S 1052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PF51T NO
BUILDING DIVISION APPI,ICATION/I'ERMIT PLUMBING-MECHANICAL V 1052
NUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DAT
BUILDING ADDRESS'.nn
g5% A2dee DR• 7SZ
OWNI"S NAM]' PHONE. CON'rRACfOR'SNAME: LIC NO:
S J ^ N � � NIC CONTROL p
•ARCHITECT/ENGINEER: LIC NO: Ap(D_RE S` Ix[AsrP �/ / ^. / ❑
CONTACT PHONE: RUIIAING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑ kl_
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby mfimr mat 1 am licensed ander prevision,of chapter 9 feemiumem, JOB DESCRIPTION
O d'Z with Section700oof Division 3ofthe Bmine,untl Professions Cole, ralmylicense is RESIDENTIAL'
u1 O Z PERMIT ISSUANCE
�Iy. in full face and effect. ❑SFDWI, ❑KITCHEN REMODEL
NE, License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RIL-PIPE,
F-Z W Date Centmcmr
NE,
4 0. ❑MULTI-UNIT ❑STRUCI'URAf.
ftp ARCHITECTS DECLARATION PANELS
Z O ? I unJcrsTand my plans shall M asW as pahlic reaads MODIFICATION
�+ UPTO2W AMPS
OZ— ❑INTERIOR ❑CHIMNEY RF,I'NR
FBF.W Licensed Pmfcssional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
yC C Q 1 hereby drum that ant
OWNexemER-BUILDER
DECLARATION —E he Contac or's License Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
X O a.U following reason(Section 70315.Business and Professions Code..Any city Lir county SIGNS ELECTRICAL ❑OTHER
W,a h which requires a Permit m construct,alar,improve,demolish,or repair one structureI�OQ Poplin itsissuance.alsomquires the applicant Bosuch pemra to file asignedstmement SPECIALCIRCUIT/MISC. r _I
f }'� that he is licensed pursuant to the provisions of the Connector's License Law(Chapter 9 ^ 'r
�a Oc (commencing with Section 7000)of Division 3 of the Businessland Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
a K e C that he is exempt therefrom and the haste far me ullegCd exemption.AnY vialwion of [I NEW BLDG/ADDITION ❑DEMOLITION
XLH Section 7031.5 by any applicant for a permn
itsubjeeN the applicant a civil penalty of POWER DEVICES [:]TENANT FOOD SERVICE
not more than live hundred dollars($500). IMPROVEMENT
SSG [:1I.as owner of the propertuma.or illy employees with wages as Their sole compensation. SWIMMING POOL ELECTRIC ❑OTHh:R
F will do the work,and the amem is not offered for sale(SeaJ04y Business
To 3 m and Professions Code:The Contractors License Law do,%net apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not Intended or uttered for NEW RESIDENTIAL I'LECTR SQ FC
sole.If.however,The huildingLir, imprnvemerak,old within one year of conrplotion.EM1t 5Q.17,FLUOR ARRA SISQ.PT.
ovener-builder will have the haden of proving That he did not build Lir improve for pur-
pmat aLsalc).
