S 1400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL IrNO 1400
14OO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT1DFNI'IFICAT'ION
BUILDING ADDRESS: jNIC
Y NO. APPLICATION SUBMITTAL DATE
aiav Rd f 1 CA
OWNER'S NAME: , PHONE: CO TRACTOR'S NAMii: LIC NO:
�UA,�� 'e,Q Luyrl�r eSr �� CONTROL
ARCHITECT/F.NGINEER. LIC NO: ADDREwS,`S,: /
ligi
CONTACT: PHONE: BUILDING PERMIT INFO
AUL Kelln/ber9 C4a1) W'_430'0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG- ELECT PEUMB MECII
❑ ❑ X ❑
LICENSED CONTRACTOR'S DECLARATION QTY EI,IiCTRICPERMPr FEE JOB DESCRIPTION
I hereby affirm that I am licensed under pmwision,of Cholaer 9(commencing
O�Z with Section70(sld Divisaw3 ofthe Bovenessand Professions Code.undnry license is .RESIDENTIAL:
40, PERMIT ISSUANCii
F-1O� in full fare,and cllist a ?s3/7� ❑SFEWL ❑KITCHEN REMODEL
UU l.icenu Clay - - Lic.p sICYL �� - APPLIANCES-RESIDENTIAL. El ADDITION [I PLUMBING RE-PIPIT
NQa pate f� � Camra• MULTI-UNIT ❑STRUCTURAL
> PANELS ARCHITECTS DECLARATION MODIFICATION
Z O N Ip I umconard my plans shall he Dad i s public mcoMs
OZ`3Q UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
F��',W Licensed Pmfesionul NII-Ins)AMPS IMPROVEMENT SWIMMING POOLS
9g�; OWNER BUILDER DECLARATION OVER IIMNIAMPS El HAITI REMODEURE-PAIR DEMOLITION
C Q 1 hereby affirm that 1 um exempt from the Conlracmr's License Law fur the
Dx'O y U fallowing reason.(Section 7031.5.Business and Professions Code:Any city err county SIGNS ELECTRICAL ❑OTHER
W 3 LL y which requires u permit m construct,alter,im,nrvu,demolish,or repair any stimarre
Fp a]O¢ prior to its issuance,also requires the applicantfor such penal o rite nsigned statement SPECIAL CIRCUIT/MISC.
2 y that he is licensed pumuannn the Provisions at he Contractor's License Lew(Chapmr 9 COMMERCIAL
�..GO (commencing w ith Section 7000)of Division 3 of the Business and Professions Case)or TEMP.MITER OR MOLE INST.
(hut he is exempt therefrom and the basis formic alleged esemption.Any Alabama of ❑NEW BLDG/ADDITION ❑DEMOLITION
ttXl k,
Section]B3 LS by any vpplicum fora permit subjects the applicant to assail penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
m no(more Wan five hundred dollars($500.
F=6 1,us ownend'(M1e norm em In eev with wa yes as Weir salecom tine, SWIMMING POOH.ELECTRIC tyrHUR EMIiM'
❑ traps y Y P Y 6 ,ensu ❑OTHER
F.. will do the tons C d e The cmm is tors License o w do for of a ply 1.an owner
ss
of
and Professions Cale:The Contractors License Law alma not apply m mm owner of OUT'LETS-SWITCHES-FIXTURES
LL 3^ pmpeny who builds or improves thereon,and who does such work himself or through
his own empleyess,provided that such improvements arc not intended or offered for NEW RESIDENTIAL EL.ECIB SQ IT.
