S0001B0440 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /z�I A
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.,3 O T T O
BUILDING DIVISION APPIACATIONPERMIT PLUMBING-MECHANICAL. 50001 Lia!(
BUILDING PROJECT IDENT IF'ICATIUN
SANITARY NO. AI'PLICATIONSUHMITTAI.DAR
DUILDINGADDRESS.
Pr.mrose — _
OWNT:R'S NAM+: PHONE:
CITRACT S Nn / I.IC N(:
of NIC CONTROL a
� �2sNChI1TFCT?NGINEER: LIC NO: D I"S. ❑
CONTACTround BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG PLEC'IPLUMB MUCH
❑ ❑ ❑ Q�_
LICENSED CONTRACTOR'S DECLARATION Q'PY ELECTRIC PERMIT FEE JOB 13FSCRIPTION
1 h achy.!firm mm I am licensed under pfovraon of Chapter 9(commencing
WOO with Section 9000)of Division 3 ofthe Business and Prof ss ion,Crdaandmylicense is RESIDENTIAL;
WOO PERMIT ISSUANCE
=_I- full force and cRyyl� 5 � ❑SFUWL ❑PLUMBIKITCHENREMODIE
�U~ Liamsc Class�_ Q -Lica APPLIANCES-RF_SIDENTIAL El ADDITION ❑PLUMBING KFPIPE
N Q 6 Dateciii —I�d�- 'Q M(CanlDECL t
/-1 a t ARCHITECTS D[CLARA'I'ION ❑MULTI-UNIT ❑S'fRUCfURAL
F a,Z I understand m plans shall be used as blit record, PANELS MODIFICATION
OZ y pr UP'10200AMPS OINTEMOR ❑CHIMNEY REPAIR
F 4tuuj Licensed Professional 201-11100AMPS PaPROVEMEN'1' E]SWIMMING POOLS
6 .J OWNER-BUILDER DECLARATION
MW
Q (OVER I0X111AMP5 L1 BATH REMODIillftl?PAIR ❑DEMOLITION
1 hereby union that I am exempt from the Course,..,License Law for the
d g U nuftocinmuxon.(Semina 7031S,Business and Parke,inw CWc Any city or county SIGNS ELECTRICAL OTHEI
u13 W y which requires a permit to Construct,alter.improve.dctncl'Ixh,or repair any structure
�.aJOQ prat its'.:. acc.rjo,a,fmoesthpal' t anorhecraii,t file a onced,ocent,rat SPICIAL CIRCUI f/MISC
y thud dp tI ah p It Common,1 L (Chapter 1,
caC, (cottnencngwth Section 7")ofDhisom 3 Ore,Business and Prf..' rvs Code)or 1171,411 MC I LR OR POLE INST.
a d e chat he is exempt thendi mn and he basis our the alleged exemption.Any violation of El EW DDHION O DEMOLITION
x^+V, Section703 byznyupPiiCant far.perl subjects theapNte
icant acst]peraltyof POWER DEVICES ❑TENANT CFOOD SERVICE
cu=V,
Sminot more than five hundred dollar Won). IMPROVElf ..
=p ❑Larowoerafthe 1-1- -1myempinyms with wages.1 theftode onat"ation, SWIMMING POOL ELECTRIC
EI OTHER
F- will do the work,and the structure is not intended oruRcrcd for sale(Sn.7047 Business
W�m and Profccaions Code:The Commences License Law diva not apply to an Owner of OUTLfi TS-SWITCHES-FIXTURES
a 3 pspcny who builds or improves themon,and who docs such work himself a through
his own employees,provided that such imp vecownts am not intended or offered for NEW RESIDENTIAL ELECfB SQ 1T.
sole.If.howeter,thebuildinimimpm
roveent i%Oddwithimme yearofcorfaction,the SQ IT.FLOOR AREA $/SQ.FT.
rrh
builder will have e burden of proving that he did not build or improve for pur-
tamer-builder
C of ruled. 'AL: �rll 'J U IJ
❑ I f the property, ly contracting with licensed contractors it,
c wata the polf.,(S WWq Business d Professions C oC:)I lie Col' mrN �..
