S 0986 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL P' ]'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0986
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS: NA SANITARY NU. APPLICATION SUBMITTAL DAL It
OW �A xw 1E I VON r CONY I A I 103 NO:
CON'I'ROLN
SI
NIC
AECIIDECDFNGINEER: LIC NO', ADDRISS: ❑
373 S I�XwT ,9 4 , 1
CONCLACp PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LOMB MECH
N ❑ ❑ ❑
.CENSGD CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FE
I hereby.ffm,that I am fav,.ad under provi i I,of chapter 9 mmmnmmng JOB DF RIPTION
Dat with Section 70410)of Division 3 ofthe Business and Professions Code,and my licenPER ISSUANCE
xe is RESIDENTIAL'
W p
FSB in full tome and effcc _ � ', ' ❑SFDWI, Ll REh10Ulil.
jut L,cenat ss Lie.e APPLIANCES-RESIDENTIAL ❑ADDITION UMEIPGRE-PIPE'
Iy Dem Conlrocoa
t p, CMUI.TI-IJN[T ❑STRUCTURAL'
��m CHITEC'I'S DF.CLARAI']ON PANELS
tanZ Innde,dimilntyplvns shell he used.,public records IZ MODIFICATION
ZpZ—in UPT02WAMPS ❑INTERIOR [I CHIMNEY REPAIR
I"y�W Licemxd Profeseinnal - - 201-I000AMPS IMPROVEMENT DSWIMMING POOLS
4k,T-1 OWNER-BUILDER DECLARATION OVER]WHIAMPS ❑BATA RF,MODELJRHPAIR ❑DEMOLITION
I hereby of irn,that I and exempt from the Conavctur's License Law far 1
iy( El OTF1i!
O y U following reason.(Section 903 1,5.Business.ad Profexslans Code:Any city or county SIGNS ELECTRICAL
m 3 LLO n wh'mh requires v permit to construct cher,improve,demolish,or repair any stmcture
pri0n.i¢issuance,also"does he applicant for Hoch permit mfile asignN smmmentSPECIAL CIHCf11T/MIS
u .
P that he is licensed pursuant the prov,isions of the Conlmnors License Law
p0 (cnnrnercing with Section 7")of kion 3 of the BEvinea,and Proms.ion.s Code)or TEMP.METER OR LII INST.
tlyi5 c y that he is exempt themboon and the basis for the allege]exempliun.Any violation of ❑NE BhDGIADDITION L1 UI' 0."ON
Www
Section 7031,5 by any applicant far a permit subjects the applicant m a civil Penalty of POWER DEVI .S El TENANT O
= nor more man five hundred dollars($510). IMPROVEM'
❑ I,as owner of the property,or my employees with wages as heir sole compensation, SWIMMI POOL ELECTRIC
WWC will do the work,and the structure is not Intended oroffered for sale(Sec.70,14.Business ❑OTHER
msad Professions Coxlu:'I'he Camracan's License Law does no(apply 10 on owner of (MITI, S-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered far N RESIDENTIAL E1.EM11 SQ FT.
sale.If. the building or improvement is sold within one year of compininn,the CORAREA gISQFT.
.
L
owerobuilder will have the buNen of proving that redid not build m improve lin put
Pox of sale.). 'TOTAL: .
El L as owner of the property,am exclusively contracting with licensed cormacmrs to
on.amm the project(Sec.7041,Bu,inean sad Profession.Code:)The Contractors Li
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts fm such projects with u commaorW licensed pursuanuo the Conwcmr's aI
Liconse Law, PERMIT ISSUANCE
❑ I Int exempt under Sea ,If&P C fortis mican
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COM PENSATION DECLARAT'lONRACK FLOW PROTECT.DEVICE
I hereby uffrn,under papally of perjury ono o1'the following declinations:
❑I have and will maintain a Certificate of Conewn0o self-insure hat Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. S'I'a IES ' I ;CONSTRUCI']ON
sation,as provided It,,by Section 370t)of the LaMn Coai for me performance of the
work for which this permit is issued FIXTURES-PER TRAPIf
Qf I have and will maintain Workers Compensation havarn e-us inquired by Section
JB(I a1'the Lubar Cadc.for the pcoformiu eof the work far which Los Permit is issued GAS-IIA.SYSTEM-1 INC.4 OUTLETS OCC...
