00020025 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL tt '1LMIT NO.
ItUDAING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI
BUILDING PROJECT IDENTIFICATION
1UILDING ADDRESS: 1 SANITARY NO. APPLICATION$UBMTTI'A D G
l 4 I fpm �Oks e , E YttN b GA
[H'SQN 100 1. PHONE: ' N I RACTOR'S NAME: LIC NO: v
.4 H s 863 as N/C CONT 01.#
CHITECUTINGINEER: .C NO: ADDRESS:
8 L£J ITIi- C ( S 6 Q
C(INTAC. PHONE, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) f B�LUG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT TEE
1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing JOB DESCRIPTION
WaX. 'th Section 70monflAvixion.1inthe Busines and Pndessions Cude,undnry lirense ix RESIDENTI I;
W30
p i i full'err and chic, 1'I!HMIT ISSUANCE-'UU I.Imme Clas . Lit.p ❑SED ❑KITCHEN I2F:MOD1?I
6 U APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
NQ a. IIaLL Contrxtor
IDV. ARCIII'I ECFS DECLARATION PANELS 1n ❑MULTI-UNIT ❑STRUCTURAL
Z p w Z I understand my plans shall be used as public records �A pp A MODIFICATION
OZ�Q UP T0200 AMPS • W ❑INTERIOR EI CHIMNEY REPAIR
<NF-; Licensed PrmRssl0mil 201.1000AMPS IMPROVEMENT SWIMMING POOLS
CG u�u11 Q I hereby aRmn ha I v n x inDEfromEthc ContmlOor's License Law for the OVER I"AMPS ❑BATH REMODEUREPAIR El DEMOLITION
O C.U finkoxia 2
g reaam.(Section 10J L5,Pusinusv moil Pmkvsions Code:Any eiry or county SIGNS ELECTRICAL El OTHER
u131s.H which requires a permit to constrict.altar,improve,demolish,or repair anym
ssmorc
.0
11 prinnnilx icv'uunce,alea reyuircvlM1e iytplicant for sucM1 pcnnit le tilmtsigncdslmemutt SPECIAL CIRCUITIMIS
mathe is licensed pursuant In the pmwisurm or1he Curnmenrr's Liccnec law(Chapter9
� (commencing wish Section OlMN))�i llivision3of the Rusinms and RnkxsionsCWe)to T'EMIt METER OR POLE 1NSf. COMMERCIAL:
d a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIAODITION ❑DEMOLITION
WM" Section 2031.5 by any applicam for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOODSERVICE
I--ZY not more than five hundred dollars(S50Bk IMPROVEMENT
i_Q Dl.moswner of the prmpcny,or mycmployees wird wages as theirmle compensation. SWIMMING POOL ELECTRIC
F-O will do the work.and lheslowmre is nal intended mothered!for mlc(Set.'/Bk1,Business ❑OTHER
Was, and Profcssinns Code:The Commcmrs Limnee Law diva not apply to an owner of OUTLETS-SWITCHES-FTxT IRES
property who builds or improves thereon,and who does such work himself or through
his own employees,pnrvidad that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ ET.
site.IL however,the building or improvement,%.old wllhlmore your ofcmoploara,,he SQ.FI'.FLOOR AREA
-builder will have the burden cl'proving that he did not build or improve for pur- n
EPecot owns TOTAL:
r of the property,am exclusively contracting with licensed contreem!%to 1
construct the project Ncr.7faH.Business and Pra[essfons Cod J The Comments's La-
cerise Law does non apply it)
i-nsclawdoesnotapplyu)an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEF. /
who contracts for such pmlemswith aconlr«tarts)licensd pursuant to Contractors L./��N s r/�l•
license law. n /a PERMIT ISSUANCE �(
1 vee entmq undlr Sect�fN�B/_.__-.nA__1—.N&P C for this reason
A L�� 1` P�{�ll��� Da1C ALTER-DRAIN&VENT-WA'I'IR(EA) VALUATION Q �j
wncr _ C
WORKER'S I!N SAT roof he RATION HACK FLOW PROTECT.DEVICE V 0"" J _!%�CI
thereby affirms penalty olperjurymne of the Billowing declarations GJJ !+.'�
D lM1ave and will rain uCeoiticmcnf Cnnseouo.self-itorm for Workers Co.,.- DRAINS-FLOOR,ROOF,AREA,COND.
