S 1725 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIIIIIAING.ELECTRICAL Prgrr No.
BUILDING DIVISION APPLICATIONQ'ERMIT PING P PROJECT
IDENTICAL v 1725
BUILDING PROJECT IDI!N'fIRICATION'
HUILOING AUDNESE.1053o N Po2TAL AvE R SANITARY NAPPLICATION SDIIMI'FI'AI.UAfE
S-Zq-v�
OWNE•R'SJ1�1r1J. P"yob 4413_0 CONI'RACTOR:S NAMIi: LIC NO:
A UPTA
�p �t�f NIC CONI'H(ILp
••ARCHY!ECT/ENGINEER: PJC NO: ADDRESS: P /
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LJ ❑ ❑ ❑
LICENSED CON'IRAM OR:S DECLARATION QTY, ELECTRIC PERMIT FEE
I hemhy ufhrm that I tun licensed under provisiam of Couple,9(cummenaing JOB DESCRIPTION
�WZ with Sro amNXRof DfOdon Jot lot innacessand Pmm,sior,C,xO �mdmy license is RESIDENTIAL:
cc in full fora unA chem. 1'E MI'I ISSUANCE
m" ❑SFDWL ❑KITCHEN REMODEL
aUU
License Clan Lica ARE ANCP_S-RP_SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
tiQ S Date Contractor
F=y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O�2 r4 I maderswnd my plans shell M-mwd as puhli,m,ords MODIFICATION
oz—, UPT0201 PS ❑INTERIOR El CHIMNEY REPAIR
I,�.H,W Licensed Prdessieml IDI-10MAhII: IMPROVEMENT (]SWIMMING POOPS
OWNER-BUILDER DECLARATION
2:2 _1 IMOAMI. ❑BATH REMODEIIREPAIR ❑DEMOLITION
ad 6 1 hereby affirm that I am exempt from the Contmewn,License Low
for the
e.p a41.V following noon.(Section 71171.5,Business and Professions Gds.Any city or county SIGNS ELECTRICA ❑jtOTHER
OTHER
3 c h which from.,u permit to construct,alter.improve,demolish,or repair any structure 0prior to its isstmace,also requ ires l he applicant for,ach permit m filen signed.smtement SPECIAL CIRCIJ I'1'/MIS(hut he ix liccn,cl,nrsounnot ,....s iomnftheCo..omn , License LaW ly (coinniumngwith Section 7(XXnofDivisi.m 3.Dhe Husint,and Ptom,,liensCcof TEMP.MEfHR OR POLE IN.".a aeY that he is exempt therefrom and the hack far the alleged exemption.Any violation of G/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the upplicant to a civil penalty of POWER DEVICES ❑1'OOD SERVICE
not mote than five hundred dollars(S500). ENT
SWIMMING ROOT,ELECTRIC
will do the work,and di,mmeure is not inteadedo,ofercJ forsale(Ser.7(94,Business
3 and Professions Cote:The Connector's License Law does net apply In nn owner of OUTLETS-SWITCHES-FI XTIHUIS
property who huildx m improves thereon,and who J«s such work him<ell'm through
no,own employees,provided that such improvements are not intended or offered for NEW RESIDF.N'1'IAL ELECT R SQ FT.
sale.If.however,the building or improvement is sold within one year ofcompletion.the SQa-76110OR AREA S/SQ.1T.
ownentruildeT will have me burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1,as owner of the properly,am exclusively contracting with licensed con memm to TOTAL:
instruct the project(Sec.70,14,1{usiness and Professimw Cade:)The Contractor's Li-
mLaw does notapply wmownef at property who builds or improve stoma,and QTY. PLUMBING PERMIT FEE
who cummds for such projects with.commatar(s)Iimrtscd pursuam to the Cantrdcan s
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner suss ALTER=DRAIN RVENT-WATER(EA) VALUATION
WORKER
an&,'SCOM PIiNrjurym DECLARATION BACK FLOW PRO]r DEVICE
I hereby affirm under penalty of perjury oto t)�Ihwself following d orker'tons:
❑Ihavc unitwillfor by
of ConsntnCodihforthe Workers Cnmpen- DRAINS-PL(H)R,ROOF, EA.CORD. STORIES 'I'YI'ECONSTRULTION
cation,as provided for uc Section J7(p of the InMn CnJe,for the perfnmtxnce of the
work for which this permit is iswed, PIXTUNI3-1'EH'TRAP 1
l have and will maintain Worker's Competes Ilion Insurance,as required by Section
the work bar
his
G �A OCC.GROUP
J71N1 alt uht '"d IFICATNli'��INSA MPTIINS FROM W RK RSpermit is iswcd. CHFASPJINDUSTHL WASTE IIMIp.RCEPTOR BUILDING DIVISION ICES ARE
My Wor G t r Insurdneecarrsrnndlidlcy numbernre:
ION
Conies Poli, No.:
:RTIFICATE OF EXEMPTION FROM WORKERS'
('Ihisecctien need not hecon,lned ifthe permit is for one hmadreddollart(SIM) - --- --� —�
GREASL•TRAP
or tete.) PLANCIIE qi
Icenifylhal in the performnnccof theworkfur%ochmispernaI is i,,ucQlahall SEWER-SANITARY-STORM IIA,IIID PP.
