31008 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMTI'NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUI DINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
09`57 t. W 0
O NER'S N PHONE: NTRACI'OR'S NAF A/C aC�OM�RfOI.N�
• CIITECI'IE1 " GLIC NOL ADDR SS: / El
N'1'AC1': PHONE: BUILDING PERMIT INFO
.�` �� _ ❑ Consultant Fees Paid by Applicant(initial) RA G ELryr PLUMB MmU
JL_p•
LICENSED CO RACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
Q C z I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
rano with Sectiun]IXXp of Division 3Uf the Business and Professions Ced,.andmylicenseiePERMIT ISSUANCE RESIDENTIAL:
CggF in full force and iTfberwr
If
❑SFDWL ❑KITCHEN REMODEL
QUU License Clmv .x-a Lic.pAPPLIANCES-RHMDENTIAI. ❑ADDITION ❑PLUMBING RE-PIPE
tiQd Daces—'�--N-y CSDECIr
ARCHITECTS DECIA 10 ❑MULTI-UNIT []STRUCTURAL
oetz Fp r= I redemption my plans shall be used as public words PANELS - MODIFICATION
oz— UP UP To 20d AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Prefcssiotul 20I.1000AMPS IMPROVEMENT
Q
X f-4 OWNER-BUILDER DECLARATION
C -� OVER HXEUAMP. ❑BATH REMODEl/REPAIR ❑DEMOLITION
C C Q 1 masa affirm on I am exempt from the Contractors Crate:
License Law for the
Ileal r}LL F followingmason.a ermit it)
ID3 construct,
Business and improve.
de Professions Col,:Any city or mantra SIGNS ELIiCTRICN, ❑OTHER
H which requires a perm.ix atm,dwi alter improve,deerrair,or mpair any mrucmre
�.u.Qg trine nr id issuance.atm rtyuires the nptlicam for wcM1 pemtit to lilcasigncJ maement SPECIAL CIRCUIT'/MIFC _-�
f } that he is licereed pucwan 1.the provisions of the Contractors hicanse Lw(Chnpter9
Qo (cnimnereingw,in Section 1600)or Division 3 of the auxin.asnnd Profex,mr,Code)or TEMP.M17117R OR 1101.11 INST. h R 1
o, mC that be is excrete therefrom and the basis for the alleged exempnon,Any violation of ❑ 6LUG/AL
ION ❑DEMOLITION
MN Section]031.5 by any applicant for a permitmbetets the applicant tu a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
I,,,z} not more than five hundred dollar(SSary. ROVEMENT
=Q ❑1,a.s owner of the property.or my employees with wage%as their sole compensation. SWIMMING POOL ELECTRIC
will do the work.and the structure is and intended oroffereo for sale(Sec.9f W.Business ❑OTHER
Iw m and Professions Cash,:The Contractor's License law docs our apply m an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves themon,end who does such work himself or through
his own employees,provided that such improvements arc nor intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.If.however the building or improvement is sold within one yea ofcompletion.Ne SQ.FT FLOOR A S/SQ.FT.
