S 1532 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EURCTRICAL PIF811 No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MEcuANICAI, J 1532
BUILDING PROJECT IDENTIPICATIl1N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I o S 5 S LZ 11) V1 e W OD" 2L . .2-0,4
DOWN'ER'S NDC HONE: CONTRACTED NA E: LIC N/C CONTROL#
• ff'�,�2.•FF--'•'• C IM pH TES R�/JD4c�iDl 51�( Lf � :'� [��bl`1(
ARCIIIIT I'/ENGINEER: LIC NO'. RPI &• 1U,&0 . Ib L-'w pAr` r`t ❑
CONTACT: •g PHONE BUILDING PERMIT INFO
P•INL NI d11�1Y t LSti) Consultant Fees Paid by Applicant(Initial)' BLDG ELECT u MECH
LICENSED CONTRACTORS DECLARATION - QTY. ELECTRIC PERMIT, FEE
1 hereby aorto that 1 nm licensed under provisions ofChapter 9(eourrovemng JOB DESCRIPTION
WoZ Ili sem;nn 9nlH))omivision3onne Busmesa and Prof sioms Code.and mynwns.is RESIDENTIAL:
wOp wt PERMIT ISSUANCE
FUU, In full force ej(eel .a� �� ❑SPUWI. E:1 KITCHEN REMODEL
�UU License Clu. Contrto, r APPLIANCES-RESIUtiN'I'IAL ❑ADUIPION ❑PLUMBING RE-PIPE
��k Date. LLI, Ill 9_A ContDECL
WW ARCIIITFCfS DECLARATION []MULTI-UNIT ❑STRUCTURAL
oz—,Z, Imath,ord myplans shall be used vspnblicrecords PANELS MODIFICATION
UP 10200 AMPS ❑IN'T'ERIOR El CHIMNEY REPAIR
WLicrxed PmEdnnal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
s�Q
OWNER-BUILDER DECLARATION
C W 1 hereby uf[inn the 1 em exempt fiom the Gtmruemr's License Law for dm OVER 1000AMPS ❑BATH REMODEIIREPAIk ❑DEMOLITION
3 W F following reason.(Section 90315,Business and 1'mfeneions Code:'Any cily or county SIGNS EL IC'I'RICAL El OTHER
W y which regnimv a permit b snot.....alter,impose,demolish,or repair any ahvdure
1''r..�d prior,to its is,mmce,also optimism,applicant Porsnch Humuttofit,asi,exUmaemenl SPECIAL CIRCUIT/MISC.
m
al he is licensed pucmanuvlhe provisions of the Contractor's License Luw(Cleprle)
W�pO( commencing with 3wtinn 901H1)ofD vixiun3efthe Bminexa and Professions Cade)or 'I'FMPMP,TERORPOLEINST. COMMERCIAL:
tRea Sectionts exempt
uodufforicam fie basis
tlfs.bjereged cavitation.
Ary,olution of ❑NEW BLDG/ADDITION FVIOLITION
XroWpp Pvarl'yol POWER DEVICES
Www nm nom than uvc lundreA dvlbus(SSfm). ❑TENANT - P OD SERVICE
�CI I,as owner of the rt SWIMMING POOL ELECTRIC IMPROVEMENT
❑ property. (So5mpinyees with wogr-s as their compensation,XQ will do the work,and the structure is not intended or envied for sale(See.9044,Business ❑OTHER
F 3 m nnA Profemi ms Core:Thu Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Iherern,and who docs such work himself or through
his own employees,provided Ilial such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SOFT.
sale.If,however,life building or improvement is sold within nncywr of complel'on,lhe SQ.PT.FLOOR AREA $/SQ.FI'.
