S 0715 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-F,LE,TRICAL. PERM]r NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 0 715'
BUILDLNO PROJECT IDEM DILATION
BUILDING ADDRESS: r SANi EASY NO. AF'PLICATIONSUBMITTALD,
OWNER'S NAME: PHONE: C/ON�TRACTOR'S NA ME: LIC NO: f/
2x C S C7V Z 3 N/C CONI11OL k
ARCHITECT GINEER: LIC NO: ESS; El• �o ClvIre( L �a __V, M
CONTACD PHONE: BUILDING PERMIT INFO
x/_,11 `Ak 2� �� n��x �I � ' ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
�OSeH P` •'I ❑ ❑ ❑ A
LICENSED CONTRACTOR',DECLARATION QTY ELECTRIC PERMIT FEE
G m 2 1 hereby alnrn Na l am licensed Bu Ander dd Professions
it]ns Code. v my license is 70F3 DESCRIPTION
01O wilds«reandtion l(1IT Diveisio-n-3 of the Business and Professions Code.and mylimnseis FN ._At
in full forte anJ c� R pl'L�I_ '� PERMIT ISSUANCE RFRID RESIDENTIAL'
�U�j License I Lick J T OSFDWL - ❑KITCHEN REMOOFI
I. Dam Commcmr. APPLIANCES-RE.SIDEN'LIAL []ADDITION ❑PLUMBING RE-PIPIT
p,�>y> ARC ITECCa'. ON PANELS El MULTI-UNIT ❑STRUCTURAL
y O:JJIIIf q I understand my phos shall he used us public records MODIFICATION
UP TO 2W AMPS
Py,F'.,O Lmenxed Rofesaonm ❑INTERIOR El CHIMNEY REPAIR
ee 201.1000AMPS IMPROVEMENT
D+5C 5,4
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
as CC of 6 I hereby elBrm that 1 am exempt from the Commdor'a License Lew far the OVER lOflll AMPS ❑I{ATH RhMOUEI SPAIN 13DEMOLITION
X 3 L U following mason.(S«tion 7031.5.Business and Professions Code:Any city or coutny SIGNS ELECTRICAL OTHER I a
LLu77 O which requires a permit to construct.alter,improve,demolish,or repair any soncture MA./�
pridrm its issuance,also requires the applicant htrwch pconan on l ikasigmedmmctneht
m SPECIAL CINCUIT/MISC.
>. that he is....nx wh
pursuant to the pmvisiom of the Cantmcmrs License law(Chapter 9
W..GC (mmmncingc
itS«tion9W0)nf Division3nfmc Rosiness and Rofcssioa Cedern TEMP.METER OR POLE INST. COMM .RIAL:
tat.{s,m eC that he is exempt thenfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElD1iMOLITION
W m Section 7031.5 by any applicant for o permit subjects the applicant m a civil penalty of POWER DEVICES
nm more lean Eve hundred dollars 55001 TENANT 11
'F'a} ( ) NO !MENT FOODSERVICE
SQQ ❑ 6o the work,the property, remycmntendesw withwagesr ale(See 7(W.Busmen, SWIMMING POOL ELECTRIC
F- will Professions
Craand ft:
ostrConti isnoti Livens Use does of apply
an,Business
6 3$ and Professions Code:The C esi theater.License law doe,not apply s an r t rrcr of 'OUTLETS-SWITCHIS_FIXTURES
his o nY who hails,or vides t a thereon.and who docs such work himself or through
- his own employees,provided that such improvements ore nm intended or nRercJ for NEW RESIDENTIAL IiLECTR SQ Iii'.
sale.If.however,the building or improvement is sold within one year ofeumpletion.the SQ.IT.FLO(IR AREA z'EISQ.FT.
mer-huilder will have the burden g N
en of proving he did not build or improve for pur. rat y
poxeaLsulc.f PAID
C1 1.as owner of the property,am exclusively contracting with licensed cmnanaom to TOTAL:
consumer the project(s«.7014,Business and Professions CodcU The Contmcmrs Li- raSa�
cense Use does not apply m an owner ofpropeny who builds or improves thereon. QTY. PLUMBING PERMIT FEE 'Qitl[t}1 a IYY4cj)
who contracts for such projects with a comm unist licensed pursuant to the Contractor's lJ(�tr�.1Ij��
Lica m Law.
