B 0290 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-MECIIELECTRICAL 1 PF.RMfi'NOyp0 /N /50
BUILDING DIVISION APPIACATION/PERMIT PLUMBINI;-MF.CIIANICAL. SOOO1 lb-
BUILDING
.VJ
BUILDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS: p SANITARY NO. APPLICATION SUHMTTI'AL VA)I
i 0 6 53 Cduv 9a a
� :RS NAME: -� tIIONE, RACTORS AM::
pI
SEC CONTNOLkOW dG ( ^°""iSS:ARCU RNGINEEµ
08 X 3 9- 99 y ❑
CONTACT: I'HONH: BUILDING PERMIT INFO
❑ Caasaltold Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPF,RMIT FEE
I hereby editor that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Qat with Section 71x10)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL
�
won w PERMIT ISSUANCE
W in full License
lased effect, ❑SFDWI. [I KITCHEN REMODEL
aU�j License Class Lich APPLIANCES-RFSIDFNTIAL ❑ADDITION [I PLUMBING RE-PIPE
I LJ Date Contractor
un 6 ❑MUI.TI.UNIT ❑STRUCTURAL
F,Dm ARCHITECTS DECLARATION PANELS
1 tr der"land ary plana sha11 he used as public mr-ds I MODIFICATION
O
Oz-p�p UlIT02MAMPS R ❑INTERIOR El CHIMNEY REPAIR
I✓�o t:u] Liceoserl Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
�mX:j OWNER-BUILDER DECLARATION OVERI00AMPS ❑BATHREMODPpy�EPA�IR ADI'D OhITIO
Z,�j Q 1 hereby affirm hoe I am exempt from the Cnmracmrs License Law for he % OM%/�
p'O y U following reason.(Section 7031.5,Business and Professions Come:Any city or county SIGNS ELECTRICAL (10THPN qq /��
W LLO l-' which requites a permit to construct.alter,improve.demolish,nr repair any svacmre
prior to its issuance,also requires the applicant for such permit to file a signed sidement SPECIAL CIRCUIT/MISC.
y that be is licensed pursuanno We provisions of the Correlatives License Lane(Clement)Ipy, 00 (commencing with Section 7100)(it Division 3 ofthe Business and Pofecions Code)or TEMP.MET ER OR POL S COMMERCIAL:
6 L eap� that he Is exempt therefrom and the basis for the alleged Orientation.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
idents, tiemimn 7031.5 by anyapplicant fmapcnnit subjects the npplicanunacivil peoalnyof .POWER DEVICES []TENANT ❑FOOD SERVICE
Fry of more than five hundred dollars(8500).
~?6 1,as owner of the n.nrm em to¢s with war Ors as th......le coo ensution, SWIMMING POOL ELE IC OTUER IMPROVEMENT
mt: ❑ trope y Y p Y g . ❑OTIIER
will Jo the work and he stmcmreis noOmcndeJ or offered for sole(See.7N4.Business
Y1C and Professions Code:The Contranur's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or imposes thereon,and who does such work himself or through
his own canfl,ees,provided that such ha Earvemcros ate no intended or offered tar NEW RESIDENTIAL ELECTR SQ IT.
sale.IL however.the building or improvement is sold within one year of completion,me SQ.FI'.FLFRag"t ® S/SQ.FT.
owner-builder will have the burden of proving that he dictum build or improve Outten.
11
pose of sale.).