wnerbuildcr will have the burden of proving that he did not build or improve for pro-
pose of sale.). O
❑1,as owner of the pmpeny,am exclusively communing with licensed contractors m
construct the project(Sec.]044,Business and Professions Col,:)The Contractor's Li-
cense
(+65
Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conterctor(s)licensed pursuant the Contractor's
Liar..,Law. PERMIT ISSUANCE
❑ Iron excnmt order Sec. .Is&P C or his.,on
ALTER-DRAIN At VENT-WATER(EA) , •^VALUATION
Owner poor
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ` coo
Ihereby affirm under peoAty ofperjury one of the following declamtinto VV
❑I hoveand will nummaina CenificamcdComem,lowlr-inure for Workeh Co.,.- DRAINS-FLOOR,ROOF.AREA.GOND. STORIES 'rYPECONS'IRUCITON
cation,as provided for by Section 3T(N)of the labor Code,for the fermentative of the
k for which this permit is lsmed. FIXTURES-PER TRAP
[ have and will maintain Workers Compensation Insurance.a%required by Section
116/offla,Li�bor Cori for the perfonnuntt ofthe work for which this permit rsisxuM. GAS-EA.S YSTEM.I INC.I OUTLETS t�UP I
Ca Worm yryyyaritVe unme inerr tP.1i19�;WLOA� Oe�BL�i GAS-
EA.SYSTEM-OVER 4(BATpol
AYN
,fC/ERGTIFICAATE OF EXEMPTION FROM WORKERS' GREASFl1NOUSTRL WASTE INTERCEPTOR 'C
COMPENSATION INSURANCE .,BUIL VISION RIES
(This section need not be completed ifthe permit is furan,hundred dollars(5100) GREASE TRAP
or IcssJ PLANCHECK FQy
leerilyshot Inthe perbrrtnance mfthework For which this permit is issucd.l%hall SEWS BY-ST)RM EA.200 FT. 411
not employ any person in any manner m its to become-sahjecun the Workers'Compen- ENERGY FEE
O ,z s:nion Laws of CullLnnia.Date WA'HRHI3A'I'E /VLNT/ELECIR /
z Applicant CRANING FEE 2
NOHCH TO APPLICANT IL after making This Cedilic:uc of Exemption,you should WAT. .TEM/BEATI.NG
h+ ; hecnt
ne subject to the Worwr'.e Compensation provision of the Labor Code,you most SOILS PEE
formwith comply with such provkimns.,,his permit>half be Jeered revoked. WATER SERVICE
gTa
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID Date ReceipeN
L)0I hcrtby affirm mat mete is a construction lending agency for the Pcdomence of
rhe work fur which thispen t d(Sec.309],Civ.C.)
1" Lenders Name r� is ism TOTAL:
Lwal el Address
I certify that 1 have read this application and state that the above information is BUILDING FEE
Tzi emmi l agree to comply with all city and county ordinances aromatic laws miming to QTY MECHANICAL PERMIT FEE /)
U ,z thn
building construction,and hereby auorize reprewentivnm
filik city entor uportme SEISMIC FEE [/
above-mentioned pmpeny for inspection pumosea PERMIT ISSUANCE T
(We)agree m save,indemnify and keep hmmlevs the City of Cupertirm against ELECTRIC FEE
Iiabihties,judgmems,msis and expenses which nay inany way accrue against.said City ALT ER OR ADD TO MF.CH. 1
in ns,yuencenith,grantingofthis permit. PLUMBING FEE l
APPLICANTUNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 11,01X1 CFM)
MECHANICAL FEE
SO D REGULATIONS.
/ AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
allilgmw.rc/Applican/Commctor U e EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building mcupam simmer handle Toward..,material HEATING UNIT TO 10101 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cade.Section 255321a)? HGTING UNIT(OVER 103,000 BTU)
E)Yn [DGp_ PAIN O
VENTILATION PAN(SINGLE RESED) Dam Rcceiptp 1!i
Will the applicant or future building occupant use equipment or devices which
mit hazardous air comamn dIbuefined efined by the Bay Arca Air Quality Ma asmonem BOILER-COMP TRIP OR 100.061 BTU) TOTA
Df°trod BOILER-COME(OVER I00L300 BTU)
❑Ye,
AIR CONDI'PIONIiR
1 have rood the hmanlous mnmriels rcyuimments under Ch:mmr 6.95 of the C. - ISSUANCE NAT'
fact®r Health&Safety Code.Sections 25505,25533 and 25,34.1 understand that If the NEW RESIDENT[AT,MITCH. SQ.Pf.
building class not currently have a terms,that it is my resrya Ihility true"l'thc nc'ary'nt R
nl merit IrnnemawhicIT�t betR'nrt ' aCerifcateo ),cup cy� 11 R
tic
Imriud eget 1 Ie'— � ISSUED BYz)Q: "�
OFFICE