S0371 AiPPLICANTTOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL Q 0371� 7'1
-BUILDING PROJECT IDENTIFICATION O / 1
BUILDING ADDRESS: SANITARY NO. APPLICA'I'IONSUBMITTALDATE
33 L -3o�y
O NER'S AME: - PHONE: CONTR .T(R'S NAF����yyyy LIC NO.
/ ?� NIC CONTROL#
• 11 ' .N :•R: LIC NO: ADDRESS: J ❑
CONTACT PHONE: 7 BUILDING.P17RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG Ii1,F.CT PLUMB MIiCH
❑ ❑ (Z- ❑
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT' FEE
I hereby affirm that licensed under? of Chapter 9(commencing _ .. JOB DESCRIPTION
CZ with Swoon 9Wu)ofO,.Lion 3 of the Business dPnife,ion.Cd and my license Is R8_�ENFIAL:
W OPERM ISSUANCE
FSin full force and effect $FDW'L ❑KITCHEN REN10UEI.
QUV Liccnsc-= Cmetr APPLIANCES-RFSIUENTIAL ❑AUDITIOX 8'PEUb1RING kE-PIPE
F Z 1x1 Dam Contractor
tnaa ❑MULTI-UNIT ❑STRUCTURAL.
A C{ITECI'S DECLARATION
F 7 w. PANELS MODIFICATION
ZOZm M I understand my plans abau he red as public recorecordso .
UYT02(N)AMI'S - [I INTERIOR 0CHI11NI7Y REPAIR
F 4!:W Licensed Professional 2014000AMPS IMPROVEMENT 0SWLMNING POOLS
xagF; OWNER-BUILDER DECLARATION OVER IIXX)AMPS [IBATH REMODEL,REPAIR [IDEMOLI"P[ON
C W a I hereby spin,that I am exempt from the Conuarou,1:eons,Law In, he
3 U following reason.(Section 7031.5,it lines,and Professions Crile:Any city uranmnty SIGNS ELECTRICAL OCHE
a: LL y which requires a permit m construct.can ,alter,improva,dcmulish,or repair any strvaore
F'u'Oa prior o is issuance,also requires the applicant for such permit to file a signed statement SPECIAL Cl RCUILMISC. { jg.
fly— ma he is licenced pucsuanno the provisions of the Cranberries Liecion Law(Chapter 9
Wa (,mumc.cing with Section 70W)of Di ,fmSof the Business and Professions Coleco, TEMP.METER OR M)LE INST COMMERCIAL,
E d C thta he Is exempt merchant and the look for the alleged cxcmptiom.Any violed on of ❑NEW BLDG/ADDITION 0 DF,MOLI'I']ON
0
vi Senior]uI LS by any applicant for a permit objects the applicant to a civil penalty of POWER DEVICES
[ITENANT ❑FOOD SERVICE
not more than five hundred dollars(5500). IMPROVEMENT
=0 ❑1,as ownerof the progeny.or my employees with rages as Meir sole cumpensmion, SWIMMING POOL ELECTRIC
d,F.o will do mework,and thecwmvre is notimended or nl7cred fol rale(Sec.7(Ig4,Business []OTHER
W m and Professions Calc:The Common's Limnsa Law docs not apply 1,1.11 Icer,of (111'1'hFTS-SWITCHES-FIXTURE
S
0.3.. property who builds or improves dwy nn,and who docs such work himself or through
his own employees,provided dot such impmvemems are not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT.
tato.If,however.the building or imom
parturot ksold within one yccrofcpleticathe SO 17.FLOOR AREA SISQ.Cr
costur-builder will have the burden of proving that he did not build or improve for put-
puxnfs�le).
O I,as Uwner of the proper,am es6mivelY nmtmcting with IiccneeJ con¢emnis m 'f0'IAL:
comhucube pmject(See 7044.Beirut,,and Professions —c,,is.Comrennr's Li- -
come Law does not apply toanowner of property who builds or improves memon.and QTY. PLUMBING PERMIT FEE
whorommch,for.such putects with acumracbms)licensed pursuant to the Co forcmr's
License[.:to VERMIT ISSUANCE.
