S 1709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC%FWCAj1g&
Pe IT NO.
BUILDING DIVISION APPI ATION/PERMIT PLUMIMNG-MEC 1709
BUILDING PROJECT 1 B IIAING ADOJiFSS: SANITARY NO. APPLICATION SUBMITTALDATE
1/V,��/- 45r. mos S�,fh,,. (Q'1LOWNER'S NAME' PHONEp� CO CT IR'S NAME:90dSLRNIC �n�CDNTRDL N
ARCHITECEENGINEER: LIC NO'. OdA )RISSMM` ❑
CONTACL PHONE: BUILDING PERMIT INFO-
' ❑ Consultant Fres Paid by Applicant(Initial) BLTH'i GLECT PLUMB MUCH
LICENSED CONTRACTOR'S DBCLARAI'TON QTY ELECTRIC PERMIT FEE
I hereby re irm anal I am licensed under pmeisinna of Chapter 9lcomnd
menng JOB DESCRIPTION
OCz with Secden]BWIOf Division 3of the Business unit ProfeWer,Code,undmy license i. RFSIDFNTI AI'
�p in full force and effect. PERMIT ISSUANCE
. UQU License Claw Lia# ❑SIUWL [I KITCHEN RE-PIPL
6 U 't APPLIANCES—RESIDENT IAT. []ADDITION [I PLUMBING RE-PII'1?
11....Z Das Commcmr
tn6 (3 MULTI-UNIT ❑S'TRUCfURAL
ARCHll lad used
DECLARATION PANELS
Z yZ Iundersmnd my plans xhall be used as public recoNs MODIFICATION
UI'T021N)Ah1P5 ❑INTERIOR [I CHIMNEY REPAIR
1-41�uul Licensed Professional 201-IUOtAMPS []SWIMMING POOLS
a ....11 IMPROVEMENT
CY
OWNER-BUILDER DECLARATION OVER IINN)AMPS ❑BATH REMODELIREPAIR 0DEMOLITION
tY
Q 1 hereby.(Hese that 1 am exempt from the fd nsi roma 1.iccnse law for ane
ipyx5, 6 U following re reason(Sestina Ilomir Business and tee.d moll Carol Any city or nnmaY SIGNS[LIiCfRICAI. ❑l7fHIiR
which requires a permit Ise cnnswn,applicant
improve.demolish, file
ea sig any swcmre
prinnnirx issuance,also requires the aPPlicum Torsuch Permit Uleasigned statement SPECIAL CINCUI'TIMISC.
(commencing
commolicensed pursuant 700(hi 'Division
ivisionf the Cn Business
Proelaw(Chode)or
(mmmencingwia dourenarn ad the
piasisfr ofthe,rd essundon,Any
or "TGMP.MF:fF.N OR POLE INST COMMERCIAL:
d t1 o K
that he is 31.5 b IM1ercfmm and arc pais for the cis the nempnnn.Any viper inn of ❑NEW BLDG/ADDITION )SERVN
Section LS by any applicant forapermil sunjal.the upplicununacivil pmmlry of POWER DEVICES El TENANT FOOU SERVICE
i not more than live hundred dollars l$50). IMPROVEMENT'
Q� [] L at owner of the property,or my nnployces with wages as aheal,ole compenxainn. SWIMMING POOL ELECTRIC
will do btu work,and the naucmre is net imended moBered forsale(Sec.]8/4,Business ❑OTHER
tend Professions Code:The Contractors License Law does not apply to an owner of DO]'LI!TS—SWITCHES—FUTURES
propcny who builds or improves thereon,and who does such work himself or Through
his own employees,provided that such improvements arc unstructured or offered for NEW RESIDIiNTIAL ELECTR5
mle,If.however the building or Improvement is sold within one year ofcompletion,Ilse SQ.FT.FLOOR AREA S/SQ.FT.
ownef-builder will have the hooden of proving that he did not build or improve far par- of A ' D
'u"A srele.). r /1
❑ I,as owner of the properly,um exclusively contracting with licensed commutes at TOTAL
instruct the project(Sec.7144.Business and professions Cndep The Contractor's
Li-,c Law does me apply to an owner of property,who builds or improves thereon,=it QTY. PLUMBING PERMIT FEE JUN 8 wo
who commas fol such project,with a es mrvesr(s)licensed punuanu.the Contractor's
License Law. PERMIT ISSUANCE
❑ lam eaempwn&r see ,B&P C for(his..sort CITY Ur (,UrrmIIIVU
ALTER—DRAIN&VENT—WATER(EA) VALUA'T'ION
•
Owner Data IO v .
