S 1410 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUS.nINr.-Fa.EcTRICAL PER`LG,ITNG
BUILDING DIVISION APPLICATION/PERMIT
PLUS ;N;NGMECHANICALSJ 1410
BUILDING PROJECT IDF:N'1'IF'IC•NHON
�09ILDINGADDRESS: SANITARY NO. APPLICATION 2MI'ITAL HATE
D Z i Z X/ PHONE: C 1 R Cf0 'g NAME_' LIC N _ tip
FS gW, N/C CONTROLX
ARCO II'TECf/i!NGINEIiR: 'r` LIC NO: )RI!S5: ❑
SL CVkA&u AN
CONT'ACI': PEONR: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRICPERMI'f FEE
I hereby ni irm that Tom
IiccnuJ under pmvision,a n(Chupmr 9(commencing IDB DESCRIPTION
WOO with section lo(XB of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
(slop PERMI p ISSUANCE
nfiill h�rcc and•(fes /�9a ❑SFDWI. ❑KITCHEN REMODEL.
Ft—u License Clan 3 Lic.M G L APPLIANCES-kP_SIOPNTIAI. ❑ADDRION ❑PLUMBING HE-I'IPIi
NG0. Ilam - T`S DElor
N en, hall bc...D,til. records ❑MULTI-UNIT ❑MODCNRAO
Z F m Z 1 undempmd Ins plans shall he used ns public records PANELS MODIFICATION
p'Z1p UPTO200AMPS ❑INI'F.RIOR ❑CHIMNEY R17PAIR
Ny.F.WI.lecnsed Pr..csslonal 201-10DIlAMPS IMPROVEMENT 0SWIMMING POOLS
�etE OWNER-BUILDER DECLAkAI'ION OVER 1000 AMT'S ❑BATH REMODELIREPAIR ❑DI:MOI.I'TION
a w a I hereby a01rm that 1 a.L exempt from me Contractor's c,An c Law for me L 4k
W3LL� billowing reason lSedion"1(II LS.Business and Professions Cade:Any city or annfY SIGNS F.LECfRICAI. (]OTHER
y which ospi...n permit to ennsvuct,alter,improve,demolish.or repair any structure
2^O� primm its issuances itis,requires flcnpplieam( such permit In file a siyned,ca,dent SPECIAL CIRCUHUMISC.
�} that he is licensed pursuant r.¢
o the provisions of the Comfors License Law(Chapter 9III" -�— IM-41
W�00lcommencingwith Section7000)af Division 3afthe Business and PrafcaluesCoth)or TEMP.MEER OR POLH INST. LOCO MI— F�.RCIAL:
that he 1s exempt therefrom and the hash for the alleged exemption.Any viol.r of ❑NEW BLDG/ADDITION ❑DEMOLITION
WX 4N. Section 7031.5 by anyapplicanl far.permit,injecus theapplicant to a civil penalty of TONER DEVICES
I,-•Zy not more thfive ve hundred dollars SSOB. ❑TENANT El FOOD SERVICE
�a ❑ I,as owner of the property.or my employees with wages as their sale compensation, SWIMMING POOL ELECTRICAITA
IMI'HOVEMEN'T
willdolhcwnrI,and lhesuuchhe is not intended aroficred fornale(Set.71X4,Business ❑01HER
al and Professions Code:The Commit License Law does not apply to ua owner of OUTI.ITS-SW'I'TCHES-FIXTU
property who builds or improves themes.and who dims such work himself or through
his awn employes,,provided[hit such improvements arc not intended or oll'enal for NEW RESIDEN'HAL ELECI'It
sale.lf,h�wever,the building nrimpmvemem issoldwithinone yell of car letion,Ihe .1'1'.IlOOR�iP� S/SQ PI'.
owner-builder will have the burden of proving that he did alt build or improve fur par- t� p D
pose of sale.)'M I,as owner of the pmpedy,am exclusively conowdr,with licensed canvanarx toqq E p(1'constma me project(See.7814.Business and Itofco,hum Code:)lac c000—c.s Li f1R "s HIYSeDroaw Law does not apply to un owner of prpcdy who builds nr improves thereon.and QTY PLIMBING PER
whocontmnsforoolipnjoctswimacommcmr(,)licemellpnrsmnnmfM1e Conarmoses C'7, 1
Licence law. PERMIT ISSUANCE t I yr VUY
I am exempt under Sec. ,B&P C for this reason Chl11YI/
ALTER-DRAIN&VENT-WA'I ER(EAI VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
f hereby affrin under penalty of perjury one of the fallowing declarations:
❑Ihave and will maimein tCetificatenf Cnnsenna sel4insurefnr Workers Cnmpen- DRAINS-F1.00R.ROOi°,AREA,COND.