sr 1 I t apply 1 f r P nY h l Id .p th rrn and QTY. PLUMBING PERMIT FEE p9
whacontrac"Trsion pntjecoormarotinaro ,)licensed parsaanm the Contrams" 171 T [) 41999
License Law. Ple MI'I ISSUANCE
❑ I um excmq under Sce. .B&P C forlhis reason
— )I
ALI PR-DRAIN&VENT-WATER(EA) VALUATION
owner Date '�tl
WOR KER'S COMPENSATION DECLARATION BACK PLOW 1-ROT..DEVICE
I ka,by affirm under penalty of perjury One Of the folhaving decl:estions:
nIhateand will mdmadan CerificaemCansemor self-insurefim W'Orhers Compen- DRAINS-FLOOR.ROOF.AREA,GOND. STORIES F7APN NSfRUCTRY
Orion,as provided for by Section 3]00 of the Ichor Code.for me performance Of the
work for which this Iv.it is issued FIXTURES-PLR TRAP
y/�� 1 have and will maintain Worker's Compen.mtion Insunnec,as occurred by Section
100of the LvMr,Cale,for the p,rfarmanceof the work for which this Permit i,issued. GAS-EA.SYSTEM-I INC.q OUTLETS OCC.GROUP
My Work Car Injru co c.ni 1 id Y�Nayn n
Carrier 'i iU'' Vb1 9� GAS-EA.SYSTEM-OVER4(En)
CIiRT11lCATEO'EXEMPI'IONFROMWORKERS' CRI:ASIYINUUSTRI.WASTEINTERCEPIY)R
COMPENSATION INSURANC17 BUILDING[)[VISION FEES
1'I w,linn nccdnm he cumplcwdlfthe prtnoil 1,Ibr on a hundred doRarr($100) GREASEIRAP
rr less.l PhANCI IIiCK FEE
certify that in the performance of the work lir which this Permit is issued L.shall SEWER-SANITARY-STORM EA.200 PI'. ENERGY PETE
0n1 employ any pe,am to eby manna m as to beconm subject 1.the Warka.'Compen-
Z Noun laws of California.Date W'AI'ER HEATER WNENT/ELECTR GRADING FEL!
Z Applicant 1
'Z'r NOTICE TO APPLICANT:If,afar making this Cenificnte of Exemption,you should WATER SYSTEMGREATING SOILS FEE
beton mhjccl to the Worker's Compcnsauon provisions of the Labm Code,you must
fonft.an comply with such Pon,nobs or this pemait shall be deemed revokol. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.let. PAIDZD Receiptp
V 0 l hereby affirm that there is a conOrumion lending agency for the performance of
W the work Ibr which this permit is issued(Seo.301 Civ,C.) TOTAL;
U LCn le ,Name *1 GTAL:
Lender's Addrms BUILDING
I Oci ily that I have read his uprilianion and mule thus the above infrom oma h
V1 corcet.lagmoto,omply with all city and County ordiounccs and%mm[awsmintingm QTY. MECHANICAL.PERMIT fF.F, SEISMIC 11111
U Z handing.... tion,vnJ M1crchy unthnrim mpruttnmtivex of thhhitymeme,trambe
ahovcmcnlioned Irmpcny for irv,pection purposes. PERMIT ISSUANCE ELECTRIC 12E13 O O
(We)agree ea r.vC,indemnify rad keep harmless the City of Cipenino agnina
liahilitics.judgmcros.costs and expenses which may in any way a<cmc against said CiryALTERORADDTOMECH. PLUMBING FEE
in consequence of the granting of this pe
APPLICANT UNDERSNO y A ' 111 Or I TH ALL NON-POINT AIR HANDLING UNIT(TO 10.01tM) MECHANICAL PER Cot
SOURCE BE
AIR HANDLING UNIT(OVER IO.IXpCFM) CONSTRUCTION TAX
Sigwmm of Applicara Contactor / Dare EXHAUST HOOD(W/DUC) HOUSING MITIGATION REE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building Occupant stere or handle hazardous material 1 HEATING UNIT(TO off"BTU) - O
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER[00.000 BI U)
Cal,Section 25532(0^
Yes No VENTILATIONFAN(SINGLE RESID) PAID
Dam Be,drt b
Will the eppliwnt 0,harm budding occupant use equipment or devices which. BOILER-COMP(31111OR](R) ROD
,o emit hazardous air Contaminants as definad by the Bay Arca Air Quality Manmm
agce
Insider! BOILER-COMP(OVER loo.old H 1L)
o Yes F7 No D
1 have mad the h ode.s x tiro,2 s ac.r 5.1 erftsa u2 l Chapter ohft of the Cali-
AIR CONDITIONER ISSUANCE DATE
4mai.11cahh&Sdcty Code.Sations 25 35J3 anJ SS crstend that if dm NEW RESIDENTIAL MECH.
huildingdwsan 'h a1 to a isuanc nsdnhty to notify the occupant
of the v ii t enf a Ceniric�ta�pf Q'cupgy� /
Onmer Of arthonzed agent ) Date T 1i 1 I O ISSUED BY
OFFICE