B 0416 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO
BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING;MECHANICAL L.ppp� D�\ (� '2'5"8'$
BUILDING PROJECT IDENTIFICATION, 'NJO�V 113 1 bJ
BUILDING ADDRESS'. - SANITARY NO, APPLICATION SUBM1'1'IAL DATE
ELS s�/y -9
ER'SNAME'. PHONB: 7. CONTRACTOR'S NAME LIC NO:
S, 'I NIC CONTROL#
�ARCHITECf/ENGINF,LR', /V LIC NO: ADDRESS: ❑CONTACT, PHONE: BUILDING PERMIT INFO
-❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON]'RACTOR'S DECLARATION QTY, ELECTRIGPERMIT ' FEE,
1 hereby of ine that I am licensed uadez pmsi.loastir Chapter 9(commencing rt JOB DESCRIPTION
OCz Nbecion 7001 ofInv'smostoftheBusiness and Profesrons code and my license. '- 'RESIDENTIALFOO an wT full force and effect PERMIT ISSUANCE
la OF License Class GCM ❑SFDWh El KITCHEN REMODEL
Q V APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE.PIPE
C
W Dam Contractor
ARCHITECT'S DECLARATION ❑MULTI-UNIT [ISTRUCTCHAT.
Fy 4 l understand my plans shall he used as public records PANELS
ZO MODIFICATION
OZ�q UPT02W AMPS El INTERIOR Ll CHIMNEY REPAIR
P 4�W'Licensed Professional 201-1000AMPS IMPROVEMENT � SWIMMING POOLS
sea OWNER-BUILDER DECLARATION OVER,ItNNI AMPS _J BATH REMODEIJREPAIR DEMOLITION
I hereby affirm that 1 am f
exeTnpt rom the Continence,License Law for the
O d O following reason.(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER /
00'3 W F which requires a permit to construct,alter,improve,demolish,or repair any structure
prior in its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
p. that he is lieensolpenuanno the p,,w mnsoldtoCo icurid sLicar Law(Chapmter
I+I^00 Rormencingwith Section 7000)nf Division)oflho Businessund Rnfes,mnr Cuda)or TEMP.METERORPO INST. COMMERCIAL:
TY m[G that he is exempt therefrom and the hurls rot the alleged exemption.Any violation of ❑NEW BI.DG/ADDITION ❑DEMOLITION
yx u' Section 7031.5 by any applicant for a permit subjects The applicant to a civil pemdiy,of POWER DEVICE'
ul^m ❑TENANT El FOOD SEkVICF.
FZD' not more Nen five hundred dolens($500), 'IMPROVEMENT
�Ci] 1,as ownerof Ne property,or myemployeerwith wagon as Nairaole uamlr,silos, SWIMMING OLELECI'RIC
p.� will do the work,and the structure is not intended proffered for sale(See.7044.To ❑OTHER
a^ and Professions Code;The Connector's License Law does not apply to an owner of OUTLB -SWITCHES-FIXTURES
and
who builds or improves thereon,and who does such work himself or through
his own empmyres,provided that such improvements are not Intended or offered for NE RESIDENTIAL ELECTS S
sale.If,however,the building or improvement is sold within one year or completion. he SQ.FII FLOOR AREA S/SQ.FT.