❑ Inmexempt under Sec. ,N&PC for this reason PERMIT ISSUANCE
y Ur Vk7MEll11'/
ALTER-DRAIN&VENT-WAl'ER HTA)
Owner Data VALUATION
WORKER'S COMPENSATION DECLARATION
\ - BACK FLOW PROTECT.DEVICE
1 hereby uffnm under penalty of pe Jury one of the following declarations:
❑Iheve and wilt mainmine Certificate of Cunsrntmself-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as Provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE.CONSTRUCt10
work far which this permit is issued._ , FIXTURES-PERTRAP
❑ I have and will crainmin Worker's Compensation Insurance,ox required by Section '
37Ml drabs Labor Code,for the Fermentative ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLEfS
My Worker's Compensation Tasmania,coria and Policy namberare: OCC.GROUP APN
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNUUSTRL WASTE INTERCEPTOR
1'ITis section need not becomplemd irthe Peyer is torrent hundred dollars(Slip) BUILDING DIVISION FEES
or less.) GREASE TNAI' PLANCHECK FEE
Loy any Natinthe perforanynetror;lotheworkfmwhich Wispermmkesoeglshdl SEWER-SANITARY-STORM EA.200 FT.
rat employ my person in any manners s nr M1ec b' a Werkeci Congxn- ENERGY FEE
z sauna laws of Califryry99ie Dote � - �mc su
O Applicant r�1 IWATER HEATER WNENT/IiLECTR GRADING FEE
y NOTICE TO APP :IL m •r making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a �'t become xubjectt t Workers Compensation provisions of the labor Cooks.you most SOILS FEE
W forthwith comply wife such Provisions or Nis permit shall be d«meal revoked.
WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY
,Z NEW RFSIDCNTIALI'LMB. SQ.FT. PAID
{)� Ihar by which
iaaeon(waimn lending agency forfee performance of Date Receiptp
w
{gs (~ the ork far this pond is issued(s«.31191.Civ.C.)
Lender's Name
� Iand«'.e Adalat,, TOTAL: TOTAL:
1 certify that 1 have read this application and state that the above information is BUILDING PEE
V) correct i agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE'
U z building construction.and hereby authorize representatives of this city m enter upon the SEISMIC LEEabove-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)egace to save, and indemnify keep harmless me City of Cupertino against ELECTRIC FEE
liebilitiesjudgmcnm.costs and expenses which may in any way uccme against said City' ALTER OR ADD TO MECH.
in consequence of the gaming of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON1'I'(TO III."CFM)
SOURC��GULATION.' MECHANICAL FEE
/C'V AIR HANDLING UNIT(OVER 10,0010 CFM)
CONSTRUCIWN TAX
Slgv of ApplicaoJCm for D m EXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building«cupadstmre or handle hazvNous material HEATING UNIT GO 100,010 BTU)
as fated by the Cupendo Municipal Cale,Chapter 9.12,and the Health and Safety -
Crude,Section 25532(a)'t HEATING UNIT(OVER IgNIXK BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID _ [).(a RccalptM
;H)the applicant or furore building occupant use cumpa cat or devices which
•emit hazardous air contaminants as defined by the Bay Aron Air Quality Mawgement' BOILER-COMP(3HP OR 100,00T BTU)
Distinct? TOTAL:
[3 Yes [3No HOILER-COMP(OVER BM.0008TU)
I have mad tiro ha mous muteoals requirements uMe,Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
rami.Health&Safety Code.Sections 25511.5,25533..it 25534.1 understand mat it the NEW RESIDENTIAL MECH. SQ.Fr
building does not currently have a mnam,Watt it is my roxpnnsibility to mmily We« t
cupir
of We rryuiremena which must be met promo issuance ofa Cenifwe of Occupancy.
Owner or aumorized agent Data TOTAL: ISSUED BY:
OFFICE