S 1478 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING.MECHANICAL 1478
BUILDING PROJECT IDENTIFICATION
6UILUING ADDRESS: ;SANITARY:NO. APPI,ICATIGN SUHMI'I'1'AL DATE
(n _Vilm C UP��n No .-7-a8O ' N F PITON �r /,•/ N'I' 'IY)R:S N(rMLA ( LIC NO:
E, CO
CONTACT: H Pt _O` J BUILDING PERMIT INFO
*(3555L
�F- , yI^t /) ❑.Consultant Fees Paid by Applicant(Initial) HLf eLEC'f PLUMB MHCH
`�LI/CEEYNLS`HDeowrRACTIOR'SDDE•CL_AR1A'li N QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions or C Cotner 9(commencing TOB DESCRIPTION
Aon with Section 7000)efDivi,,en 3 oflhe Busmen.,and Pmfcssions Code,rnd,ry license is RESIDENTIAL
�OO . PERMIT ISSUANCE 35'S`C�
1y.. ro fWl force and effect. ❑SPDWI. El KITCHEN REMODEL
�U'7 License Claw Lic,4 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
2j Uale comeNg r
F y ARCHITECT"S DECLARATION PANELS ❑MULThUNIT ❑STRUCTURAL
Z O h z I rude...and my plans shall he used as Publie records MODIFICATION
OZO UP 10200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLAMATION
C Q 1 hereby affirm that I am exempt from the Cnnlmclor's License Lew in the OVER 1000 AMPS [_1 REMODEWREPAM ❑DEMOLITION
d U following mason.(Semon 911.315,Business and Profes,aces Gd,Any city or county SIGNS ELECTRICAL ❑(TrUER
which requires a permit to co vrud,fli o improve,demolish.or repair airy stntanre
laricarto its 'e,also requires Ilmappleandfor such permit t file it signed statement SPECIAL CIRCUIT/MISC.
ppl�y bar Iscushcersed pursuant to The provi,,imis ofI Contractors hicesse Law(Chapters
fy60 na(mmuchemscultSect 9000)ofDavision 3 ofthe Banes ]Profirso...s Coddor TEMP.SITTER OR POLK INST COMMERCIAL'
that he Is warion therefrom and the nasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOL]BON
(yam y
Section 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of POWER DEVICES 'NANT ❑FOOD SERVICE
of mareoma five hundred do]] 1$5010),
F 7a P PROVEMENT
�d0 I,axowner nRhe prepcny,or myemployees with wagosasthei(See 7044,Bsinen, SWIMMING POOLELECTRIC
{.. will dmhework and the he Cort rsnoe,La,aedor Law
dos ,,,I apply ,as Business OTHER
m and Professions ldN e:'The Cmmmcnrr's License Law does
nm apply In un owner of OUTLI!I S-SWITCHES-FIXTURES
Q' .. progeny who holed,or.,pave.thereon,end who docs such work Rural
onhmugb
his own employees,provided that such incpmvemams are not i,tnadenl or offend for NEW RP,SIDENTI L ELECTR SQ PT, W. Oct
sola if h men 'Idi g P acut IJ RM1' y' f PI tion.the SQ.IrI'.FLOOR AREA $ISQ.IrI'.