❑ I,as owner of the propertam exclusively contracting with licensed commands ter TOTAL
y,
consumer the project(Sac.70,14,Rosiness and Professions Code;)The Contractors Li-
nen law does not apply to an owner of property who builds or improves Ihcreen,and QTY, P PERMIT FEE
who contracts for such pmJuas with o contmcon%)licensed pursuant To the Contractor's
License Low. PERMIT ISSUANCE
❑1 am exempt under Set. .It&PC Ins This reason
Owner Date ALt'IiR-DRAIN.g VtiM'-WATER I' VALUATION
WORK ER:S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE,
I hereby affirm Linder penalty of pcfjury one of the following declumdons:
O l have and will maintain a Certificate of Consent o self-insult for Workers Conifer- DRAINS-FLOOR.ROOF.AREA.GOND. TYPE CONS'TRUCIK
Baden.as provided far by Second 3700of me Later code,far me perfmmanee of theC T
work Ter which this permit is issued. FIXTURES-PER TRAP, 1J
❑ 1 have and will maintain Worker's Compensation Insurance as required by Section �Cq�,Rp}�
37W of the Leben Card,for the performance of the work for which this proton is issued. GAS-EA.SYSTEM I INC.4 OUT LE I'S �� 1r OCT'997 APN
My Workers rape eauon sumnce artier and Poliq number are: �11T [J]JU�
Collies C Policy Nn.: OAS-PA.SYSTEM�OV ER 4(EA)
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, GREASPIINIIU$TRI.WASTE IM'ERCEI'TOR
BUILDING DIV ION FEfiS
(This Batton need not be completed if the permit is forme hundred dollars($I(p) GREASE"TRAP
BY-Lir lcss.l PLAN HIiCK Flili
I certify That in the performance of the work for which Thi.permit isissued,le hall SEWER-SANITARY-STORM EA.2W FT,
not employ any peon in any manner so as m bccn on supjea m the Worker.,'Compen- ENERGY FEE
z scion laws of California.DaCr
Date WATER HEATER W/VENT/ELER
Z O Applicant - t GRADING FET?
.N. NOTICE TO APPLICANT.If,la0cr making This Certificate of 17semptinn,you should WATER SYSTEM/TREATING
a , become subject to the Workers Compensation provisions of the Labor Code, ,,it must SOILS IFI:
(1.1 forthwith comply with such Provisions Lir This permiTshall be deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh1R. SQ.F1'. PAID
V k for
thauhaeis.ee (See 3097.
agency Tonic perfonnunec of Dae Rcceipg
fL Fa the work for which this permit is issued lS«.3W7.Civ CJ
Q U Term%Name TO'T'AL:
I clder',Address TOTAL04 :
I certify that 1 have read this application and state that the aMnt information is BUILDING FEE
FC.) (i!) correct.l agree to comply with all my and county insurancesinsurancesand state laws relating to QTY. MECHANICAL PERMIT FEE
Z building construction.and hereby auhurim mpmvnmtives of This city To enter upon The SETS M IC FEE
abnvonumtiored l000my for inspection purpmex PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmlcxs the City of Capard against ELECTRIC F[li
Iiabilitics,judgmcros,mets and expenses which mayin any wayaccmc against said City AINER OR ADD'TO MECH.
in amxcq actur of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND W - COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM
SOURPE REGULATIONS. MECHANICAL FEF.
eC oA�7 AIR HANDLING UNIT(OVER IO.Tk10 CFAt)
yka /O 7[ / / CONSTRUCTION TAX
Sis�ereof/cpplicam/Commcta Date EXHAUST HOOD HOUSING MITIGATION FEE,
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future building occupant store orloarri haianlnus material 11I22ATING UNIT(TO 100.00(1 BE U)
as defined by The Cupertino Municipal Cade.Chapter 9.12,and the Health ami Safety
Csdu,Sectio 25,532(a)t HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE kHS1U) PAID
Will Thea applicant or future building T use equipment or devices which Dam Receipt p
PP gby then Area
BOILER-COMP(3HP OR HI0,000 BTU)
sit District? aux ter ttnnwninanT.e as dcfnW by the Bay Arca Air Qmlity Management
• IlistricB TOTAL:
❑Yes ON. BOILER-COMP(OVEH IW,(klfI RTIII
I have real The has admi,mammals requirements under Chapter 6.95 of The Cali- AIR CON DI HONER
P ISSUANCE DATE
Ibmia Healthes&Safety d Th Sections 25505,25,533 and n,mili 1 understand that if the NEIV RESIDENTIAL MECH. 6Q.<T_
buil in Jocs no to ❑y hvv mman6 main is myresJsrnxCe" mheofyccatedpam
oITM1c�•Juircmcros ichm met prionoissuanm nfa Ce" he of tXcupancy
or
cut /U Wy
Owner a uumomed agent [)am TOTAL: ISSUE7D BY:
OFFICE