S 0188 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —2
CITY OF CUPERTINO BUILDING-ELECTRICAL PEpp11TN0 O � X�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J SV(
BUILDING PROJECT IDENTIFICATION
lUILDING ADDRHSS: ^ SANITARY NO. APPLICATION$UHMITIpI.DATE
e t) w
y S NANT.:IVT,-i W L4 4904f O G CONI' OR:S NAME: LIC NO: ^�
{� _ NIC CONTHOLX
AR(CUITECP/E NEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
❑ ❑ ❑
LICENSEDlot am ONnRACnder p DECLARATION QTY ELECTRIC PERMIT FEC
1 hereby affirm That I am licenced under provisions of Chapter 9(commencing JOB DESCRIPTION
O0,Z with Section 7000)n(Divixiou3oftho Business and PnafceslonsCodo,and mylicassc is RESIDENTIAL:
O p PERMIT ISSUANCE.
�Wr L ease lass effect. ❑SFDWI. (3 KITCHEN REMODEL.
Uf�11 License Class Lic.M APPLIANCES-
yQy Dateso . Contractor RESIDENTIAL ❑ADDRION (3 PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI.UNIF ❑STRUCTURAL
Z p 4 Z 1 understand my plans shut be used ac public reconL PANT-IS MODIFICATION
oz— UPUPT02W AMPS El INTERIOR El CHIMNEY REPAIR
W Licensed Pm(essiomal 201-I000AMPS IMPROVEMENT C]SWIMMING POOLS
S y� O
OWNER-BUILDER DECLARATIN
OVER INX)AMl',9 ❑BATH RNMODEVRBPAIR El DEMOLITION
6 I hereby.Sect m I uui exempt es a the Contractors License Law for the
igqi55at6U Whichingreason.Permit
to]03LS, t.alter, end improve,
dirloli Cde:Any city or cnumY SIGNS ELECTRICAL ❑OTHER
t++3 W E' which regnirex n permit re cnmwa.alter,improve,h Permit t or repair any SIGNS
_
O� pnonnits issuanee,also requites the applicant for such Permit fileesigned statement SPI!CIAI.CIRCUR/M15C. is
MW he is licensed pursuant to the previsions of the Contractors License Law(Chapter 9
E (commencing with Section 7Bgp of Division J tefihe Business unit Pmfcadions Codi TEMP.METER OR POLE INST COMMERCIAL:
d y that he is exempt therefrom end the hasis for the alleged cxemptinn.Any violation of ❑NIiW BLDG/ADDITION [I DEMOLITION
i417 LL, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
^zpN„ m more than five hundred dollms(E5W). IMPROVEMENT
6 El 1,as owner of the property,or my employees with wages as their sole compereanion, SWIMMING POOL EL t RIC
will do the work,and me suucwm is not intended or offcted for sate(Sec.7011,Business ❑OTHER
and Professions Cole:The Contractor's License Law does not apply to an owner of OUTLETS-SW D'GT .S-PIX" VS tm
a' r properly who builds or improves thereon,and who docs sack work himself nr mmugh r
his own employees,provided that such improvements we not intended m offered for NEW RESIDENTIAL ELECTR Q Irr
sale.If.however.the building or improvement is sold within one you
of completion.meAREA VSQ.FT.
er-hnllder will have the burden of proving that lie did not mild or improve for par-
pose clinic.). TOTAL: /'ryt••IV�Jj
] L ns owner of the pope ,t nm exclusively ennbacting with licensed enntmemrs to
construct me project(Sec.701,1,Business and PmfcTh
a,mr,Ca oci e Coma L
mctori-
se Law does rent apply to an owner of property who builds or improves Oareon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmctorta)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
❑ l am exe ade .B&P c har th, reason
c ALTER-DRAIN&VENT-WATER(EA) VALUATION
wncr, firif our
RK C PENSATI 'LARATION BACK FLOW PROTECT.DEVICE -
1 hereby affirm under penalty it perjury ane ret he following dcela amnc
❑ Ihave end will meintnin aCenifcam of Consenuo self-insure lar Worker's Compere- DRAINS-FLOOR,ROOF,AREA,GOND' STORIES 11 'fVPii CONSTRUCTION
smion,as provided liar by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURPS-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code.for performance ofine work for which this permit is issued. GAS-F.A.SYS'1'ENE d INCA OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number ma:
Carrier: Policy No.: GAS-P.A.SYSTEM OVER 4 TEAT
CERTIRCATE OF EXEMPTION FROM WORKERS' GRBASUINDUSTRL WASTE:INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(niswtionneednothecomplaWifthepermitis foronchundreddolim(SIW) GREASETRAP
or less.) PIANCHECK FEE!
I certify that in the pirhrearcrefrhe work forwlikh This permit is issued,l shall SEWER-SANITARY-STORM EA.200 hT.
not employ any person many on patio as to hoemne midoin m tire pc
e Workers'Comn- (ENERGY Fl!E
O Z indoor laws of California.Data WATER HEATER WNENTTLECTR
70 Applicant i GRADING FEE
q y NOTICE TO APPLICANT:If,afar,making this Cenlficaa of Exemption,you should WATER SYSTF.M`TREATING SOILS FE
a [' bccomc subject to the WarWes Compensation pmvisinns of the Lubar Cede,you must
W G forthwith comply with such provisions or this peneu,letll be deemed revoked. WATER SERVICE!
Q
] sL CONSs aON6FJSDINGAGENCY NEW RESIDENTIAL PCMB. SQ.IT. PAID
L) (herehy elf rmihm thereem isconstruction lending urgency for the performance of Doe Receiptp
Hthe work(or which this permit is issud(Sec.3097.Civ.C.)
lender's Name TOTAL:
Lender's Address TOTAL:
I certify that I have read this application and nate That the above information is BUILDING FEE
(0./1 correct l agree to comply with all city and county ordinances and nam laws relating m QTY. MECHANICAL PERMIT FEE
7
L> G building comosection,and hereby vumoriu repowenmdves of this city to enter upon the SEISMIC FEE
move mentioned property for inspection Proposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino again ELECTRIC FEE
liabilitics,judgmems,costs and expenses which may in any way uccme against said City ALTER OR ADD 90 MI°CH.
in consequence of the granting of this permit. PLUMBING FEE
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN1T(TO IBdNID CFM)
5 Ri REG A'1'IONS. MI3CHANICAI.FEE
ss
ALR HANDLING UNIT(OVER 10,00 CPM) CONSTRUCI'ION'TAX
,mumerd'Ailligunumor mmctor Dale EXHAUST HOOD(W/DUC) HOUSING MIT'TIGATIONI4iE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore ar handle hazordous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cite,Section 25532m)^ HEATING UNIT(OVER DECOCT)AO()BTU)
❑Yes F7 No VENTILATION PAN(SINGLI!RES ID) PAID
Data Receipt p
Will the applicant or future building occupant use equipment or devices which
emit heraNaus air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(3HP OR ItXTffX)BTU) t
Diahrio? TOTAL:
❑Yes ❑No NOILIEN-COMI'(OVER 100,00 HIT
I have read the baondem,materials namcauems under Chupar,6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forma Health&Safety Calc,Sections 25505.25533 and 25534.1 undeman l That if the NEW RESIDBNTIAL MECH, SQ.IT.
building does not currently have a tenant,that it is my mxpnnsibility to notify the occupant
of the r.quirements which must ed met prior to issuance of a Cenificme of Occupancy. V—
Owner or aumonted agent Data TOTAL^ ISSUED BY:
� OFFICE