S 1594 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
"Cl TY OF CUPERTINO BUILDING-ELECTRICAL PEtITNO. 1594
BUILDING DIVISION ' APPLICATION/PERNUT PLUMBING-MECHANICAL `V
BUILDING PROJECT IDENTIFICATION
B UIhIIINO AIIIlRESS: SANITARY NO. TAPPLICA1ION SUBMITTAL DATE
OWN 'NAMIi: / PHONE: 2 CONTRA C OR AME: LIC NO'.
ls'^// CN NIC CONTROL#
IHITECTIENG I N Eli, LIC NO: ADDRESS ❑
CONTACT. PHONE: 6UILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG BLEU PLUMB MUCH
LICE fiD CON'1'RAC'TOR:S DECLARATION QTV. ' ELECTRIC PERMIT FEE
1 here antro,mat 1 tam heemwl add,provisions or Chapter 9(connnenmag H DESCRIPTION
WOz with Scotion o00)ofDlvision3ofthebusinessand Profession.Gade,andnayllnenso is RESIDENTIAL,
W 00 PERMIT ISSUANCE;
F�W uF in fill force and effects �,rC / ❑SPDWL El KITCHEN REMODEL.
aUVW License Cf f��/� Lie# APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RIi-PIPE.
yC Data ^ Contractor
k.SN> ARCIIITHCI"S DF.CLAIAION PANELS ❑MULTI-0NI'F ❑STRUCTURAL
z O c,z I tmdem'and my plmrs shall he used a,public red+nd, MODIFICATION
p UP 00200 AMPS
„,,- Licensed Profassianvl ❑INFERIOR [I CHIMNEY REPAIR
d, at 201-IOOOAMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER UE Ce Contractor's
OVER Into AMPS ❑RATH REMODEUREPAIR El DEMOLITION
4'CC11 I heroby uffrm that 1 urn exempt from the Conlnmlar's License Law ror the
O d U following person.(Section 9(1315.Bleiness and Professions Code Any city or a., ly SIGNS EI.HC'I'RICA]. �OTHER
3 W F which requires a permit to construct.alter,improve,dunoll,h,or repair any.almmnre
prior to its 1 xsuance,also rcqui res the applicant forvuch perntitm files si6ned natentum SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W p� (emmnancinp with Section 9001)of Division 3 of the Businesstmd Prorecions Code)or TEMP.METER OR POLE(NST. A
that be ix exempt Ihuermn,end If,bels f the alleged exentpfion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC W Sudan 91131.5 by any applicant fnna permil subject,the applinal lu u civil penulty of POWER DEVICES
W^vi ❑IMPROV' ❑FOOD SERVICE
ten mom wthan live hunfficd y,dollars(55110).
F-'�q ❑ Lothe worroRhepmpoaduc myereadeswithwng Freddiei(So.u,mpenrihao, SWIMMING P 'LECTRIC IMPROVEMENT
will do the work,andthe viaduct not intended oroffcrcd Freddie(Su.9144,Business ❑OTHI?R
WM and Professions Code:The Convector's Incense Law does not apply to an owner it �.. OUTIUT. S CH .-FIXTURE.
property who builds or improves thereon,and who does such work himself or through
his own employers,provided Ian such improvements are not intended or olTerad for NEW RES Ah ELECT SQ FT.
sale.It,however,the building or Improvement i s sold wi thin one year or umtplulion,the 11 FLOOR AREA SBQ.FT.
owner-builder will have burden of proving that he did not build orinaprove[orput, A ►1
pose f.al r TOTAL: 6/
❑ 'Iof the p Pentanexclusively contracting ith 'licensed t t to �p�/
constructl project(S 90448 dProfessions CJ ',)TooContractors Li-
cause
' ""��
c s 1 d t pplyt n w fproperty h builds p thereon,and QTY. PLUMBING P IT FEE AIR
who ¢acts 6renchp J mwlhdamv hus)lcensed pu nt m the Gmtmmrs IIVVU
License Law. PERMIT ISSUANCE
❑ lam esemFtmader See. ,B&P C for thi,reasnn Y�f' (.11rC'h 111
Data Own
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Owner
WORKER'S COM PHNSATION DECLARATION HACK FLOW PRO'I'ECI(DEVICE
e I hereby offinn under penalty of perjury one of the following declarations
_
I huveamd will inaintaln aCertificamofCmrmnt to sell trate far Workers Cmnpan- DRAINS-FLOOR,ROOF,AREA,CONI(.