My Workers O,mpnsamim rte turner end Pnllcy number or: GAS-EA.SYSTEM OVER
Carrier: �c PIONrRa:� CITY Ut' rntbT,INO
Cl AT OF � TION INN FROM OR ERS' GREASEFINDUSIRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IFCS
(Timis srclion aced not M1c coanplemdif lM1C Parmit is fonmchundred dolbars lS llXq
less.) GREASETRAP
nr III ANCHECK IrF
cenifythat la the f1he work for which permit is issuedC,;.]that]
.- SEWER-SANITARY-5'I'ORM EA.21X1 FI'.
nm ploy any person in any manner xs as In banana subject In the Workers Compen- ENERGY FEE
s an Laws of California.Date WATER HEATER WNIINTIELECTR
pplicnnt I GRADING ITIi
NOTICE TO APPLICANT IL agar making this Certificate of Exumpton,you should WATER SYN'1'BM/PREAHNO
' Mtt, e.subject to the Workers Compensation provisions of the labor Code,you must SOUS FEEm
IlI4 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI,MB. SQ.Pot PAID
UZ I hereby effort that there is nconstration lendingagancy lin the perfonnmao,of Ricetptp
V aha work far which this permit is issued(Sec.3W),Civ.CJ
TOTAL:
O (~ Lender's Name
ya Lenders Address AL
I certify that I have read this application and%rate that the above information is BUILDING FEE
La UJ coon,l agree to comply with all city and cmatyoadinanees:rod state 1.11 rel:oingm QTY. MECHANICAL PERMIT FEE
U Z huildon.e...
tomla ,andheaeby amh.rize rcprescnmtivesaOhis airy b,eater upon the SEISMIC FILE
tieremtnentioned npeey for in,glunpurgses PERMIT ISSUANCE
(Wc)a emsmx,indemnify end keep hamdessthe City of Cupertino rpmoll ELECTRIC ERE
liehilitics,ju mems,coos and expenses which may in any wary uceme against sviJ City AI.TFRORADD'rOMEClf. PLUMBING FET:
innnwa ncenftm'Caring aroo,Permit.
AI'PLI NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10.0100 CFM)
SOU MECHANICAL F
'E REGULATIONS.
FEE
AIR HANDLING UNIT(OVER 10091 CFM CONSTRUCTION TAX
ignauare of
HAZARDOUS
AppllcuRDO Data "HAUSTIiOOD(W/DUMIT
C'1) HOUSING IGATION 1717.17,1717.17,IIAZA
Ol15 MATERIALS DISCLOSURELauri
Will the applicant or occupant hanAl
re building swcupastore or e moral eus material HEATING UNIT(TO I0N1,1X0 IIT
as defined by the Cupenino Municipal Care,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER IIA BTU) /
W, No
VESTLAI ION PAN(11/1-1.17 RESID) PAID
,' ODane Receip,#
Will the a plicate or furore Wilding raccupant use equipment or devices which
emit havaadoes ar comaminanrs as defined by the Bay Area Air Quality Management BOILER-COM POR IW,000 BTU)
District? TOTAL;
a u CN. BOILER-C P(OVER IW,000 BTU)
have read the haando..rearials rcquimmrnts ruder Chapter 6,95 of lire Cali- AIR CO I'I'IONER I CB DA'Pli
fo Health&Safety Ode.Smions 25505.25533 and 25534.1 understand that if the NE RESIDENTIAL.MECIL. SQ.PC
h ding does not cnrrendy have a tenant.that it i.s my resprovil imym notify the ax'upunn
f me r.goiiemem,which must be met prion.issuance of o Cenifeme of 0cet pnncy.
TOTAL:
Owner or amhnrixml uBem Date ISSUED By
OFFICE