S 0624 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION- APPLICATION/PERMIT PLUMBING:MECHANICAL S 0624
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: SANI'I'ARYNO. APPLICATION SUBMITTAL DATE
9;2 L l 8eke'i C7-. .�. 7
OWNER'S NAM PHONE:. CON/IPCTOR'S NAME: .LIC NO:
I� V O L UUe� SOI CONTROL#
ARCHITECTMISGINEER: I ADDRESS:
as39Y�F
5Y0AfArAewii&ke s
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B D ELECT PL M MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE A [:]
� ❑
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Woo with Sectinn EXXpmf Division 3of1he Business and Professions Ccde,and my license is RESIDENTIAL
F C in full force and effect. PERMIT'ISSUANCE
II - - ❑SCOWL D KITCHEN REMODEL
Uz License C Lia#
an 'Date TSDEmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I„❑y ARCHITECT'S DECLARATION _ D MULTIUNIT D STRUCTURAL
z p PJ z I understand my plans shall be used as public records PANELS
a Pu MODIFICATION
O'Z UP T02(N1AMP5
0.' � Lsensed Profwsnonnl El INTERIOR OCHIMNEY
MING POOL
..1
OWNER-BUILDER DECLARATION 201-I WBAMPS IMPROVEMENT E]SWIMMING POOLS
I hereby a1Tam that I am exempt from the Contractor's License Law for the OVER 100 AMPS D BATH REMODEUREPAI D DEMOLITION
p(3 0.F following reason(Section 7(131.5,Business and Professions Code:An it r count D OTHER
WW 0. y city n y SIGNS ELECTRICAL
F O which requires a permit le fanatrmet,alter,improve,demolish,or repair any Nmeture
% prinrtait,issuaars.alsnrequocxdeappltcant foreuch permtuo filen signedstatemem SPECIAL CIRCUIT/MISC.
y�y that he is licensed pursuanttothe provisions efthe Contractor's License law(Chapter9
W GC (commencing with Section 7000)of Division 3ofthe Bueinessind Professions Code)., TEMP METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
W-^,ry Section 70315 by any applicant for a permit subjects the applicant m a civil ONEWBLDG/ADDITION [I DEMOLITION
z not more than five hundred dollars($50T, ) p penalty of POWER DEVICES El TENANT . DFOOD SERVICE.
QFQC ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT.
y0.� will do the work,and thestructure is not imendelmotiered for sale(Sec.7044,Business DOTHER
LL13 and Professions Code:The Cmmrecter's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
CC44 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are tat intended or offered for - NEW RESIDENTIAL ELECTR Ns
sale.If,however.the building or improvement is sold within one year ofcompletion.the - .Q.FT. it, AIEA S/SQ.FT.
asner-builder will have the burden of proving that he did not build or improve torpor-
,we
orpar-p salon).
❑ 1,as
I,as owner of the property,am exclusively contracting with licensed contractors i- TOTALemisc :
cern, a the project(See.90004,owner
Business and ry who
ds or
The ves throam, Li- �
c Law does not apply Wan owner of prnpeny who builds nr improves Neremn,and QTY. PLUMBING PERMIT FEE IJp
who contracts for such projeed with a commcmgs)licensed pursuant to the CommcnsAs (aGNt,('
License Law, PERMIT ISSUANCE C,l
❑I am exempt under Sec. B&P C for this reason T/Abi
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION 'BACK FLOW PROTECT.DEVICE
I hereby affirm-tide,penalty of perjury one of the following declarations:
D lhave and will maintain a Certificate of Consent o self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
D I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance M the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
y Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy Na: GAS-EA.SYSTENUOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEBS
(This section acral he completed ifthe permit is forone hundred dollars T$100) GREASETRAP
or IessJ PLANCHECK FEE
Icertify that in the performance ofthe work forwhich this permit is issued,Lshad SEWER-SANITARY-STORM EA.2(X1 FT.
not employ any person in any manner xo as to become subjects the Workers'Camper- ENERGY FEE
Z
smian laws of C is.Date -
O WATER HEATER WNF.NT/ELGCTR
Applicant ��(YI�� Npfj GRADING FEE
NOTICETO AP LICANT�f after Compensation
mCertinsof of Exemption,you should WATER SYSTEMITREATING
F become subject m the Worker's visions or his provisions b the Labor Code,you must SOILS FEE
forthwith comply with such provisions or permit shall be deemedrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V 0 k for
roe thauhere issued(See.30 len ding agency fur the performance-f Dm carps# .
V. �-+ the work for which this permit Is issued(Sec.3099,Cie C.)
0 V Lender's Name TOTAL:
Lkl Lender's Address TOTAL:
is
1s 1 certify that I have read this application and state that the above information's BUILDING 1 rE CU /sk
V) correct.1 agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U building consauction,and hereby authorize representatives ofthis city to enter uponthe I I SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hataless the City of Cupertino against PERMIT ISSUANCE ELECTRIC F
liabilities,judgments,costs and expenses which may in any way accrue againstamil City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING LEE
APPLICANT UNDERSTANDS ANO WILL COMP WITH ALL NON-POINT AIR HANDLING UNIT GO l0,01R)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
91W It 7 AIR HANDLING UNIT(OVER IgOX)CFM) CONSTRUCUON'I'AX
Signatur<of Applic UConBaxter Date EXHAUST HOOD OMMUCT) HOUSING MITIGATION PGG
HAZARDOUS MATERIALS DISCLOSURE
Will no applicant or future building occupant store or handle hazanlous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 - - HEATING UNIT(OVER 100,0X)BTU)
❑Yes ON. VENTILATION FAN(SINGLE REMD) PAID
DaeWill Receipt#
andthe applicant or future definedfirry,occupantuse equipmentordeviceswhich BOILER-COMP UHP OR 100,001 BTU).
mitict,i us air contaminants as defined by the Bay Arca Air Quality Management TOTAL'
DiurieB
.DYrs -
ON. BOILER-COMP(OVER IIIq(NN)BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT.
building does not currently have tenant,that it is my responsibility to notify the occupant
of tine rw{uiremeats which most be met poor to issuance of a Cerlitieate of Occupancy.
Owner or authorized agent Date- TOTAL: ISSUED BY:
OFFICE