S 1571 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEg IT NO
• "'BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 1571
BUILDING PROJEC`f IDENT'IF'ICATION
BUII.IIINGADDRISS., SANITARY NO, APPLICATION SUBMIT-FAL DATE
OWNI' NAI.IE:
PHONE C - ACf0�:5 NAME:MG NIC CONTR)L#
KCHITEC'IYLNO1NIILW LIC NO: )DRS - ❑
CONt'ACT: PHONE: BUILDING PERMIT INFO
I� �'�A S El Consultant Fees Paid by Applicant(Initial) RL❑DC FLECI' PLUMB ME❑CH
FW
VWkf/!`7 LICENSED CONTRACFOR:S DECLARATION V QTY. ELECTRIC PERMIT / FEE
OZZhence,aflinm mat I;,it,hocti under proviso+,of Claq+mr 9 mnmmencia, 1013 DESCRIPTION
wo, with Section 7gXlloflavism.3ofthe Businessand Professions Code. troy license is RFSIDFNTIAL
F o= in full force and effect. PERMIT ISSUANCE
W� ❑A DWL ❑KITCHEN REMODEL.
I.F.UV License Class Lio.k APPLIANCES-RESIDF.NTIAI. []ADDITION ❑PLUMBING R17 PIPE
NQL Date T'S DELL
ARCI{1TECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
P.D N PANELS
R OO y Z unJecqund my pans shll he n.ctm PunMODIF
TION
ZU'T0201AMP5 DO C1 INTERIOR CHIMNEY REPAIR
F•4 t:W Licelnad Pmfe,,i...I 201.10XIAMPS IMPROVEMENT SWIMMING POOLS
u' ION
C C Q I herehy ufErm tea lam lexempr froUILDERmhthe CoCLARmrac or's Lianne Law for the OVER 1000AMPS C3BATH R13MODE1/REPAIR ❑DEMOLITION
sl1 0.V following rcaon.(Spe ion](DIS,Business and Pmfi ions Code:Any city or roomy SIGNS ELECTRICAL. El OTHER
41'3 W y which require,a permit m......ruc,afar,improve,demolish,or repair any structure
ma
F•Wpoor to its issuance.aim)requires the applicant for such permit to rile a signed comment SPECIAL CIRCUIT/MISC.
"y mat he is licensed pursuant to 11cPm,f,4asof the Contrremrs Lict,me Le.(Chapmr9
G� (commencing With Sattion 7000)(If Division 30 the fm,inessmd Profesvine C...e)or 'PUMP.MET ER OR POLE INS'[ COMMERCIAL;
LE G O mat he is exempt therefrom and the basis for the alleged exemption,Any violation of
xmeG p g a ❑NEW BLDG/ADDITION ❑DEMOLITION
44.• Section L5 by any applicant fnrupermit suhjceulhe applicant toacivil penalty of POWER DEVICES
i... v< []'TENANT El FOOD SERVICE
^zQof mom than rive hundred dollars($SINq.
❑1,¢+nwner..rime pmpeny,nr myempl�yees with wvga ac their sole n+mpcnsatian, SWIh1MING POOL ELECTRIC IMPROVEMENT
' P=.m will Jolhework.ind mr,or cmrc is not imendedorofleted forsale lgeo.7o4QBu.cincss [I OTHER
til3— end l'rol�axi^nuCoJ^fimerovc�ruct1fr^IjamcoLaw dournorofpplYmunowncrnf 3 OUTLETS-SWITCHES-PIXTURNS 3 O
1 m+penY h builds p the d h da hum k hinowl(or throughr S• /
his awn employcea Provided that such improvements am not intended or offered fur NEW RESIDENTIAL ELECTS F
sale.11,however.the huilding or improvement is soft wbhim one year ofa.nplanum,the SO 'R lk A�tpt4 n $/SQ IT.