sale.IL hawevecWC M1uilding orimprovemem ix sold within aneyemof comple(lugthe1_9SQ.E7. F LSV.fT
mer-huskier will have the burden allowing that he did nut build or improve fim,ur-
Isown. 24 ANTU
Oso,as owner of the property,em exclusively contracting with littnsed<onvaaun,to TQ4Aii
construct the project(See 70TL Business and Profession Cade:)Iam Contmatnfs Li- /�
c se law does not apply m an owner of property who Oildsor improves theran,and QTY, PLUMBING PERMIT Irl?FL�I CIT'
whocialow,fnrauchpmix(swithaconuuctm(s)licensed pursuant to the Contractor's C'1 t Ur yyr'Llst 115
Lieciae Law. PERMIT ISSUANCE
❑ I am exempt under See.L .R&P C for this reason
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
�- I hereby affirm under penalty of perjury one of We)allowing declarations:
� * ❑Ihave andwillmainminuCeniOcam of ConsemmxelGinsure Gm WorkefvCompen- DRAINS-IT.OnR,ROOF,ARFA.COND. STORIES 'TYPE CONSTRUCTION
ration,as provided for by Serum 37W of the Labor Cade,[or be
perfmary nue of the
wark for which this permit is issuul. FIXTURHS-PER TRAP
I have and will maintain Workers Compenmtion Lnumace,as required by Section
3700of(he Lala,,Code,far the p:rfumenceof We work fmwhich this Permits,issued. GAS-HA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wnrke((sC mpeneation In d1scameramd Policy a GAS-IA.SYSTEM-OVFR4(EA)
yW COr1AMefm LIN, _policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUS'TRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITIS
(Ibis section need not he complied if the pemmil is 6f one hundred dollars($100) G r
err less.) PLANCIIECK IIiP,
I cenifybet in We Performance of We walk far which this ,,air is issued.(shall SEWER-S II'ARY-STORMEA.200FT.
am employ any Pc.,.in uny manner m ns m trtcome subject m the Workers ComPen- ENERGY FEE
CeZ variant Laws al California.Dole W ,R HEATER WNENDBLECTR GRADING FEE
) Applicant
NOTICE In APPLICANT:If,after making miv Cenilicute of Exemption,your should WATER SYSTEM/IRHVHNG SOILS ITR,
1-�
become mbjcm 10(he Worker,Compensation provisions of the Lahr Calc,you must
Rat i forthwith comply with such provivinn.nnhis permit diedbe Jared rcvnkcd. WATER SERVICE
+ Q
a CONSTRUCTION LENDING AGENCY NIiW RF.SIDEN'I'IAI.PLMH. SQ.PI'. PAID pate Raeip(p
UQIhemtry a".that(hereia a consom,homlendingagency lnrlhe fcrfammnee of
the wark for which do,permit ,issued(Ser 9(19].Civ.CJ
Lender's Name TOTAL:
U Lender',Addmsv TOTAL: -
Iy�r W I certify that I have read this application and state that the above information is BUILDING THE
i.Iy mnec(.I agrcemeomply with all city and cnun(y oNinances and slam laws rehtingm QTY. MECHANICAL PERMIT FEE SEISMIC FEE
L) Z building conaretiogond hcHbyuu(horiucmpoesntatives ofliiseity memterupmn the
shave-mentioned property for inspection pmpnes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,casts and expenses which may in any way zccme against said City ALTER OR ADUTO MECIL PLUMBING FEE
in mecgaemce of the 6rummil of this penal.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 I0,(KM CFM) MECHANICAL ITR
SOURCE REGULATIONS. -
_ AIR HANDLING UNIT(OVER 10.000 CFM) CONS'rRUCI'[ON TAX
Sig etreof Applicam/Cm actor Doc EXHAUST HOOD OVIDUCT) HOUSING MIT IGA'IION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dmapplicunt or future building oecupmno am handle hxnedousmmcnid HEATING UNIT(TO I0I,000 BTU)
as dcfmd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,05)BTU)
Code.Sanaa 25532(0)'
,DY°s �No VENTILATION["AN(SINGLE RES ID7 ,Alp
1)we xecapt a
s Will the applicant or future building occupant use equlpnmm or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazarrous air contaminants as defind by We Bay Arca Air Quality Management TOTAL:
Dlstrut9 BOILER-COMP(OVER I0LW 1 BTU)
C]Yea ❑No
I huve read the hazardous materials ncreiremenn underChapter 6.95 of W,Cali- AIR CONDITIONER ISSUANCE DATE
fame,Health&Safety Code,Seamier,25505,25533 and 255311 undemwnd that if the NEW RESIDENTIAL MECII. SQ.F-r
building does not currently have a tenon)that i1 is my resp reN it,to notify the beeupmt
of the requirements which most he me(prior to issuance of Certificate of Occupancy.
Osoermmidenized agent pate TOTAL ISSUED BY:
OFFICE