not employ any penton in any rammer so as to benmx sabjeet to the Workers'Conifer- ENERGY FEB.
Z cation Laws of California.Dale WATER HEM HH W/VENTNLIiCTR AK
a
Z O Applicam GRAD AKS
in NOTICE TO APPLICANT:If,after making this Cenilirmc of Exemption,you should WATER SYSITNIGREATING NE
SOILS FEE
a , become subject to the W'orkces Compensation provisions of the Labor Code,you must
ar forthwith comply with such provision er this Perini?uhull the deemed revoked. WRIER SERVICE r Uu, Lltt 9a
In PAID
CONSTRUCTION LENDINGAGENCY NEW RESIMENRIAL PLM. SQ IR.
rU ,� Date Receipt N
L) Q k hereby which thithat
permitthem i issued(Seei30 len ding agency for the Performance of
'he work fur which this permit is issued(Sec.J(IY7,Civ.C.)
I.L. I--' Lender's Naare TOTAL
WLendef's Address TOTAL:
a 1 certify that I have rend on,nppliciamn and state That the above infuratmion is BUILDING FEE s:SDU
to correct.I agree to comply with all city tend emery anhaawes and time laws relating to Q'I'Y. MECHANICAL PERMIT PEE
L) z huilding can.umetion,and hereby authorize represemmives of this city memerupm the SEISMIC FEE
above-mentioned property for improm.purposes. PERMIT ISSUANCE
(We)agree Io save,indemnify and pe
keep harmless the City of Cupertino against
IiLLCrRIC FEE
liabilities,judgments,costs and expenses which may in any way accuse against said City g1.TF.R ON AI )TO MECH.
in emmegnu a of the gmming of this permit PLUMBING FEE
APP. A 'I'UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING IT
IIfoon CFM7
SO
a:, )NS MIiCHANICA1,ITli
V AIRHANDLINGUN '(OVERRI.nX)CEM) CONSTRUCTION TAX
Sig a fApplicanuConlmcmr Dm EXHAUST 11001)(W/DU HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding mcupant store or handle hazardous matennl II RATING UNIT(TO IKIMXI NJ)
1)
os defined by the Cupertino Mu..toted Code,CMmmf 9.I2,and the I le:dth and Safety
Code,Section 255320)^. H IzXIING UNI'I'(OVER IMAM 11' )
❑Yes [D No VENTILATION CAN(SINGLE RESIGN PAID _ L'^ 9703
Dam RccemtX
Will the applicant or future building occupant use equipment or devices which miBOILER-COMP(3HP OR IlN1,pN1 BTU)
V et hazarou
ds air conutminsnts m defined bBuy y the BArea Air Quality Management TOTAL: s•-O
Dimrieq
❑Yes ON. BOILER-COME((1VER IINI,(IINI R'I'U)
AIR CON DI'I'ION ER
1 have re:d the hazardous materials tcquim33 an under Cimper flg5 of the Cali- ISSUANCE DATE
fnmi dt '&Safety Code,Senium 8505,8533 mA 15531.1 utdedtatd that if rite NEW RESIDENTIAL MECH. SQ.fT. �}e
It n Jt ,sol currently have a trump.But it is my responsibility to notify the occupant (fes
'oft •qui.nems which mural Motel ptionoissuunce nfn Cenihcmc of cup �a�
Ow n uhnrized agent 1:e ISSUED BYk„TOTAL: / '�[J /QNJJas..(A^,C4
OFFICE