owner-lamider will have the burden of proving that he did not hold or improve for pun- -�/V ('L/(,,,I
pose of role.),
❑ 1 as owner of the property,am exclusively contracting with licensed contractors 10 1 L
construct the project(See 70x1,Business and Professions Cale:)The Contractors Li-
ave Lawdoes not apply manowmaofpropeny,who huildsor improvesdereon,trod QTY. PLUMBING PERMIT FEE
who contracts lir such projects with a contractor(s)licensed pursuant o the Contravenes
License Ir, PERMIT ISSUANCE
I ant exampumden Sec. ,R k P C Ila this rcawn
AI:fER-DRAIN&VENT-WATER(FA) VALUATION
Dae
WORKER'S COMPENSATION DECLARATION RACK FLAW pRUfliCl'.DEVICE
I hereby affirm tinder penalty of perjury one of the following declarations:
❑I have and will maintain a Cenificam of Consent m self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE C(INSTRUCI'ION
souse,as provided for by Soclino 37(X)of the Labor Cods,for the pert ntmce of the
work for which this permit is issued FIXTURES-PERI'RAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
371O ofmc Lahnr Code,ror the p,rfornnnaeoftlet WorkN. forlar which this l/wrmit is issued. GAS-EA.SYS'1'1?M-I INC.4 OUT LETS OCC.GROUT' AI'N
My WirtlfC� n+TAI
gyi(+� . coriepol Policy dIc 'M GAS-EA.SYSTEM OVER 4(Eq)
J Carrier. /�. IVIJ
GIiRT'II+ICA'IT?OF XIim Folic FROM WORKERS'
COMPENSATION INSURANCE CREAST NNDUSIRL WASTE HO ERCEPIOR
BUILDING DIVISION
(This motion nenl not be completed dam parotin is forone hunJrW dollars(SIM) GREASE TRAP
or less.) PLANCHECK FEE
I,any matin the in.......raeofinewod fm,.bjimff,mthrmm1rr,W. shall SEWER-SANITARY-ST(IRM V.A.2lp f4.
not employ any person in any mannecco as to hcmme.ubjem m the Workers'Co.,.CnENERGY FEE
zz saLaw,of Colifsont,Date WKI'ER 1117AFER WIVEN'UELEC'IR
Qtin..Applicant - GRADING FEE
vy NOTICE TO APPLICANT.IL after making this Cenificale of Exemption,you should WATER SYSTENY RF.AUNG
a ; hec nne mllo ocl to the Worker's Compensation pnrvlslom of the Labor Code,you nmst SOILS FEE
!✓a fonhwincoontply with.such pmviammorthis permit shall he Confused revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLMR. SQ.FT. PAID
U Z thereby affirm that them is a consumption lending agency for me performance of Dmm. Rc<eiptp
V - the work for which this permit is issued(Sce.3(97,Civ.C.)
0 F' Lender's Name TOTAL:
Lender's Address TOTAL:
I certify mat I In..read this appliemmn and stat,tear the above information is BUILDING F'
Ur) correct l agree 1.comply with all city and county ordinances and mme law,relating In Q'I'Y. MECHANICAL.PERMIT FEE
V Z building construction,and hereby authorize mpowepaiivcs of this city to enter upon the SEISMIC F'LE
shovcnmcntinncJ pnspcny for inspcmi^n Puryeses. PERMIT ISSUANCE k+�
(We)state to save,indemnify and keep harmless the City of Cupertino against ELECTRIC 113E r V
liabilities,judgments,co,ta and expenses which inany way accrue against said City AI.TERORADDTOMECH,
in aquence of the gmminWWsit mP/Pe d. PLUMBING FEE
mse
APPLICAN 'kfJERO 1). WILL WILL CUA PLY WI I'It ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL FEE
SOU . EGULATIO
AIR HANDLINGUNITIDVER 10,00"CFM) CONS'I'RUC'OONTAX
Si ILutm yad Ct echv Date EXHAUST HOOD Ovmucf) 1HONfif TIGATION FF.E
I IA]ARDOUS MATERIALS DISCLOSURE
Will the applicum or fuwrt M1uildint uc,upum core nn bundle bazadons mamrlal HEATING UNIT(To 101,010 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'( HEATING UNIT(OVER 100.000 RTID pit 1
p ANS n
❑Yes ❑No VENI'ILA'I'ION IAN(SINGLE RESIII) PA
Dam ReceiptN
Will the epplicam nr fulnre building ucctgwnt use equipment Or UeviCta WhlCh B(CLER-COMP LIHP OR I(N1,INNI BTU) III VI
mit hazwdous air conutntinutns uc defined by the Bay Area Air Quality Management ++' LI r I nIV TOTAL
District?
❑Yes [:1 No BOILER-COMP(OVER 101,000[1 TO)
I have real the harardou.c materials rcquirtmenr.+under Chapter hAIR CONDITIONER95 of me Cali- ISSUANCE DATE
rnmia Ileallh h Safety Cale,Sections 25505,25533 and 25534.I, c,,u I that if the NI?W RESIDENTIAL MECH. SQ.FT.
mildingdoesno eu end,haveaumand,mut itis my resrymeininy to notify theoecupam Z q,' v0
of me requirements which muss be met Her to kmapo,of v CeniOcwe of Oveapancy.
Ownenr authorized agent Date TOTAL: ISSUED BY: ✓ '�
OFFICE
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