F,, as o
1, wnns
er of the property.an,esclivively convecting will liceed commands 10 'TOTAL: JUL 08ANSI
construct the project(Sec.70,14,Business and Professions Code:)The Conwemrs Li-
cedw Law does nor apply in an owner otpropmarty%he builds or impraves Harder.suit QTY PLUMBING PERMIT FEE
whoconhactsforsuch projects with a controcmr(s)licensed pumuwt to the Contractor's
License Law. I'ERMI'T ISSUANCE UC 1rl/f'CfII EIV
❑lam exempt under Sec. .B&PClnr this anon
Owner Date ALTER-DRAIN&VENT-WATER BA) VALUATION
WORKERSCOMPENS ION DE CI,ARATION BACK FLOW PROTECT DEVICE
Ibme affirm under penalty of perjury nap of mefollnwing deduatinns: '
❑I have and will maintain a Cerificate of Consent to self-insum for Workers Compel- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE.CONSTRUCTION
sided,as provided for by Section 37W of the Labor Code,for
he performance of the
work for which his pemrit is issued S % FIXTURES-PER TRAP
1 have and will maintain Worker's CompencloW insurance,as'required by Section
3700af he labor Code,frome performance of the work for which his permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS UCC GROUT' AI'N
My Worker's Compensation Insurance currier and Policy number am:
Corricc Policy No: GAS-EA.SYS 1'EM-OVER 4 HSA)
CERTIFICATE OF EXEMPTION FROM WORKERS' OR WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING IJIVISION FEES
(Thi.section need not be completed if the permit is for one hundred dollars is l W)- GREASETRAI'
mless) PLANCIIECK PEE
I malty that inambencloorme ofdm work furwhi his Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not emnpiny any person in wy mnnne tax bectlJoe mO
enthe Workers'Camped- ENERGY Eric
".tiro L. alifomia.Date 1 WATERBEATER WNENT/L'LIiCI'R
Applicant, L a GRADING FEE
H r~Ni NOTICE,TO APP ANT.If,after makin is Cenificara of Exemption,you should WATER SYSTIBOUREATING SOILS HE
a, bttrntm sabjan eWarkels Cnmp<nsation provisions of the labnrCome,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,1,T PAID
UQ l hereby affirm thnuhem is aconstraction lending agency for the performance of Ore Receipt TO
F-' he work for which this Permit is issued(Sm.307,Cii,C.)
0 V Ixnder"Name 'TOI'A L:
Lenders Address TOTAL
1 1 certify that 1 have read this application and slate hoe he olwwe infommatinn is BUILDING fEE
In correct I agree to comply with all city and county Ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF.
LJ Z building construction,and hereby anthorixe representatives ofhis city m enter upon he SEISMIC FEE
uMrve-mentioned IF per,,for inspection Factories. PERMIT ISSUANCE
(We)agree nm save,indemnify it keep harmless the City of Cupertino against ELECTRIC WiG
liabilities,judgments,tideland expenses which may in any w.yaceme against rad City ALTER OR ADD TO MECH.
in conwquonce of he granting of hmr
is pert . PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WI'PIT ALL NON POINT AER HANDLING UNIT(TO 10.000 CFM)
MECHANICAL IEE
SOURCE REGULA'I'TONS.
AIR HANDLING UNIT(OVER 10,00!)CFM) CONSTRUCTION TAX
Signamrcof Appsmad/Commcmr Dam IIAUST HCOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant Blore o handle haxarduus material HEAONG UNIT(TO 100,(1(111 HTIB
as ddnned by he Catering Municipal Code.Chapter 9.12.and he Health and Safety
Code,Section 25532(a)'t HEATING UNIT(OVER Igl,lgq TO U)
❑Yes No PAID -
VBNTII.NrlONPAN(SINGLERFSID) Date Receiot#
WJl the applicant or future huildiog occupant use equipment or devices which BOILER-COMI'(3HP OR IW,(DO BTU)
omit hazardous air comams imer as defined by the Bay Area Air Quality MYnagefdeal TOTAL:
Disvim? BOILER-COME(OVER 100,000 BTU)
❑Yes IQ No
I have read the harardous mmquire
eriuls requirements under Chapter 6.95 ofthe Cali AIN CONDII'IONEIi ISSUA CERATE
Tania Health&Safety Calc.Sections 25505,25533 and 25534.1 understand that if he NEW RESIDENTIAL MECH. SQ,FL
building does nm rnrenlly have it tenon,than it is my responsibility to nitrify the meopam
alt reyuircmmns which must he et rots" Ore of Certifirail nf(knu
Ownero bonze]agent Date TOTAL: ISSUED BY:
OFFICE