owner fodder
will have the burden of proving that he did not build.......ve for pur-
Pnre fsale) - -
❑I fon p pc ty , t exclusively- contracting with I' n:d t ruts m TOTAL'. ✓
construct w r jet(S 71004 Homes,and P f C d)The Coni t T r s Li - - i -
se ha d t apply t f, pony h builds p darner,and QTY. PLUMBING PERMIT FEE /
who vntts forsuchp 1 c[r with aconti t Olicensed pursuant to The Cearacm s
License Law. PERMIT ISSUANCE
—O
❑ 1 am exempt under Sec. .B&P C for this reason
Owner I Date ALTER-DRAIN&VENT-WATER UTA) - VALUATION
WORKER'S COMPENSATION DECLARATION .2(_9 oi/
I herebyaffirm under It f BACK FLOW PROTECT.DEVICE �i
penalty o of Con one o the insure or Workertion:
❑one as and will for byneCeni3700 of Consent le Code,for the Weekes Compen- pRNNS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section)700 of the Lahur Gde,for Ne Ferfnrmnnce ol'she STORIP.9 TYPE CONSTRUCTION
work for which this permit is issued, FIXTURES-PERT RAP
[_] 1 have and will maintain Worker's Compensation Insuranc,as required by Section Z-
3700 of the[.be, fm the Performance of the work fee which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS t L/u L7 OCG GROUP APN
My Worker's Compensation Insurance career and Policy roadder am:
Cartier: Policy Ism, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASF.IINDUSTRL WASTE INT ERCEPIOR
(This section need not bo wmplewi ifthe permit is Corona hundred dollars(S 100) BUILDING DIVISION PEES
less.) GREASE TRAP PLANCHECK FEE
I codify that In the prodrandaV aide workfnr which this permit is issued,is hall SEWER-SANITARY-STORM BA.200 FT.
nmomploy auypenan in any manse ao es to becomesvhjecitothe Worker+'Compen- ENERGY FEE
A, nation Lows r Tom am WATGR HEATER W/VP.NT/HLPATR
7�O Applicata \ �O GRADING 17EE
G rt, NOTICE T [CANT.If.a ter makmg this Ciati icme of Exemp im,you should WATER SYSTEMIT GATING
a ; become subject In the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
W forthwith camply wbheuch pro,kinner this permit shall Is,doomed revoked. WATER SERVICE.
1
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID
V 0 k or by which tat p1mithat reisa ed(Sea construction lending agency for the performance of a Receipt is
the work for which this pemtit is issued(Stu.3797,Clv.CJ
w (✓ Lender's Name p TOTAL:
FUkI Lender's Address TOTAL: , /
04 1 certify that 1 have read this application and state that the above information is BUILDING FEE
UI; correct.1 agree to comply with all city and county ordinances anti sire laws miming m QTY. MECHANICAL PERMIT
V Z building construction,and hereby authorize representatives ofthis city trader upon the SEIS I FEE
are ove.mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless the City of Cupertino reg dr,I ELECTRIC PE
liabilibux,judgments,coils and expenses which may in any way accme.gainst said City ALTER OR ADD TO MECH.
in asequence of tire mi
e granting of This pert. I' F 9-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)A I I MEGHANICA
SOURCE.RF,GtILATI 5.
4 ,� /1 S /^� p� AIR HANDLING UNIT(OVER 10,011 PM CONSTRUCTION X
Signoiure of AAppplicant/Contractor l'Y•KI 7Date7 EXHAUST HOOD(WIDULT) ION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huildiag,..,r,.1 sins,handle hazardous material HEATING UNIT 00100fN TU)
m defined by the Cupertino MadiciLliGode,Chapter 9.12,and the Health and Safwy
Code,Station 25532(.)? Nn E 1HEAS'INO UNIT(OV00,000 BTI))
F-1 Yes VENTILATIONP (SINGLE REBID) PAID s'--
Date Receipt# ,
WIII the at,Onam er fnmre deft vg occupant use ea Air Qua or devices which BOILER- P(3HP OR 100,000 BTU)
emit hazardous air contaminnnd by the Buy Area Air Quality Management TOTAL:
Dislricil
E]Yes BOILS -COME(OVER 100,000 BT U)
Nn i
I have read the hazardous mat,d.la requirements under Chapter 6.95 of the Cali- AT CONDITIONER ISSUANCE DATE
forms Health&Safety Gds,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL ML+CIL SQ.IT.
building does not wtrently have a tenant,that it is my responsibility to notify the occupant k9
fthyw"oeats wit h,uu t bn atm priory issuance of a Carta sof Oc opo y.
.64 A. ill w�t9'�s�J iia } /4� e/UL R ti7o ru tie;
authorized agent S Date TOTAL: ISSUED BY:
OFFICE