pryh ld Illi theburden fp 6thth JJ and build p for par,
L IJ. V �
❑ 1 f th p p ny I s IY i tig hl licensed contractors m TOTAL .25';P. 3
c mstmd the p,.,car(See,7044.Bukncss and Professions Code.)The C nbadors Iv
cruse Law does not apply to an owner of pnpny who huid.,car improves thereon,and QTY. PLU !(RA)
FEE D
who contracts for such projects with a contrndorls)licensed pursuant the Contractors N`e (�
Licmnse Law. PERMIT ISSUANCE ��; f O J
❑ l am exempt under Sae. ,B&1'C for this rcaxnn
AL'T'ER-DRAIN&V EA) p Y M1
Owner Data O CIT'�r�
Wmmude,SCOMPENSATIONDECefollo ON BACK PhOW OTECT
I hereby affimr under penvhy of perjury one ofihe following declamations:
❑I have and will maintain a Certificate orcoment to self-insure for Worker's Camper, DRAT OR,ROOOND. S'TORTES TYPE CONSTRUCTION
cation,as provided for by Seeder 3700 of the Labor Code,Far the prelm nanee of the
work for which this permit is issued. FIX S-P TRAP 7y ,
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700olOdLah...Code,formepnfomtanceofthe work far wmvhlhispennit is issued. GAS-EA,SYS'] -1 Y.TS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy n oularme: \
Carrie, Policy No.: GAS-EA.SYSTEM- �• ��
CERTIFICATE OF EXEMPTION FROM WORKERS' OggASPIINpI15TRL WARCGPIOR
COMPENSATION INSURANCE INfDIVISOhPFP&S '
(Thisscaiea erosion,be coedll lhepermitis forme hundred dollars($100) P /
or lcxsJ CREA9E'fRAF PLANCHE r.
Icurhythhia rhepnfor mance uUme work for which this jamom is issued,(shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person In tory amenerso as to become chirin m the Workers'Compete- ENERGY FEE
,Z shim,Law,vof California.Data WATER IIIiATFR W/VENOEI.ECTR
O Applicant rGRADINGFEE
fin NO[ TO APPLICANT:if,after making this Cenificute of Exemption,you should WATER SYS'fEMO REMIND
e
(~ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
m0hwiah comply with such provisimas(it(his Permit shell be deemed revoked. WATER SERVICE
a A
CON9'IRUC'fiON LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.Irl'. PAID
Z Ibemny uffrm flint there i-eacnnstmction lending agcnoy for the perfonnancenr Dato Recdpt#
C..7 . the work for which this permit is issued(Sec 3097,Civ,C.)
W N(~ Lenders Name TOTAL,
V Lender's Address TOTAL: 126, 0
�+ BUILDING FEE
1 certify that I have rend his application and.mm that the above mnnmmmn is �
E' ran correct.i axrce In comply wdh au city and amunty oNinance.v and ante laws renting m QTY. MECHANICAL PERMIT FEE
U ,7. building censmrction,and hereby nmlussize repmmnmtivw of his city tat enter upon the - SEISNEC EE
above-mamioncd propony for inspection larpao.
(We)agree to seve Indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ,S• Sa ELECTRIC PPA? 25'?i
If
liabilities,judgments,cads and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
consequencein of the granting of this permit. d ��Z• PLUMBING FEE TIG, wo
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) 24jr9' MECHANICAL FEE .
SOURCE REGULATIONS. Zoo- 70
AIR HANDLING UNIT(OVER 10,000CP14) CONSTRUCTION TAX
Signawreol'AT,IuanUComnwmr Date EXHAUST 14001)(WADUC T) HOUSING MITIGATION FEE
HAZARDOUS MAI HEATS DISCLOSURE
Will the upplicantorfalum huildingoceupant stem ormialle hazardous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) o e� ••��[[..��
El Yes ❑No .� VEN TILATION FAN(SINGLE RESID) �8'. yo PAID _nate` Recaeipp
Will the ap,iicvnt or fumta nadir.,occupant use equipmmrt or deviceswhich
BOILER
vainOR IfI(1.OW NTV7
TOTAL'
I emit hazardous air contaminants as defined by the Buy Area Air Quality Management
I. Di.arict4 b b
❑Yes No BOILIFR-COM P(OVER 100,000 BTU)
IM1uvm rend the hazardous materials requirements niader Chapter 6,95 AIR CONDITIONER5 of the Cali- ISSUANCE DATE�/����\ Ji,
fomia Health&Safety Cale,Senctions 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.Irl'. l �`/�Y�J�lI �
huildig pees not currently haven annual,that it is my respansina,m unity the omupam
cattle requirements which mum be and prior to issuance of it Cenifcate or Occupumcy. it ,
Own,,or aemedeed agent Daae TOTAL: LCJO, 7 IssueD Ev:T�- AliA.GJ
OFFICE