evourmuilder will have the burden of proving that he did not build nr improve fur pore
pests ofsalu). -
❑ 1,us owner of the properly,am exclusively contme(ang with licensed wmvualon d, T(YIAL:
,milda Ilio project(See 9(144.Business and Pedvsaions Coda)'I'he Cenleir n',Li-
rue Law does not apply to an owearef property who builds or improves Ihcmmq and QTY PLUMBING PERMIT- FEE
who connects for such pojeele with a contmctuds)licensed pmsmmun the Convectors
License law. PERMIT ISSUANCE
lamexcmptundr .Sec. ,B&PCfm fliurc...n
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WORKER:SCOMPENSAI at"mr, hi DECLARATION BACK PLOW PROILC'I'.DEVICE cels,/
1 hcrehY xf0nn under Penally ofperjury one of the following dedamlinne: f/��/
r ❑an,as made maintainstion3700 of the Enter Code,for the Worker's Gtmplo- DRAINS-FLOOR,ROOF, GOND. STORIES TYPE CONSTRUCT ION
swinn,as pmvlded for by Section 39fN1 of alis Labor Code,for the performance of the
k fur which this permit is issued. FIXTURES-PER TRAP p
.I have and will maintain Workers Compensation Insurance,as required by Section
3900 of kmhe[L,.larr CCode,fortthhteperfundeyn'cenlThe work mrwbieyhtm�i�s�pfermi/lAissi ifdl GAS-EA.SYSTEM-1 INC.4(OUTLETS OCC.GROUP APN
My Carticr:rl SIN, CRi I/"w'ic Plde y Nrt.Y -11D J�`�I� GAS-I:A.SYSTEWOVF.R4(EA7 AP11 n
CERTIFICATE OF EXEMPTION FROM WORKERS' '• 2
COMPENSATION INSURANCE CRIiASItNDUSTRL WASTE INTERCEPTOR
(Tak,ecimeneednolbeatnpleded it tiro pcnnit is for onehundreJ dollar(SlfsOCJ7ysBUILDING NF14,ILS -
GRBASF'I'RAP
'rle")I PI,ANCHFCK F. rC'r(jl
Icertifylhatintheper[o sancto[ work s ,,lunom,aichthls tare Wokt is er,Cootie - SEWER-SANITARY-STORM RA.200 FT
our umPlny any person in airy sanctions roe lu become subject m the Workcrd Cnmpen- ENERGY PCE
,7., mtisn Lnvsof Califeradu Duro WATER HEALER W/VENTELECTR
O/ O Applleanl GRADING LEE
q NOTICE*10 APPLICANT.If,after makingBis CumBimle of Exemption,yon should WATER SYS'I EVIL RENTING
H ^�' become subject to the Worker's Compensation pression of the Labor Code,you must SOILSFEES
forthwith comply with such povismns or this permit shall Ed derned revoked. WATER SERVICE
a Q
CONSTRUCT]ON LENDING AOF.NCY NEW RESIDENTIAL PLMB. SQ.lip. PAID
U 'Z I hurch, that pe thereissconswct 30 len ding agency fanhe perfnnnanwof _ Dale
the work for which mfr permit is issued(Sec 3097,Civ.C7
Lender's Name TOT L:
O G Lender's Address TOTAL:
y Icertify that I have with
oristy and counand sore cum the above infnnnulinn is BUILDING FEE
.Hr Z bunking Iagree rowFoand hereby city and tonna entrances and sunolawsmlringto QTY. MECHANICAL PERMIT' FEF.
U �i building construction,and hereby authorize representadves nNtis cilytonnr upon the SEISMIC PEE
above-Tensioned pmPerry is,,inspmtion purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino sgcre, PERMIT'ISSUANCE. ELECTRICIT E
Ilvbilitics,ludgntcnts,cosFound expenses which may in any wuyaceme ugninslsaid Cily ALTER OR ADD TO MECH.
in n
sequerovef the ,Hing of Ilia permit PLUMBING FEE
APPNT U' E'S ANDS AND WILL COMPLY WITH At L NO I-POINT plk HANDLING UNIT(TO IO,IHIO CPM)
SO C.REG AT01S. MECHANICALFEE
.A qtr A AIR HANDLING UNIT(OVER 10,00007M) CONSTRUCTION TAX '
Signnwre ofA plicon 'anovcmr Date EXHAUST]l00D(W/UUC'D HOUSING MITIGA'T'ION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building nwupam store or handle hazadous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Swoon 25532(s)a. HEATING UNIT(OVER 1011,ow if I'U)
❑Yee ❑No VHN'I'HATION FAN(SINGLE RESID) PAID
Will the applicant or Nato building creased use vyripuent m devices whirl Date Receipt if
emh hazavlo..s air contaminants as defined by the[lay Area Air Quality Management BOILER-COMP(3HP OR 100,000 RTU)
12 Ah: _
DislddP
❑Yu 7 N BOILER-COMP(OVER 100,000 BTU)
`
I have rend the hazardous materials requirements under Chapter 0.95 of the Colli- AIR CONDITIONER ISSUANCE DATE
even Health&Salry Code,Serious 25505,25533 and 25534.1 undemand built Fee NEW RESIDENTIAL MECH. SQ.Up
building dws nr nurtendy have.tenam,mat it is try responsibility to unify the occupant
of me occurrence,which owe be Fort pdo'Io iswanec or.Cre ificvteof Occupancy.
Owner or aulhorimd agent Date TOTAL: ISSUED BY:
OFFICE