30472 (2) APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O^ Q .�a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J< 4 2
nuu.DING PROJECT ii;WfIk'ICA'I'ION
BUILDINGADDRESS,:p SANITARY NO. APPLICATION SUBMITTAL DATI
10 1l,
I OWNERSNAME: I I PHONE: CONTRACI'(IR'S N Mi:. LICN
K , Vs_� NIC CONTROL N
ARCHfiECT/F.N :ER: of
LIC NO: I >RESS. ✓Y /� Vv ❑
CONTACT: PHONE: JY BUILDING PERMIT INFO
37816 e(�i Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
PF A ❑ ❑ ❑
ICENSED CONTRACTOR'S DE Al[ON (QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WIZ with Section 700b.f Division 3 of the Business and footrest...Cadc,ondmylievaneis RESIDENTIAL,
F00 'nfull force and effect. PERMIT ISSUANCE RESIDE ❑KITCHEN REMODEL
UW License Close Lica APPLIANCES-RESIDENTIAL CADDITION C PLUMBING R17 PIPE
FFZ u7
Data—Conductor
F=u, ARCHITECTS DECLARATIONPANELS []MULTI-UNIT []STRUCTURAL
zbI2? l understand my plans shall he used es public recoNs MODIFICATION
I Oz—, UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
rr+pJ , Licensed Professional 201-1000AMPS IMPROVEMENT
�Yd OWNER-BUILDER DECLARATION OVER IOOOAMPS
C BATH REMODEUREPAI D OLITION
U Q 1 hereby affirm that 1 am exempt from the Co License city
o for the
36U following reason,(Secuon]OJLS,Business and Professions Cale:Any cry. county SIGNS ELCCOUCAL []OTHER
which requires a permit m comment.eller,improve,demolish,or repairany eaadare
priorto its issuance,ulsorequims the applicant forsuch pemiil to rile asigned statement SPECIALCIRCIIII'/MISC.
2i that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Wy Z0 (commencing with Sation]000)of DivisinnJolohe BusinuouredProfcsaions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
a p"o tY
that he is exempt therefrom and the basis for the alleged escri f ion.Any violation of C NEW BLDG/ADDITION C DEMOLITION
.`n. Section]03 IS by any applicant lot a permiosubjats the apphcanuch civil petwltyof POWER DEVICES
not marc than rive hundred dolhu,,($5W). ❑TENANT []FOOD SERVICE
CQ I,eR ow net of the property, employees with we their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
eCs".G ❑ d pe ct Y etnp Y gee as pe
ill do the work,and thestructure isnot s LicenseInflated does
sale(Sm.7041,on weer o6 []OTHER
a,3m andProfessionswhom Cale:The Contracture License Lawdmsnot apply tolf or
of OUTLITfS-SWRCIfES-FIXTURES
progeny who builds or aided s thsuch i and who does such ante himself or through
his awn ride -,he provided ohm such improvements are nm intended o pletiod for NEW RESIDENTIAL ELECT. 1'.
