S0549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PrRMITNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0
BUILDING PROJECT IDENTIFICATION Q\J 5
BUILDING ADDRESS: SANTPARY NO. APPLICAT'If1N SUBMITTAL DATE
2/to 13 La Pla Yel Cf 22
OWN SN1A�ME: PHONE CONTRACTOR'S NA E: LIC NO:26� NIC CONTNOI.
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V Lu b _� � lt'e ! � 1
ARCHFITCHENGINEER: - LIC NO: ADDRF-SSS ❑
66 ` Cc;✓ ' zhnA2. a�1
CONTACT; PHONE: BUILDING PERMITINFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELK PLUMB MUCH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE ❑
In ny1l t d tl 1 d e p rete pt /( int nsn;ng - JOB DESCRIPTION
WOO PERMIT ISSUANCE OZ wuh5 f ?INMa II) ionJ urthc Bus nusand Pn fie..' aCd d ryl'se v RESIDENTIAL:
IA
F.'_U i 'n1u11r nw Jsll ct. - ❑SFDW'L ❑KI'ICIIhN REMODELaU Liccnac Clam Lic.M APPLIANCES-RESIDENTIAL L1 ADDITION [I PLUMBING BE PIPE
F.Z Iy Dale - Contracmr
❑
mQly h911LT1-UNIT ❑ST tUCI'URA.
zi ARCHITECTS DECLARATION
ZFOOZ l understand my plans shall be used ax public records PANELS MOOIIICATION
OZ 4), UP TO 2W AMPS L1 INTERIOR ❑CHIMNEYREPAIR
F W ioamed ProfrWonal 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER ANSI AMPS Ll BATH REM O i R� O '1faT ,
C'w S:owQ 1 hereby dfimw OTHER
t that 1 am exmnpt from the Contractor's License lalite the �1 Ya
[di : UU following indoor.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑
y which requires a Permit wm
ctstruct,alter,improve,demolish,or repair any structure Ole
f-LL'�Q prior m its issuance,also requires the applicant for such peranitto file a signed smtanent SPECIAL CIE UITMISC.
W ad that he is licensed pursuant m the provisions of the Contractors License law(Chapter 9 v
WLL 0 (commencing with Section 7000)of Division J of Bee Business and Professions Gyle)or TEMP.METER OR DOLE NST. COMMERCIAL:
a.L c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xm Section 7011.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than live hundred dollars($500). IMPROVEMENT
=Q ❑ Las owner ofihe progeny or my employees with wages as their sole compensation. SWIMMING P(IOL ELECTRIC El OTHER
P. will do the work.and the structure is not intended or offered for sale(Sec.7WU Business
wandP I Cd Th Contractors Ice La d t apply to owner of OUTLETS-SWITCHES-FIXTU
property who miles,or improves thereon, d who dov. such work hirowlt or through
his own cbiplcjce. provided that such'rimproverners are not intended or obered for NEW RESIDENTIAL ELECTS SU
sale 11 however the av id , nprmement s sold w lho o e,emoo rep eller the - F H AREA SISQ.pI'.
crbuilder will have the hurden ofsowing that he did not build orhnprwc for par- AUG0� f: ). 'I' 1'A L: G 1 $ -
1 we r f the p pt rym exclus' ly ting with 1 e 1 contractors U.