ns providedrorbySection 3]00of the Labor Coda,for no pefureence of the STORIES TYPE CONSTRUCTION
wotrk ror which this pumit ix is,uwl. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compression Insurance,its required by Section
3700 or Lubar Code,l'it dao performance of the work far which lids permit is torch GAS-EA.SYSTEM-I INC.40U'1'LI I'S OCC CROUP APN
My Worker's Catep,p,�tion nxuranceutriera"IPnlieyn `rare,
Coppice -CSP% s �— Polioy Na: 3,2=
' .. } GAS-P.A.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM (IRK(Rti'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
('Phis section need not be complr4wl if the puntit is for one hundred dollars($100) - - ,BUILDING DIVISION FIVE.
or las) GREASE TRAP PLANCHECK PEE
(certifythatin@cperrormanwoflhe work ror which Inspector is issued,l,hell SEWER-SANITARY-STORM EA.20B FT.
not eanpley any person in any manner sops;to become subject to the Workers'Chiral ENERGY FEE
Z cation Lawsof Califomia.Data WA'T'ER I IBATEIt WHEN fII!LECTR
7OO Applicant I GRADING FEE
q h NOTICE TO APPLICANT.If,after taking this Cell of Exen trona,you should WATER SYSTEMITREATING
hewnnanubjeel to the Worker's Gampen allon pare visinnv.1 do Lahr Code,you must SOILS FEE
W forthwith comply with such provision,or this permit shell be deemed revoked. WATER SERVICE
Q
CONSTRUCTION GAGENCY NEW RESNENTIALI'LMB. SQ.PT. PAID
I hereby anion that there is nconxbvetion lion lularding vgcncy for performance of Dille aipt#
U
r the work for Which mi,perm(i,issued(Sec.3097.Civ.Cf
O U Lender's Name TOTAL:
W Lender,Address 10TAL:
1 certify that 1 have mod this application and shim that the above information is BUILDING
�ih career.l agree mcomp1,with al1any and rnuntynnlinances and sure laws rotating to QTYMECHANICAL PERM IT FEF.
U ,Z building construction,and hereby authorize representatives of this city to enterupon the SEISMIC E
abeve-mentloned property fill olfaction purfn,ee. PERMIT ISSUANCE
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Ifdhli,i,,.pdgmantx,nosls and avlahsoe wlichnay,in any wpyrurne aenintarid City ALTER OR ADD TO SUCH.
consequence of the gnodar,of this permit. PLUMBING FEE
APPLICANT UNDERSTAN DS AND WI LL COMPLY WITH A I.L NON-POI N' AI R HAN DLING UNIT(TO 10,000 CPM) MECHANICAL FEE
SOURCE.REGULATIONS
AIR I IANDIJNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatureof ApplicanUCcnuocmr Data EXHAUST]1001)(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ucupant store or handle hazardous material I(EATING UNIT('TO 100,1100 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the I lculth and Safety
Code Search 25532(,)9 HEATING UNIT(OVER 100,000 BTU)
E:IFe E]No VENTILATION FAN(SINGLE RESID) PAID
Irate Receipt#
Will ided,appontaimnde t,.,delding btheB uso Ae.Air Quality or Mices ragatint BOILER-COMP(.iHP OR 100,000 BTU)
n hazardous sir aimmninantn as def ted by the&ry Aren Air Quality Mnwgemenl TOTAL:
duP
El Yes E]No BOILER-COMP(OVER IIH),000 PTU)
1 have read the hmardous materials requirements under Chapter 6,95 of Be Cull- AIR CONDITIONER ISSUANCE DATE
romla9a h no Safety Code Su�2111,1.1,u�11114 mwnd that it Ne NEWRFSIDHN1'IALMI3CI1. SQ,En.buildi nomurc U Neuoupomd ac •L/
O e nt Date 'TOTAL: ISSU17D BY:
OFFICE