I an,exempt under See. ,B&I'C fm mtsrcann
ALTER-DRAIN&VENT-WATER(IIA) VALUKI]ON
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby albnn under penalty of perjury one of the following declarations:
❑Ihaveand will maintainnl2nlliuncuf Cunsennnsdf-Insurefn Worker's Cnnlpun- DRAINS-FLOOR,R00F,ARl!A,COND. STORIES TYPE CONST RUCTION
,alio.,as provided fur by Section 370(1 of he labor Code,for the porfamounce of the
work for which this permit is issues. FIXTURES-E'ER TRAP
have and will maintain Worker',Compensaiun Inwmnce,as required by Section
)of the Labo}}rr Crd,f,l-ff000r the ii,rTurromet,ofthe work four which this permit is issued. GAS-EA.SYSTEM-1 ING4(IUTLEIS OCC.CROUP APN
and policy
My Workk�...{�yEIFICAI OIC%fM e,aONYFRa"ITOM� /�r� ('AS-EA.SYS'I'IiM-OVI?R 4(EA)
TTr COMPENSATION INSURANCE GRIiASFIINUUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This rearm neod.ot be completed ifthe prim,is Intuit,hundred dollnrs($Its)) GREASETRAP
or tvn) PLANCHECK 171":
I«nifythal iniheperfornwnemfthe work farwhich thiepcnnit is Issued.I shall SEWER-SANITARY-SFORM EA.200 FI',
not empiny any Person in any manner so m m beecomwbjeer to the Workers Cnmpm IiNIiRGY FEE
ZZcation Laws of CaIthina u.Date WATER HEATER WIVENITiLECIR GRADING IEE
Q Applicant ` G
NOTICE TO APPLICANT:If,after snaking this Certificate of Exemption,you.should WATER SYS'I EMITREATLNG
ti .. SOILS FEE
a } femme subject the Workers Csion,orthis proal hal of the Labor Code,you must
� forthwith comply with such provision.a or this lwnnil.ball be Jo�mN revoked WATER SERVICE
= CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID � ipt X
z
UQ Ihereby afForon,there is a comuucno.lendingagenperformance of
far the performanof DAc
V. mework farwhich Ibis permit is issued(Sec 3097,Civ.C.)
O U fonder',Namc O AL.
} U Led Address o
y I n fY that L have ad this application d a t met h binformation is HUILUI
.F. Qi!) re 1,.1.B t c ply thII t do ry M' d u t l Ian.gm QTY MHCHANICAI,PERMIT FEE
fJz buld'tg construction.and hereby athmi pvs.dafvrs oflhsdty or enerupmt the SEtIS�pl'�q/f �UYtHIL._
^' abov,-ntantioned P,,,pny for iuspeclion purposes. PERMIT ISSUANCE IIJiC'1'RIC rLIi
(We)agree lit save,indemnify and keep harmless the City of Cupeninn against
Iiabilities,judgments,cmus and expenses which may in anyway accrue against said City' ALTER OR ADD TO MECH. PLUMBING FEE V
in consequence of the granting of this permit. -
APPLICAN UNDERSTANDS ANU WILL COMPLY WITH A).L NON-POINT AIR HANDLING UNIT GT)1000111 CPM) MHCII ANICAL FEE
SOURCE M LAI IONS,
�� /4i(/✓ix�_`. / AIR HANDLING UNIT(OVER IILIN)O CFM) CONSTRUCTION'LAX
S' nM ApplicanoConuactor I Date EXHAUST FOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appliomt or future building occupum,mre or hondle haZardaas Inacriul I IhA'1'INO UNIT'(TO 100,M)RTID
as delined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553263? HEATING UNIT(OVER IINI.(XX)RTU)
❑Yes ON. VENTILATION FAN(SI NO LE RPS ID)) PAID pate RecciptN
O
Will thor e
xantarfarm hildiea lh BOILER-COMPI3HPOH 100.000 BTU)
hazardous air conmminanva,d,fiMed by the Bay Area Air Quality Management
WI fOTAheDmilhHelY
BOILER-COMP(OVER 100.0 KI RTU)
❑Yes ❑Nu
I have read the hmardous mmeriuls requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornia health&Safety Code,Stolon,25505.25533 and 25534.1 understand that if he NEW RF,SIDENTIAL ME'11. SQ.FI'.
building doec nn mlY havwmnunt.mmhis mY responsibiliry ni otifYt 'ncupum
of the which mus r prior to issuance ofa CeniB,wo' a cy
Ow r uirem,vc agent G`J Dar 'IMAL ISSUED BY, — ✓ "�
OFFICE