some.as provided for by Section 3700 of the labor Code,for the performance of the STORIES TYPE CONSTRUCTION
walk for which th'Is permit is i.aueJ. FIXTURES-PER TRAP
❑I hme and will mainmin WnzwA Compensation losunmec,os respired by Setawn
3700 of the Labor Cale,for the performance of the work for which this permit is issnaL GAS-EA.SYSTEM-I INC.4 OUTLEf5 OCC.GROUP APN
Carter:
f�yt ncc currierand Policy W TO.95?1
Currier. !C 1>==�C Policy Nn.: —G GAS-EA.SYSTEM OVER 4(W)
CERTIFICATH OP EXEMPTION MOM WORKI:RS'/Zl&a
COMPENSATION INSURANCE ' ` V ID GREASEIINDUSTR1.WASTE INTERCEPTOR
BUILDING DIVISION PEES
fl'hissection need nm be eomplcmAif the permit is fortune handled dollars(S I(p) GItBASH'IRAP
or Ins.( PLANCHECK P1!H
I stray that in the perforreaneenfthe work far whichthis permit isi.aeucd,Lshall SEWER-SANITARY-S'IORM EA.2(M IT.
not employ any person uny mam
manner so as to become subject in rise Worker,'Camper ENERGY FET!
o z sate Lawsof California.Dam WATER HEATER WNENT/ELECIR
ZO Applicant GRAVING FEE
ti NOTICE'TO APPLICANI1 H.altar hookingthis Certificate of Exception,you should WATER SYSTENVIR17AI'INC.
a , bc'n c subject n,the Worker's Catnpon'.0is.p.,i,in is.1'the latwr Curie,you must SOILS FEE
W fathwith comply with such provisions or Ibis puradi shall he dcemed revoked. WATER SERVICE
Q
CONS'IHUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.IT. PAID
L) Q I for
ratshord I,issued
lendioagency Rtfbe podnnnuna•of Date RaeiptX
Lks Fme work for which this permit is issued(Sec.31X2,Co..CJ
Lender's Name TOTAL:
L) Lenders Address TOTAL:
Hy I certify that I have rend his...hernial and scaleflea the above inhalation is BUILDING FEE
rA correct.I agree manna,with all city and county stn immcex and smm laws eluding m Q'I'Y. MECHANICAL PERMIT PEE
(-) Z building consmentn,and hereby authorize representatives of this city w enter upon the SEISMIC FEF.
uhave-mentioned property for inspection purpaws.
(Wc)agree m save,indem y a keep harmless the City of Cupertino amiml PERMIT ISSUANCE ELECT RIC FEE
liabilibes,judgmenrsWS.costs and e n which y in anyway accrue against said City A1:1'ER OR ADUI(I MHCII.
in cmsc,ucnce hisre tmit. PLUMBING PEE
APPLICANT ANf WIh1 :OMPhY WITH ALL NON•I'(IIN'f AIR HANDLING UNIT(T010,(000 CFM)
S(lll LMECHANICAL FEE
AIR HANDLING UNIT(OVER 10,(X0 CFSU CONSTRUCTION TAX
gnaw of ApplicanVContractor Dam I;xUAUS'I'I IOOD(W/OUC1) HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Wid the applicant or Poore huilding tccupem store or handle hazardous material I IF.ATING UN1'C(To l 101,000 BTU)
as defined by One Cupctino Municipal Code,Chame,9.12,and the Health old Safety
Cale,Section 25532(x)'! 1 DENTING UNIT(OVER 100,010 BTU)
[-1 Yes ❑Nor PAID
VENTILATION PAN(SINGLH RPSIUJ Dote RecmptX
. X511 @c applicam or furore huilding by she B use ea Ail Qu ut devices which
emithmaWous airconmminmt as defined by the Bay Area Au Quality Management BOILER-COMP(JHP(yR 100,000 BTU)
Dlddct7 TOTAL
❑Yes E)No BOILER-COMI'IOVT:R 100,000 H'NI
I have who the hvitual,mmeriuls myuirernems under Chapter 6.95 of the Cal l- AIR CONDII'IONER ISSUANCE IJA'TE
III Health&Safety Code,Sections 25505,25539 and 25534.1 understand that it the NEW RP_SIDENTIAL MECH. SQ.IT.
building does not cmrenfly have a mnnnE that it!,,I,,respmsihllity m notify the xcupant
of the reydrement,which most be met prior m issuance of u Cer ifiche of Occupancy.
Owner ar authorized agent Date TOTAL: ISSUED BY:
OFFICE