S 1447 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING.ELECTRICAL. PEI`117 NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL. _ V 1447
y ; BUILDING PROJECT IDENTIFICATION`
BUILDING ADDRESS' /r - SANITARY NO. APPLICATION SUBMITTAL DATE
NE 'S NAME: PHONE' CPNTRACTOR'S NAM n: LIG O:
C C NTROLb
ARCIII'I F: TIF.NOINEEIL LIC NO. DRESS,
CONTACT. PHONE: GJ� BUILDINC,PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTYELECTRIC PERMIT s FEE ❑ ❑ ❑
I hereby afronthat 1 mo licensed under Is f Chapter 9(ormicamm, + JOB DESCRIPTION
with Section 9000)orD' _nor 3ofma els _ f RESIDENTIAL:
w0c) std Pmfess'o is C,de,and mY w mIs
WOO PERMIT ISSUANCE
F1_ full force
�t�yntJ effect, � SSFDWL ❑KITCHEN REMODEL.
Q,UV icense. - ♦ Lick APPLIANCES—RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
ale Lim,# tar
ARCHI'TECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z'yp 7�
p IdJ y lhll M1l blidMODIFICATION
UPq02WAMPS
El INTERIOR [:1 CHIMNEY REPAIR
F �u� Licensed Pool..must 201-I(dOAMPS IMPROVEMENT " E)SWIMMING POOLS
p(�
OWNERBUILDERDECLARATION OVER IIlIN1AMP$ ❑BATH REM �P DEMOLITION
C 1 hereby xfflnn that nm exempt from Ibc Cunrvcmr's License Lnw Por the
aay� Y U fallowing reason.(Section 70315,Business and Professions Code.Any city or county SIGNS ELECTRICAL L1 OTHER
n+a u,Ir` which 9 fourth to 't 'Irim, p d olid p' e"frcmre QIFX
sh prie t t alsoIli 'ppli o Ir c1b mill fl .'g ed smmmon SPECIALCTRC111T/MISC.
ggg 6� that he licensed pursu It Ib p Minn.or the Contractors L L (Chuprer9
GL�O (a,mmancing with Section 9000)of Division 3 of Ilia Business and Pm(cssion,Code)or TEMP.ME"TBR OR POLE INS . COMMERCIAL:
d ly c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section)031.5 by any applicant for a permit subjects the appliatmt to a civil penalty of POWER DEVICES
uxlrWit [_1 MEANT ❑FOOD SERVICE
(. not Tire Tiv wne fivehundred B,dollars
yemp.
C' QI] deffie nk.md,IN,am,or myemployeeswith fferefraeireble.7041, nation, SWIMMING POOL ELECTRIC IMPROVEMENT
2222 willdn.hewnrk,and the he Coro r,mtim License Law
apply"1044,nosiness ❑OTHER
¢a]3 m and Prnfcrxinre Cnde',The Gmlmdnr'e Liceme Law does not apply in an owner of OUTLETS—SWITCHES—FIXTURES
F propeny who builds u Imprnvm thereon,and who due,such work M1lmso of or Nrnuyh
his own employees,provided that such improvements am not mon led nr offered it,, NEW RESIDENTIAL ELECTS SQ FL
sale If,howeventhe budingar improvement is soldwit hinone yearefcompletion,the - SQ.UP FLOOR AREA $/SQ.FT.
rd
owason-builder will have the huen of proving that he did not bui If or lreo- PA A
prove for po
pace of sole.). �Y
I]1, f th p,(,party, ly contracting Ih I' e I 'nl a l to TOTAh:
construct tpr1 I(See]1144B end Profession,CJ n The Contract.,',Li-
t s Law does net applyt I property who build:or impore4 thereon, d QTY. PLUMBING PERMIT' a�.rr.