WORKER'SCOMPENSATION DECLARATION BACK FLOW I'ROIT!CI'.UI!VICTi
lave
and w ll finanmai under po minute ofComene of the follarwior declarations:
n
LOIhuvetend will far by ection3Mof the LabrCod i,for
for Worker's Container- DNAINS—PLOOIt.ROOF,ARI!A,COND. STORIES TYPE CONSTRUCTION
workf as provided for by Sermon J]BB of The Lahr Cale,for The performance of the
work for which This pemdt is iaoued. FIXTURES—PER TRAP
(—I I have and will maintain Worker's CompensationIce, required by Section
3700ol'I&lobo.Co&.Tor arc performance of The work,k f,,,or wM1ich thin permit is issued. GAS—I!A.SYSTEM-I INC.q OU'I'LI!TS OCC GROUT' APN
My Worker's Compensation Insurtenac canier and Policy number am:
Carrier: Policy Na: OAS—EA.SYSTPM-OVER 41EA)
CERTIFICATE OF EXF-MPTION FROM WORKERS' GREASFANDUSTRL WAS TE INTERCEPTS OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisseatimimia om be completed ifthepemdl is fmonehundred d.11.,($100) GREASETRAP
a less.) PLANCHP,CK PBH
I certify that in the pvrfomtance ofthe work for which this permit is issued,I that[ SHWER—SANS TARY—STORM EA.200 FT.
not employ any person in any manna so as m Wo
become subject e,the rkers'Compen- ENERGY FEE
z satian Was of Caloorrin.Date WATER HEATER WNENT/ELECfR GRADING PER
z '] Applicant
NOTICE TO APPLICANT:If,after making chi.CeniRcam of Exemption,you should WATER SYST EM/l'RT!Al'INC, SOILS FEE
become subject m The Workers Compensation provisions of me Iabm Cada.you most
forthwith comply with such pai...mlhis permit shall he deemed revoked. WA'T'ER SERVICE
0
Uz CONhem isa'IONLENUINGAGENCY NEW RESIDIiNFIALPLMB. SQ.TT. P Dae Raeipl#
L) 1 hereby work me
tri that them is mini(See 13097,Cin.agency for the performance of
0 f^ thewnrk fm which this penntt is isxueA lSa.309],Civ.CJ
� V tender's Nano TOTAL:
Lender's Address TOTAL:
y I certify that I have rear(this application and state that the mto a innot
fominn is BUILDING FEE
rA correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,�77. building construction.and hereby authorize representatives of this city to enter upon the SEISMIC IF
abovo-menlianed property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilldes.judgmenls.costs and expenses which any in any way roans against said City ALTER OR ADD IU MECH. PLUMBING FEE
in ,sequence of the gmndng of this pe
APPLICANT UN STANIS ANI)I IMPLY WITH AL4NPOMT ATR HANDLING ON]'I(SO 10,000C17M) MECHANICAL FEE
S ' CEREGULA t S.
AIR HANDLING ONIT(OVER I0,000CFM) CONSTRUCTION TAX
.'gnawre of Applican omono EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA HT 5 MATERIALS DISCLOSURE
Will Ncapplicant orf buildingoceupanlamemharrdlehaaardemeradrial HHATINGUNI'PT01W.000TU)
us defined by the Cupertino Municipal Code,CMp¢r 9.12,and the Health and Safety
Code Seokm 25532(a)'I HEAPING UNIT LOVER 103,00 BTU)
❑Yea ❑No PAID
VI!NTILATIONFAN(SINGLE NP_SID) Dam Receipt#
Will the applicant or future Wilding occupant use equipment or devices which BOILER—COMP USHP OR IU(I,OINI BTU)
emit hmar&us air cmnllormanls as declined by the Buy Arco At,Quality Management 1.:
District?
❑Yes E]No ROILER—COMP(OVER 110,(11(1 BTU)
I have reaus d the haeurdnreatimds requirement,under Chapter 6.95 ohne Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 255M.I understand that if the NEW RISIDENT[Al.MUCH. SQETT.
building dice,not currently have a roma.thea it is my responsibility m inu fy the acupunl
of the requirements which moa be met prior m issuance ol'a Cenilicme.1 Occupancy.
Owner or vmhonecd agent [)are
TOTAL ISSUED BY:
OFFICE