S 1854 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO.
CITY
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL kJ 1854
BUILUING PROJECT IIIF.NTiF'ICA'f10N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'VIAL DATE
Z C �
�Z _ l_ 23
OWNER'S N M : Ii: COO 'S AMF LIC NO
d 9 4
`I NIC CONTROLp
• ARCHITECT/ENGINEER: LIC NO ADD D / ❑
CONTACT PHONE: BUILDING PERMITINFO
P ❑ Consultant Flat Paid by Applicant(Initial) BLDG ELECT /'LU MECIi
� /
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRI ION IGY
I hereby aflirm that]'am licensed under Imnvisi my of Chapmr 9(commencing
O8Z with SeClloa](.YIh.Lpinvision 3ofthe BusinessanJ Pndessinns Cale,and my license is RESIDENTIAL,
ulOp PfiRMIT ISSUANCE
mlull force unit uR ❑SFDWL ❑KITCHEN REMODEL
aUV License Class �� Licp �4 APPLIANCES—RFSIDENTIAI, ❑ADDITION []PLUMBING RE-PIPE
FZZLLI Dale Conuunor
Vide, ❑MULTIUNIT ❑STRUCTllRAL
F,Om
ARCHITECTS DECLARA'Uf PANELS MODIFICATION
024—
pZ=^Z I understand my pram shall be,used as public n coNx UP TO 21pAMPS
El INTERIOR ❑CHIMNEY REPAIR
;:4t:W Licensed Professional 101-100AMPS IMPROVEMENT (]SWIMMING POOLS
gg2� OWNER-BUILDER DECLARARON OVER I(NYIAMPS ❑BATH REMODF.1/RE^IR 0DEMOLITION
CC ''� I herehy aflirm thus 1 am exempt from the Courtrai License Luw for the �J
�q�( d U following reason.(Section 7031.5,Bminess imd Profession,Code Any city m entry SIGNS ELILCTRLCAL []OTHER
Y73 q F which requites a proof do armlNmt ulcer,improve,dmnnlish..r repair any l ruCfure
FXN70 pnonnidsissuance,also mquitc he applicant for ouch pennino beton.vignedmaoment SPECIAL CIRCUIT/MISC. ��
pppW� Thur he is licensed purxuunnn the pnrvisiom afthe Cnmmcmr's Licenu law lCbapmr9 COMMERCIAL,
aQpC (commencin6 who Section]100)n[Dlvixion3nfrhe Business and Profensinm Cale)or TEMP.METER OR POLE INST.
q q�q' shat he is carand lhemf ran and the basis for the ii exemption.Any violation of [I NEW BLDG/ADDITION C)DEMOLITION
ItXI ,Wj Section'al by any applicantfor a Permit subjects the applicant o v civil penalty If POWER DEVICES'
rot more than five hundred dollars($300). ❑TENANT FOODSERVICE.
~^ZrIQ I,as ownerufthe n,arm employees with wages their sole Compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
�� ❑ prWe Y Y P Y' ger us Ansa ❑OTHER
will) work,and thenmcmm is orf intended,roffered fnrvale(Sce.](H4,Business
�m and Professions Code:Tic Cor mefnr's License Law does not apply man txvner of OUTLETS—SWITCHES—IIXTUR
pmperty whit hullds nr improves thereon,and who dues such work himself or through
his own employees,provided that such mi,mvemcros meant intended or offered for NEW RESIDENTIAL RLEC4'R T.
sale.If,however,the building or improvement is send within oneyea.or cempletien,the SQ.FT.FLOOR ARBA 5/SQ.FT.
iter-builder will have[lie burden of proving that he did not thin It or improve for Par-
construct
ur-
of sale.).