d,
mol tin p oncel p IIN4 w Er, :: d Profession,whoCal imp ve t 1 9 i-
c 1 d s t apply in fp pony �h builds improves th e t A QTY. � PLUMBING PERMIT
Li i m eH for euehp olcaawth neon n'd.)Emnsed puesuann theC a t 's
Lin 1 PERMIT ISSUANCE' —.►1_,t
I].l am exempt under Sec. .B&P C for this reason
ALTER-DRAIN K VENT-WATER(EA) VALUATION
Owner Dam
WORKER'S G
COMPENSATION DECLARATION RACK FLOW PROTEGE DEVICE
1 hcrchyammt under penalty to perjuryoneof the following declarations:
❑meas andwillfor bynaCion 37 eofCo Labor ode,m other Workers Comp ere- DRAINS-FLOOR.ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
cation.m pmvided for mi Section JOW of the labor Crate,mother pcµotmance of the
work for which this permit is issued.orker FlXTURFS-PER TRAP
❑ 1 have and will maintain Rome
e pirdfrs Compensation Insurance.h required by Section
37M nine Labor Coda.fanhe performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP AI'N
M r We C mfacas tiny tsmm.ce amer ane Policy numhe
policy No.;, 7[Yy/47n3A GAS-EA.SYSTEM (E
-OVERYA)
CERTIFICATE OF E) MPFION FROM WORKERS' GREASFANDUSTRL WASTE INTIiRCHMOR
COMPENSATION INSURANCE _BUILDING DIVISION PLUS
(Thi,woonmcd not becompinted ifthepetmlt..foronehundmddollas(5100) GREASETRAP
' or less) PLANCIiF.CK FEE
leerily thin irmanefnnnaevorhe work for which tho,wrinn is send. le.11 S17WER-SANITARY-STORM EA.200171
not employ tiny patxun In any manner so as to hecoma,.bice radio Workers'Compel- ENERGY FEE -
Z .canon laws n1'Cehli...ia.Date WAT13R HEATER W/VF.NT/ELECI'R GRADING FEE
` NGI ICI?'FO APPLICANT.IC after making this Certificate of Exemption,yen should WATER SYSTENOMEN'1'ING SOILS FEE
become subject m[tic worker's Compensation pmvoiens of ate Unfair Code.you nnot
forthwith comply with such powmemor this permit shall be deemed revoked. WATER SERVICE
= z CONSTRUCTION LENDING AGENCY HE RESIDENTIAL PCMB. SO.Fr LAID Date Reccin#
U O I hereby affirm that there is a construction lending agency for the perfonnancc of
the work for which this permit is issued(Sec 9099.Ci,C)
ULenders Name '10'I'A h:
Ulenders Address
1 I certify that 1 have read this application and state that the above infomtntiTOTAL:on is BUILDING FEE
F-' I, comet l agree tocomply with all city and county erdimanccs and state laws renting to QTY.: MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction.and hereby authonre representatives of this city to enter opera the
above-mentioned property for inspection purposes PERMIT ISSUANCE ELECTRIC FEE
(We)agreeu save,indemnify and keep haemless the City of Cupertino against
liobilities,judgmenu.costs and expenses which may in any way access,against said City ALTER OR ADD TO MECH. PLUMBING EEE
in consequence of the grading of this Permit. '
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CFM) MECHANICAL FEE
SOURCE.RE 1, '
AIR IIANOLING UNIT(OVER IRINNI CPM) CONSTRUCTION TAX
a l
Signamreof pplicantlContmctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant nrfuture building occupant store or handle hanerdoas material µBATING UNIT(TO 10O.M)BT U)
vs Adinral In the Cnpcnino Municipal Code.Chapter 9.12,and the Ilenllh and Sudety
- Code.Sac tion 255]2pµ.1 - H HATING UNI'I(OVER I ill B'FU)
E]Yb, [0_1 No VENT NATION FAN(SINGLE RESID) PAID
Date Reccipt4
Will the applicant or future building occupant use equipment m de,ieex which BOILER-COMP(JHP OR 11x.000 BTU)
emit Iurandous air contantinads as defined by the Bay Area Air Quality Management TOI'N.:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nn
I have read the barmdeos mateda6 mNfrements trader Chapter 695 of the Cali- AIRCONDITIONER ISSUANCE
DDATEE`
fomiaHealthg does n Scurry Gds,.Sections255a5.25533and2553.1 to notify
that Vila NEW R6SI06\TIALMECH. SQ.
building require encset rrentlywhich have he mentthrto ismy uace of a ertycuseofythe«cup:em -
of the requirements which must he met prior to issuance of a Cenifcae of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE