PHONE: Bl11LDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLLW3 MUCH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 heocbrallied,rem I am licensed kinder pnsv ono.f chapter v(camme..in, JOB DESCRIPTION
O wlll 111 tree antlelfnflusioin Sof Clot BaslnessnkiJ l'mf,saion,%Cnsla.mdmyliacnw is PERMIT ISSUANCE
FCC RESIDENTIAL
Fy.W U to ❑SFDWI, �❑'1nK�ITCHEN REMODEL
aVU License Claw Come APPLIANCES-RESIDENTIAL. ❑ADDITION $f.UMBING RE-PIPE
Q d Dae Commnor
ARCH]'T ECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
F�'A PANIiLS
ZOyz InnderstanJ my plans shall he u.wA us public recarJa MODIFICATION
14—CUP10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
f-.~; Licensed Professional 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
hi`�99p� OWNER-BUILDER DECLARATION OVER III(XIAMI'S ❑BATH REMOUEIJREPAIR ❑DEMGLII'EDN
s'!W Q I I...by uffrat that 1 nm exempt from the Contmove's License Law far the
O d U following reason.(Section 7131.5,Business and Professions Cole:Any city or county ❑OTHER
which reyui as a permit to construct,neer.improve,demolish,or repair any slmcmre SIGNS EL[CfRICAL
prior to itsissuance,also requires the applicant for such permit to file it signed statement SPECI AL CIRCUIT/MISC.
that ha is l lcensd pursuant In the pro,,aionrofta Cn anemr's License Law(Chapter9
•+00q
(commencing with Section 71XH0of Division 3ofthe Boniness fail l'mfessians Cole)., TEMP.METER OR MOLE INS'r. COMMERCIAL
L :
iE c LL that he is exempt theafmm and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Is. Section 7031.5 by any applicant for a pemtit subjects the applicant a civil penally of POWER DEVICES ❑ ❑
mm ttTENANT FOOD SERVICE
{. �< no more than rise blinded)dollars S500).
CSO ❑ Lav owner of the pcFrty,or my employees with wages as their self,compensation, SWIMMING FOUL ELECTRIC IMPROVEMENT
2• will Jo the work,and fee%fracture in not intended oroRered for sale(See.7614,Rusin,, ❑OTHER
WF
m and Pmfenion%Cale:The ov smare. License Law does oft apply s if r,thou of OUTLETS-SWITCHES-19%TIJRES
hik o,y who build,or improves thereon,and who Joan such work
te himself or through
his awn employeese pmlding ohm such mentis soldlire not intended or afraid for NEW RIiS1UEN'I']AL F.LECI'R SQ Cr
sale.ILhawevcntec vette boder of passing
is he within not
nJmprovetfomthe SQ.FT FLOOR AREA LSQ.Fr.
ncr-builder will have the burden of proving that he did not buil)at impede,far pur-
pow1,assole).
❑ I,as owner of tlto property,ten eschuivcly cafia,,i ng with Ica ad caraour',
Ouse La the project(Sec.o an ownHaner
and Professions Cade:)Tho Conhznon, kid Q r A O D
Li-
cause Lawdosmmapply toan with
erofpropcny who
sedporiuntmaes Commu,nnd TY. PLUMBING PERMIT FEF.
uhn cataracts far such projects with a conaaemrts)IimnuJ pursuant m the Cnnaannrs
License Law. PERMIT'ISSUANCI?
❑ 1 it,exempt under See. ,B&P C for this reason
Owner Dune ALTER-DRAIN At VI?NT-WATER(EA,) APR 21 'ION
WORKERS COMPENSATION DECLARATION BACK PLOW PlonECT.DEVICE V,1
Ihereby addition under penalty ofperjuny,one of the following deductions I�r yr VVrcillf
❑ [have and will maintain a Certificate of Consenuo self-houre for Workers Compete- DRAINS-MOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTIGN
saint,as provided far by Section 37M of the Labor Code,for the perfarntanre of the
work far which this permit is issued. p55_ FIXTURES-PER TRAP
❑ I have and will maintain Workar's Compensation Insurance,as required by Section
3700Ofine labor Cole.for the Performance of the work lir which this Perot is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My W.r %Con U In+tmnc a dPolicy nu'Qbe
lateen. L mei'nlicy Nn: �e -3'. 960) GAS-EA.SYSTEM-OVER 4(TEA)
CERTIFI 'A'I'L?OF BXB PITON FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI.WASTE INTERCEPIOR BUILDING DIVISION MR.(This semi..need nm M completed ifthe pcmiif is far.ne hundred dollam(SI(C)
or bass.) GREASIiTkAP PLANCIIECK FEE
Ic,rdfy than in he pertormanceol'the work for which fluispennit is is..'i'I%hull SEWER-SANITARY-STORM H.A.200FT.
nm employ any person in any manners.as m ficamne%abed m the Workers'Counter- BNERGY FEE
O z satin.Law,of California.Data WATER I IEATER WNGNT/ELECTR
z 0 Applicant GRADING FEE
h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTIiM?RFAI'ING
bwame sahjert to the Warkcr's Compcmeln.pmvisiotts of the Wmar Gude,yon trust SOILS 171M
forthwith comply with such providursor this permifshall be deemed revoked. WATER S17RVICH
0
CONSTkUCI'ION LENDING AGENCY NEW RIiSIDF.NT1A1.1'LMB, SG ET. PAID
L) O Iherehy nfBmnhanbcrc isacotuvnmion lcnding xganay far the pmlitnnwme of Umc RaulptN
Ck< Fthe work for whichthis permit is noted Sea.3097,Civ.C.)
Lender's Nome TOTAL:
!U Lenders Address TOTAL:
I certify thin I have mail phis application and alone that the above indmntmion is BUILDING FEE
tr y correct.l agree to comply withal)city and couraynodumees fnd,ohn laws relating a, Q'IV, MECHANICAL PERMIT FEE
Uz building construction,and hereby authorise representatives ofthis city toemerurym the SEISMIC FEE
above-metaioned property for inspection purples. PERMIT ISSUANCE
(We)agree am
,save,indemnify and keep hannlrs%the City at Cupertino against I3LEC RIC FEE
Iinhilitiex,jadgosn,,,.1san!expense which may in tiny way.cane against said City ALT ER OR ADD TO MECH,
mo.nsequ.nceoffhe ranting off' PLUMBING FEE
APFI.ICA N1 STAND D tet .1.COMPLY WITH ALT.NON-PD 'T PIR HANDLING UNIT f10 10,IXp CFFD
MECHANICAL FEE
SU t at f10NS.
AIRHANDLINGIIND(OVER 10,000CFM) CONSTRUCTION TAX
Sig mofAppli...MCmdevelo, Dat EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI ER1ALS DISCLOSURE
Will theapplicant or fuana huiid'egoccupant store or handle hamNommaterial IIEATIN ,UNIT(TO 1sLona i'Dll
us defined by the Cupertino Municipal Code,Chapter 9,12,and the Hari th and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 100,00X1 BTU)
❑Yes ON. PAID
VENTILATION PAN(SINGLE kESID) Date RecaiptN
mod that nppllnta infnts a building by the Bt use ea Air a lir devices which
emit haraNnus air contaminants as defined by the Ray Area Air Quality Management BOILER-COMP(31{P OR 100.000 BTU)
TOTAL
District?
❑Ya ❑N. BOILER-COMP(OVER 100,0001{1'U)
I haverefd the h:mtNnux toot rtuiament'umler Chntfer6.95uf,hc Cnli- AIR CGNDTITONER ISSUANCE DATE
Farm.Health A,Safety Calc,Sec' ns 51 ,25533 x.121134.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
uJ ' yhav m, it is myrovpalmility to nntifythe occupant
the mgti hlchm moissnmt Tofu Ceplfnnc u' cyfwtmy.
O er lir 110�tailed em Data TOTAL: ISSUED BY:
OFFICE