❑1,m owner of the property,, ennes,im l Cvdle,s ng with j Thu
hcnntraztors m TOT
onse Law
not (Sea]61d,BusinessanJrywho bei GdcO proCommaon, nd
censehewdncsmurh onapply man ith arontrccra whosedprsuant nuc,Contractors t)'1'Y. PLUMBING PERMIT F
who commcu(nr such prajens with a conracmr(s)licensed pursuant m rhe C.monnr's
License Law. PERMIT ISSUANCE
1 an exempt Under Sce. .B&P C lir this Tensa,,
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Owner Ome
., WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herebafli
y rm under penalty of perjury one fine IL hoe"ng dolour ions:
I have and will maintain a Certificate of Coreenno self-;marc for Workds Com Nn- DRAINS-FLOOR,RODE AREA OND. STORIES TYPE CONSTRUCfIOf
radian,as provided for by Section 3700 of the Labor Cole,for the performance of the
k�ar which this pcnaills issued. FIXTURES-PER FRAP
�7 have and will maintain Wnrkc/s Compensation hoo mace,m required by Section
3]OOo/thc laborCade,for the perframanre ofthe work for whichmispermit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.CROUP AI'N
My Wmkf,6��mnlrc� ypn lAytm cyIr IIrand lWicy t nh
Carrier. �I/fI`-1'l� Policy No: GAS-{iA.SYSTEM-OVER4(EA)
CERTIIICATEOFEXEMITION FROM ORKERSGREASNINDUSTRL WASTE IWERCEPOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisweinn need nut he Car,hated if the permit is reform hundred dollars(11000 GREASETRAP
nr less.) 1'LANCHECK IEE
I certify that;.the penformanceor me work forwhich this Permit is issued,Idwil SEWER-SANITARY-STORM EA.200 FT.
n I employ any person in any manners,as to beeome.uajecl tit the W..keW Carmen- ENERGY FEE
Z varied Laws of California.DamWATER HEATER WNIiNT/ELECTR
zQ Applicant GRADING FEC
N NOTICE TO APPLICANT:IL after raking this CeniOcare of Eaemprlon,you should WATER SYSTflNV7REATING SOILS ME
a? became subject to the Worker's Compensation provisions of the Labor Cale,you most
forthwith comply with such prnvisiomar this pcunilsorth be deemed revoked. WATIiR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIIICNTIAI.PLMN. SQ.FT. IPAID Dom eaiPr is
'T1Inrchyvffrm that there censvucdon lending agency for tlie prifan ace of
Othe work for which Otis Permit Is issued(Sec 3097,Civ,C.) O
Q U Lenders Na
W LmTO L
No,.. r TOTAL:
enders Address A
LNG FEE
certify amt I have read this application unit such,that the none informann n is
Fr (0.A correct.1 agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL.PERMIT FEE SE S'WWQFCE
VZ building construction,andhercbyauthpnn
nrlee representatives ofus city loeaterithe .rl
above-inenrioned property for inspection purposes. PERMIT ISSUANCE1� C/t7nv BLLCI'RIC
(We)agree u,save,indemnify and keep harcule"We Cir,of Capetian,agaimt
liabil'nies.judpwris,costs and cNarevs which may many way recructummt said City ALTER OR ADD TO MECU PLUMBING 17EE O
in camequence of the grmling of this permit.
APPLICANT UNDERSTANDS AN D WILL COMPLY WITH ALL NON,POINT AIR HANDU NO UNIT(TO 10,0111 CFM) MECHANICAL PEE d
SOURCE REGULATIONS.
AIR HANDLING UNIT QUIVER 10,00 CFM) CONSTRUCTION TAX
Signature ofApplicauCendmcmr Date EXHAUST GOOD(WIDUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE �F
WJlthe applicamorfmure buddingcecupantsmre,r handle hm...does material HEATING UNIT(TO 1(1(1.010 BTU) !N
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Itenth and Safety
Code,Section 255321.)4 HEATING UND(OVER 100,001 BTU)
C]Yas VENTILATION FAN(SINGLE RISID) PAID pate RecciptM
• Will the applicant or future building occupant use equipment or devices which BOILER-COMP(31{POR 100,f0
emit hazardous air comeminsons as Jerined by the Ray Area Air Quality Management
L:
DishinT BOILER-COMP(OVER J00AOO BTU)
E]Yes 6No
I have madrhe hazardous matered,re,micarnal,under Chapter 6.95 of the Cali AIR CONDII IONER SSUDANCEaDATE
(rondogdoes&SafmyCode,
eaSections 255O5,isn533
myand25534.I .renmM that if the NEW RESIDENTIAL MGCId. SQ.Ff. / Ore
building docs not currently have a tenant that it is my responzihility m notify the occupant VV
of Nercqui nts whichmwthe tprinr In is no,,
ce oft.Certificate of upon . 3
Ownerati hodud,gcnt are, IOTA SSUEU BY: ^ ��
OFFICE