snto.ILh.wev wll hbuilding burdenmvement isat sold hedid none ildorI provetfonJhc SQ,FT.FLOOR AREA $ISQ.PT,
owner-builder will have the burden.(proving that he did not build w improve for par-
posCofsele.). .-
❑ I,a nwner of the progeny,em exclusively cotmm�ing with licenwd i.mrunnrs m TO'1'A
nswct Ne es not apply
(Seo.]fano Business and property
who
but ds or i The Contractor's Li-
caneLawdasnaapplyman with
aontrnpcny whosedporimprovcs thereon,and QTY PLIJMBIN PER IT FEE e'� n
who contracts for such poojma with a eommemt(q licensed pursuant to the Commetorsll� i7 19n�
License law. - PERMIT ISSUANCH s7
C lara.1hodundcr Se.. ,B&PCfmddomawm •/ G
Owner Data Al— DRAIN&VENT-WATER(FA) )L VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE � L�'
I hereby affirm under penalty of perjury one of the following declaration: "RN. 0
C 1 monorail will maintain a Cenifcme.fC.mvm to self-insure for Workers Compen. DRAINS-FLOOR.ROOF,AREA COND. STORIES T iCONSTRUCI'ION
emion,as provided I'm by Sectio 371X1 of the Labor Cale,far the performance fore of the
work for which this permit is issued. FIXTURES-PER TRAP
C 1 have and will maWorkers Compensation WorCompensation Insumncc,as required by Section
37M.fdhe Labor Cale,for the perfrr.ance.Ohe work for which this Permit is ismed. GAS-EA.SYSTEM-1 INC.4 OUTIZPS OCC.GROUP APN
My Workers Compensmion Insurance command Policy number are:
Cartier: Policy No: I GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE(IP EXEMPTION FROM WORKERS'
/
COMPENSATION INSURANCE GREASF/INDUSTRh WASTE INTERCEPTOR BUILDING,DIVISION FEES
(This section need not be cnmPletcd ifthe permit is forme hundrM Jollms IS 100) GREASE TRAP
.rlees.l I'LA CK FEE
Toy my person
ff.anynmenraOhe work fur whijethio the Workero'Companl SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any rtmnner sonmbecome subjceuothe Workers'C.mpen- CERGY E
Z sation Laws of Celifomia.Dan.
Q Applicant WATER HEATER WNENT/F.LECTR OR D C FEE
11-a- NOTICE TO APPLICANT If,after making this Cenifcum of Exemption.you should
WATER SYSTEM/TREATING
ai 5
become subject y the Worker's Compensation or the provisions ut of the Labra Code,you masa 5
� forthwith comply with such provisions or Nis pcmtit shallthe demand revoked. WATER SERVICE ,
Q
CONSTRUCTION LENDING AGENCY NEW RESI DENTIAI.PLMB. SQ.Irl'. PAID
L) 0 Thereby affirm that there isuconstruction lending agency for the Performance of nm Receiptp
D. e+ the work for which this Permit is issued(Sec.3W7,Cl,C.)
Q U Lender's Name TOTAL:
� W lenders Address TOTAL:' 1 certify that I have read this application and state that the above information is - ULT. ING FEL' �•
LI) conem.l agree u.comply with all city end county mdinmce.and state laws relating 1. QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives of this city to enter upon be SE CFEE
above-numm ned property for inspection purposes.
(We)agree t.save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEB
liabilities,judgments,costs and expenses which nmy in any way.roue against said City ALTERORADDTOMFCH.
in conecquence of the granting of this permit. PLUMBING FEE
APPLICANT.0"IERSTANDS AND WILL COV13,VY WITH AL1 .ON-POINT AIR HANDLING UNIT(TO I0,(pO CFM)
SOURCEREGU ONS. MECHANICAL FEB
AIR IIANDLING UNIT(OVER 10,1X1(1 CFM) CONSTRUCTION TAX
gnamrc pie ucon actor D' EXHAUST HOOD(WIDUCD HOUSING MITIGATION EE
HAZARDOUS MATE LS DISCLOSURE
-.� Will the applicant or future building occupant store or handle hazardous metered HEATING UNIT(TO 100.000 BTU)
as defined by the CaN:dno Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x1] HFATINO UNIT(OVER 100,000 R'I'U)
E]Yes ❑No VEM'ILATION FAN(SINGLE RfSID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt M
•emit Inloo ms air ontaminants as defnsdb the Ba Area Air BOILER-COMP MP OR 100,W0 BTU)
District? Y Y Quality Management
TOTAL:
- ❑Yes CNo BOILER-COMP(OVf:R 100,000 BTU)
I hove read the hazardous malcrias requirements under Chapter 6.95of the Cori- AIR CONDITIONER ISSUANCE DATE
form.Ilcalth&Safety Cade.Sections 2M05,25533 and 25550.1 understand that if the NEW RESIDENTIAL MECH, SQ.PT
" building does not currently have a tenant.that it knry responsibility Gommify the occupant Tj
of the on limneme which must be neo prim to issuance of a Ccnilicate of Occupmtcy.
Owner or authorized agent Date TOTAL: ISSUED BY: J
OFFICE