S 0759 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,QRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PING RING CMp IDEANIFIC S 0759
BUILDING PROJECT IUEN'PIF'ICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAO
OWNER;Si AML; P )NE: CONTRACTORS NAME: LIC NO'.
/�1.. NIC CONIItOLX
IMP NCHI FEC('/IENGINEER: LIC NO: ADDRESS'. ❑
FCONTA�. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EILECP PLUMB MECH
LICL'NSED CONTRd underti DECLARATION QTY ELECTRIC PERMIT FEEBmh Nm I um licensed under Provisions of Chapter 9(cnmmencirg JOR DESCRIPTION
ol fee Division 3of[n,Bnim,,and Prmfesstons Code.and my license is PF.RMITISSUANCE RESIDENTIAL1 plaUUt Lica ❑SFDWL ❑KITCHEN REMODEL
v_u Dae Contractor
APPLIANCES-RCSIDEN'I'IAL ❑ADDITION C3 PLUMBING RE-PIPE
,=on ARCHITECTS DECLARATION _J_JMULTI'UNIT ❑STRUCTURAL
Z p H on I undersand nhy plars,hell M used is,public records MODIFICATION
OZ�z UPTO?00AMPS ❑INFERIOR ❑CHIMNEY REPAIR
F1Gw I.iccn,ul Profmsionul - 201-:Pop AMPS IMPROVIEMEN'F 0SWIMMING POOLS
C Q I hereby affmh
OWNEthat R-BUILDER DECsto LARATION
Contractor',Licenu Low for the OVER I000AMPS ❑BATH REMODEUREPAIR EI DEMOLMON
k 3 a U following maum,(Section 7131.5.Business and Professions Code:Any city ter county SIGNS ELLLTRICAI. ❑OTHER
W 0 y which requires a Permit m construct,alter,improve,de a iso,or repair any stmeture
2.1!: prior to els issuance.also requires Ne upplicanl Enoch p;tmit m de SPECIAL CIRCUITIMISC.
Nan he is licensed pumuantta the Provisions of the Contractor.License law(Chapter 9
C (commencing with Section 7000)of Division Sof the Business anU Pcfcssions Co K)... 'IFlat P.M ETER OR POLE I NST. COMMERCIAL:
6 6 o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
x^ Section 7031.5 by any applicant for a permit subjects thca,deant to a civil penalty of POWER DEVICES
i ,more[Iran Five hundred dollars($500). BNANT ❑FOOD SERVICE
MPROVEMENT
Lafte,s, of the Fluorin te,try Maemployees wlNwpgnsas their sole compensation. SWIMMING POOL Il
will Professions
Colleand 's a Controar s license
Law peddo for of apply to an Business O'I'I11!R
a 3 m property whio b Codc;The over demr's licence law dors not apply m an t through of Olfl'LE-f5-5WITClICS-IIXTURES
his o
property who builds or improver thereon,and who dors men tints himself or through
his own employees,pmvh4J That such
armoraprovc old ware not intended of oleic,Iia NEN'RESIDENTIAL.ELEGTR SQ IT.
alee,lohowever the
veth hndep rI pemem)that heltninoneycarrfcprost,ion.the SQ,1-7.Fl.(R)R ARCA $ISQ.14.
eofsale).will neve the harden ter proving that hedid not nulla or improve ter ,Pur-
0 1 astatine,ale.). T
❑ 1, eof'he See.70y,.Bexclusively cmlle%sem,won:)Topedmmrnsesi- TOIAh; Q�y _CEIVE
ZV
smwcn Ne pnOswn(sec.](1 W.Baseness and Professions G.1e:)Top commmors Li- 1\L
nal.ow Jncz nm apply lm pn owner of propcny who milds or impmves thcrmn,pod QTY. PLUMBING PERMIT FEE
whocontraets f�rtech projects with ucontractors)licensed pursuant to the Contractor's DECI 1 p (�
License law. PERM I'1'ISSUANCE! EC 8 1997
❑l am exempt tinder Sec. ,B&P C for this reason
ALTER-DRAIN&VENFT-WATER(EAI VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEBY,
1 hereby affirm under Penalty of perjury one of the following Jcdmalinns:
'b I have and will maintain a Certificate of Consent nh self-insure l'or's tkers Comps., DRAINS-FLOOR.ROOF AREA,COND.