.tion,as provided fnr by Section 3700 of the labor Cale,for the performance of the )RIES TVP.CO l(
work for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
370 of the labor Core,for the perf0narrom of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS DCC.GROUP APN
My Workers Compensation Insurance comerand y No.:number am: � / Z Q
Carrico Policy No.: CAS-GA.SYSTEM-OVER J(EA) (0
CERTIFICATE OF EXEMPTION FROM WORKERS' Q S
COMPENSATION INSURANCE GRHASUINDUSTRL WASTE INTERCEPTOR
'
(This section need nal be completed if the permit is fnnmc hundrW Jnllure($IfN)) BUILDING DIVISION FEE
GREASE'TRAP Ly ib
or loss.) PLANCHECK FEE
leenifythat in the performance ofthe work for which this ramit isisvued,l shall SEWER-SANITARY-STORM EA.21X1 FT.
tint employ any person in any manner so as to bm
ecoe subje tI.the Workers'Commn- ENERGY FEE ' 1/�
O ,� .tion Laws of California.Dam WATER HEATER WNENTEIRCfR
Z Appbeaat t GRADING FEE
= NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
a > become subject m the Workers Compensation provisions or the Lzhn Code,you must SOILS FEE
forthwith comply with such provisions orthis permit shall bedeemed minded. WATER SERVICE '' I
1 CONSTRl1C1'ION LENDING AGENCY NEW RESIDENT IAL PLMN. SQ.FL PAID
U0 Ihereb,mliml that them i...onmaion binim,agency for the perfonnaneeof 011e ^—
[L
,he work fnr which this mmol,issued(Set.3099,Co.C.)
Q l.endels Name TOTAL
} W lender'.,Address TOTAL'.
0. 1 certify that I have mud this application and state that the ularvc information is BUILDING THE
f cO correct.I agree to comply with all eiry and county ordinances and stale laws relmingm QTY. MECHANICAL PERMIT FEE
UZ huildingconswction.andherehyauNudn represemativex ofthis city toener upon the SEISMIC FEE
ebure-mentiond property for inspection purposes. PERMIT ISSUANCE
IN'el agree to save,indemnify and keep hannlers the City of Cupertino against ELECTRIC FET:
liabilities,judgments.costs and expenses which may in any way accrue against said City g1.TF.R OR ADD TO MECH.in of roti at u, PLUMBING FEE
ollneyuenmo gat go
APPLICANT UNTIE S'UN DS ANI ILL COMPLY WI 111 ALL NON-POINT AIR HANDLING UNIT LTO 111,1100 CFM)
SOAR[i REG .ATI)NS. MECHANICAL[TH
AIR HANDLING UNIT(OVER 10,0W)CFM) CONSTRUCTION TAX
t naw pplicanUComm Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
F IOUS MATERIALS DISCLOSURE
Will Ne of orfuture building occupant store or handle hmardom material HEATING UNIT(TO 100.000 BTU)
v de ireG by the Cupertino Municipal Curb,Chapter 9.12,and the Health and Safety
Crab.Session 255321.,12 HEATING UNIT(OVER 100,001 RTU)
0 Yev [D No PAID
VENTILATION FAN SINGLEHESIDI --
Will thea applicant or future building t use a or devices which Dme Receipt k
pP g«cII,B ywprten BOILER-COME3HP OR 11X.0110 HTU)
it hnramm�s air conlvminansa ins Adilud by the Bay Area Ar Quality Management TOTA
O Yes No h; 4
Uisln'n:' BOILER-COME(OVER 10TOhmBTU)
O
I have renal the hwasid.x materials u.9 vrements oder Chapter 6.95 of the Calc AIR CONDITIONER
ISSUANCE DATE
fnrnia Heaps&Safety Cade,Sections 25505.255]3 and 25511.1 understand than it the NEW RESIDENTIAL MECH. SQ.FT.
huildingJmsnmc rrentlYbmm mnanl.Nm it is my rczponsibility nlnrnify the«cupant
I armeon hichm m ofa Certificate of Ltapancy.
a em Date TOTAL: ISSUED BY:
OFFICE