S0262 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 0262
IIUILDING PR(IJECI' S IDENTIFICATION t,7
UILDING ADDRESS: ` SANITARY NO. APPLIG\'P ION SUBMITTAL !
DAI'1
A Pin
WNER'S NAME: PRUNE: CONTRACIY)N:S NAMEi LIC NO.
SO Z Pi
N/C CONTROL#
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ARCHITECT/ENGINEER: LIC NO: A URF_SS: / / t�' ❑
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-CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI.DG P.LECT PUUMH MECH
A ❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
1 hMxZereby affvm Ih t 1 1'censed d P ':ium of Chapter 9(commencing -__ JOB DESCRIPTION
,ob with Section 7")of Division 3 ofthe Bus s.and Pnfessions Code,and my lice se is RESIDENTIAL:
PERMIT ISSUANCE
W�0 in inn force und If 6233 Sy ❑sFDWL [I KITCHEN REMoorl.
QUU Ltccns lays (.• Lic.p APPLIANCES-RESIDENTIAL. El ADDITION [I PLUMBING RE-PIPE
FZm Date Contracmr LCog,J �nroy"1
mQL ARCHITECTS DECLARATION T L1 MULTI-UNIT ❑STRUCTURAf.
PANELS MODIFICATION
ZOyZ I understand my Plan,Aall he used If,PIblicr«orde,
Oil T021NIAMPS
❑%HRIOR IMNEY REPAIR
u] Licensed Ptnbessiomil 201-HAOAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IINNIAMPS [I BATH REMODEUREPAIR C1 DEMOLITION
tY Q 1 hereby offr tis hat 1 am exempt form the Coal License Iry for the
3 W FU• following reason.(S«tion 7031.5,Business and Professions Code:Any city.'county SIGNS ELECTRICAL ❑OTHER
y which requires a permit to construct,alma improve,demolish,or repair any"meture
^LL'Wn potato t ':. nceal. rey .Ih appl'c tf hpemitt fl ,, dali,dwm SPECIAL CIRCUIT/MISC,
Toy Ihcth licensed p .0 n the p f,h C trot L lu IClapmr9
,4nc (commenemgwith Seeuon 90noof Dr,....If3of the lfux'ncxs and Profession,Code.)or 11IM Ir.M ETER OR POLE I NST. COMMERCIAL:
W0.ea that he is exempt thcmfmm and the ha xis fnr the ullcScd exemption.Any viohi ion of ❑NEW BLDG/ADDITION ❑DFMOLITION
kuMN Section 90315 by any applicant for a permit subjects the applicant o v civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
=O nal mom than five hundred dollars 0500). IMPROVEMENT
E]1.as owner of the properly,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC i
p. willdoewood
rkethesrurpre isnot intendedB
moeredfn0W,sale(S«.9Best.,, ` ❑
thOTHER
W 3« and Professions Calc:The Contractors License Law does not apply to an owner of OUTLL TS-SWITCHES-Iq%'TUNFS
.. property who builds or improves thereon,and who docs such work himself or through
his own employees.Prrvidcd that such improvement,are not intended or oWred for NEW RI!SIDENTIAL F.LF.CTN SQ FT.
sale.If,however.(lie building or improvement is sold within one yearof<nntplet in I. he
SQ.FT.FLOOR AREA $ISQ.IeI'.