anion,as provided for by Section 37W of the labs Cade,for the performance of the STORIES TYPE CONSTRUCDO;
work for which this permit is ismer, FIXTURES-PER TRAP
❑1 have and will maintain Workers Compemation Insurance,as requited by Section
37g)of the labs Cede for the performance ofthe work for which this permit is issued GAS-IEA.SYSTEM-I INC.a OOfLETS OCC.GROUP Al'N
My Worker's Cnmpensminn Insurance aria[and Policy numher an:
Carrier: Policy No.: GAS-PA.SYSTLM-OVER i MAO
CERTIFICAIH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREA DINDUSTRI.WASTE INTERCEPTOR
(This section recd ern he completed Him Permit is firma,hundred dollars SEXU BUILDING DIVISION FEES
less.) GREASE TRAP PLANCHECK IE
I certify Nm in Ne performance ofnhe work for which Nis permit is is.mN,Iphull rsSI!WF,R-SANFARV-S'fORM EA.2IXIIT
not employ any paoo e subject n in any manner so as, hecomsuhjeco the Workers'Coroner- ENERGY FEE
� Z smion laws of Coifamia.Date WATER HEAFFR W/VENT/ELECI'N Wy
Z O Applicant GRADING FEE
NOPICH TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM"TREATING
a, necom,subject to NI Wnrwe,Compensation provisions of the Latin Coda you mus[ SOILS ILEI°
Iimhavah comply wohach provisions or this Permit shall he deenmilms.ked WATER SERVICE
.a7Z CONSTRUCTION LENDINGend AGENCY NEW RI!SIUENI'IALPLMIi. SQ.FT PAID
VO kfarchhich isthat
Permit i isacntSer.onlendie.agencyfor Ne performance of Dune Receiphp
the d er,for which this pcmtit is iaucd(Sec.9pJ],Cie.CJ
Q V Waders Nurse
Larder',Address TOTAL:
I,cooly that I have read this appliculinn and store that the shove inlormmion is BUILDING FEIi
tail correct.I agree to comply with all tiny and county oninances and spite laws relating to QTY. MECHANICAL PERMIT FEE
V Z building constmc[ion.nnr hereby authorize representatives mfthls city m enter upon Ne SEISMIC FEE
mane-mentioned property for inspection purposes. 11IERMIT ISSUANCE
(We)agree a save,indemnify and keep harmless the City of Cupertino against ELEC,'R IC FEE
Iiahil ities,judgments,c..sts and expenws which may in any wayment,agui......dCity ALTER OR ADD TO MECH.
in ,sequence of the gmming of this permit. PLUMBING FETE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO IOLIXX)CFM)
SOURCE EGU 4P MECHANICAL FEES
AaI OaI AIR HANDLING ON]'1'(OVER 10,0X0 CPM) CONSTRUCTION TAX
Signa IFApTmNcommmor Date—` EXHAUST HOOD(W/DUCTI HOUSING MITIGATION FEE
HALARM)US MATERIALS DISCLOSURE
Will the applicam or future building occupant stem or handle hrwaddi material HEATING UNIT(TO 100,0(10 BTU)
as derma,M1y the Cupertino Municipal Code.Chapter 9.12,and the Health and sale,y
Cade,Section 25532(.)! HEATING UNIT(OVER 1 00.000 BI U)
❑Yes ON. PAID
V ENTII.ATION FAN(SINGLE RFSID) -
Will the applicant or future Wilding occupant use ocimpmcm or devices which Uma Receipt a
mi,hasanmus air con r rico,as du6ned I, he Bay Are.Air QmI,Iy Management BOILER-COMP 13HV OR H0,0XN1 RU)
'District's TOTAL.:
0Yes 71No BOILER-COMP(OVER I WJIW BTU)
I have real the hmatdoas mmerial.s requirement under Chester 6.95 of the Cali- AIR CONDITIONER
P ISSUANCE DATE
forma Elcahh&Safety Chile.Sadism 15505.25533 smyr responsibility
25534.110 aetsmnd Nm nine NEW RF_SIDEIPI'IAL METH. SQ.Ff.
hudthe aspropoll
of
o whichrrently....be
pi it is myyse I it iblltytonotifyccupancy.
ter m,regairen,Tts Toren man be met prior to L muga of a cenmemo mf oTavmwy.
Owner or.mhoriroJ agent Date TOTAL: ISSUED Y.
OFFICE