- who t t.forsuehp d Is onto a coil tor(,)licensed pumant le the Con- t 's //.. p
Lice Law. PERMIT ISSUANCE 4
I]I am exempt under Sm. B&P C for his reason
Owner Time ALTER—DRAIN&VENT—WATER EA) ALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW MITI'EC'T.DEVICE 1 LAI/`1/'N
I hereby affirm under penalty ofp jury one of the following decluratiory l I/W
❑I have and will mainhtin a Cenirtwte orCon,entlosell-insurerorWorkers G,m,sch- DRAINS—FLUOR,ROOF,AREA,COND.
cation,as providal for by So,( h 3700 of the Labor Code,births peboannencr of the STORIES "TYPE CONS[RUCTION
work for which ills permit h'I,,tmd, FIXTURES—PER TRAP
❑ I have and will maintain Workers G,mpensmion Imumnee,as required by Section
3700ofdo Labor Code,fur the perfarmanaof the work for whim,lin permit is imuul. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN.
My Worker's Compenwhon Insurance carrier and Polley number arc:
Carrier: Policy No.: OAS—EA.SYSTEM-OV HR 4(EA) .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTEINTERCEPTOR s
�r less.)(This vection need not he complaed if fl epermit is mrone hundred JoEm($100) - "EUILI}IFI.D�VISION NEES_
GREASETRAP PLANCHECK FEE
I) Iceniny that mile,any manner
I work far which this permit ie ns'Con rll SEWER—SANITARY—S'IURM EA,200 RE
not entpiny any person' ymanner m,as wbewubjecun tM1e Wnrken'Cnmpen- ENERGY FEE
Z station Laws ofC foram m
Q Z7' -k -ATER HEA'T'ER W/VENT/IR.F.C'I'R
z Applicant A� GRADING FEE
ti NOTICE'I( .If,afro mal tng Ihtx C cam of WATER SYS'IBM/TREATING -
become sumac,to the Workers Cotn,maotion una,kitin,of the Labor Cade,you must SOILS FEE
W A fodhwdh comply with such provisions or this Fumit sliall he damned raveled. WA'T'ER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Uo 1 hereby affirm than vo, ,aoncwmion loading agency rnr the pedormrm,,I Dales re tb
W H the work for which this permit is issued(Sea 3099,Civ.C.)
C) V fender's Name - TOTAL: ,
LH Lender's Address - TOTAL:
1 mniry That 1 have road this application and xhne Ihm the mbove'mformatlon is BUILDING FAtl
V) correct,I agree to comply with all city and county onlir ances and one laws relming to QTY. MECHANICAL PERMIT FEE
wilding construction,and hereby authorize Npresenmtives of this city m enter upon the smsmicTif
shove-mentioned propeny for inspection purposes. PERMIT ISSUANCE.
(We)ogre,1,save,mouranoy and keep harmless the City of Cupertino against ELECTRIC FEE
Iinhilities,judgmentr,ttmmand expen,ev which may in any way accrue a,ir,t,md City ALTER OR ADD TO METH.
nsuence of the'junta of this permit. PLUMBING PEE
AaI" eyI.]CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
� . AIIt HANDLING UNIT(OVElt 10.000 CPM) CONSTRUCCIONT
Slgnmm
vofAppicanUConm
tmcr Date EXHAUST HOOD(W/DUCT) HOUSING MITICATIO [?c
HAZARDOUS MATERIALS DISCLOSURE.
Willlh,applicanl or face,,haddtng oCCupam score in handle hawnlousmvmrial HEATING UNI'C(TO 100,000 BTU) - ��
a,defined by the Cupertino Ishimm pol Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Date um4
Will xia airconta contaminants
defined occupant u,cea Air Qshout uality
Management
BOILER—COMP(3HP OR 100,000 BTUj
it hvznNmt,air umtaminunG an defined by the Bay Area Air Quality Manugemeot - _ O,1,Al.
ixaicR
C3 YO, ❑No BOILER—COMP(OVER 100,000B I U)
Ihave rad hie hazardous materials recruitments under Chapter 6,95 ofthe CnliAIRCONDITIONER
ISSUANCE DATE
fornix Health&Safely Gale,Sections 25505,25533 and 25534.1 understand that The NEW RESIDENT JAI.MEGA, SQ.FF.
building does nol curenlly have a herantarat it is my respnndbility m notify the occupant
of the"arra meals which must he met prior m issuance Mu Cenifiwte of Ocimpaney.
Owner ar authon,cal agOhl Date TOTAL: ISSUED BY:
OFFICE