owner-builder will bavc the harden of proving that he did nm build or improve fnr par- j, 1 D
pest,of sale). P W
TOTAL:
❑1 as owner of the prvpent wor excluvively contracting with I' d - t act n it)
construct the Project(Se 9014Ba- and Rf:: ne Cod )The Contractor's Li- w•/ �
cense Efes,does not applyt of property who builds oimproves th eu and QTY. PLUMBING PERMIT FEE rs e
who contracts for such projects with a contranogs)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE V 1`u'C�111wU
I am exempt under Sce. .B&P C far his ist V V
ALTER-DRAIN&VENT'-WSJ 17R(EA) I )N
Owner Date - I1�
WORKER'S COMPENSATION DECLARATION BACK FI-OW PROTECT.DEVICE '��
1 hereby affirm under Penalty of Perjury one of the following declamlion,: �V
❑Ihme and will maintain aCetincme of nmscnno self-insure fnr Worlers Compen- DRAINS-FLOOR.ROORARFA.COND. STORIES TYPECONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the performance of Ne
work for which this permit is issued. FIXTURES-PER TRAP -
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
TlWof the Uatur Code.f..the performanmof the work for whichod,Pcrn ti,issued. GAS-PA.SYSTEM-I INCA OUT LETS OCCGROUF APN
My Workers tsmiu KI zee carrier and Policy nu y�
Currier: Fu gLq� Policy Nu.:n e1. 11QS GAS-HA.SYSTEM OVER 4(HA)
CERTIFICATE OF EXEMI'DON FROM WORKERS' GRHASPIINDUSTRL WASTIf INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVIS20N PSIS
(Thi,section necdmalta cnmpined ifthc Permit i,before hundred dollan(SIBB) GREASELRAP
PLANCIIIiCK FEE
or lea.)
I certify that in performance oOhe work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any counter so as to became subject to the Workers'Compsa- ENERGY FEE
sation Laws of Califomia.Date WATER HEATER WNEN IFLECTR
GRADING IL
Z O AP hand A L'
NOFICE TO APPUCAN'1':11 ,ter making tbl,CcIitirnm of Exeno'con,you should WAI Hk SYSTEMO REA'I'ING
SOILS 11:1! A NIS
F heenme subjectm tical hilar Compenxadis pmu, hal of the Labor Calc,you mm�
W ti forthwith comply wilh,uch provisions or this pemtit shallRdeemed revoked WSJ HR SERVICE
5Z CONSTRUCTION LENDING AGENCY
NEW HESIDEYI'IAh Pthfli. SQ, PAID Date R eipt#
V 0 I hereby affirm that here iso conmacti n lendingageccy fonhe perforunceof
the work for which this Pert is issued(Sec.3099,Co.C.)
' Icndcr's Name TOTAL
SLe de Add TOTAL:
BUILDING
I Rtythat Ih read this appIetIh
sH. 0 correct,I agree to eniney with all city and county viffinraccdstate coso,lafir,of qpy.. MECHANICAL.PERMIT FF,E
U building construction.and hereby authorize reprcantmivesofthis city menter uptm the SEISMIC IIiI
above-mentioned property for in,pectlon purgtws PERMIT ISSUANCE FLECIRIC FRE
(We)agree m save.indemnify and keep henries,the City of Cupertino against
liebilities.judgmcins.costs and expensss which may in anyway arcane against said City ALTER OR ADDTO MECII. PLUMBING FEF
inconsequence a(Ihe graining nr this peril.
APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,000CFNE NIFCHANICA FEC
SOURCE REGULATION.
r AIR HANDLING UNIT(OVER 10,100 CFM) AD
Sig74
nature ml.PPlkan Data T:XHAUST HOOD(W/DUCT) E
IIA9ARDOUS MATERIAE S DISCLOSURE
Will Ne applicant or future building occupant store or handle hazardous material HI!A'I ING UNIT CID 100ANI RFU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Calc.Section 255321v1? f11!ATING UNIT(OVER❑10,61%1 B'I'U)
❑Ycs ❑No V17N'I'ILATION FAN[SINGLE RFSI D) Receipt#
Will the applicant or future budding occupant use equipment ar device,which 11011 ER-COMP 13HP OR 11911X0 H'IU)
mit
District'
us air aantumieants as defined by tire.Ituy Area Air Quality Munugcmdnt T(YI'A L:
Disridp BOILER-COMP(OVER IINL0X113TU)
CI Yes E]No
I have read the ha>allous material,equirenscros under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUA 'CIi 6AT:
fomia Health&Safay Code,5«tions 255115.25533 aM 255U.1 undcamnd than if the NEW RESIDENTIAL MICH, SQ.FT,
building does not currently have v tenant,that it is my responsibility m natily the occupant
or the r,quiremenn which most be met prior to issuance of a Certificate of fkcu ardcy.
Owneror authorized agent T Unte 1
COT/d.: ISSUED By:
OFFICE