S 0163 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL
BUILDING PROJECT IDENTIFICATION S 0163
BUILDING ADDRESS: SANITARY NO. APPLICATI)NSUHMITTALDATE
194/Y w N Aelve CUP6ferl0s) e
OWNER'S NAME: .�[G E I'f10NE: - CONTRACD)R'�w� LIC NO: NIC CO 'ROI.#
Z52
•ARCHITECT/ENCINEF:R: F LIC NO. ADDRI3S: ❑
CONTACT. PHONE. BUILDING I'F:RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) IIW� E iG P.G liC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1���/lh
1 heresy affirm that 1 an licensed ureter provisions of Chapter 9(earn.acin6 JOB DESCRIPTION
pKZ with Sxtion lfXllp of Division3nf the Busimessand Pmfessions Code,and my license is
W O p PERMIT ISSUANCE
Fal in full fnrccind affect. nDWL lH7C[TCHEN REMODEL
�U{�,)' License Class hic.N APPLIANCES-RESIDENTIAL ❑ADDITION UMNIN(1 Rlil'll'li
T-ze W 'ate Codecs
Fps ARCHITECTS UF.CLARATION PANELS ❑MULTFUNIT ❑STRUC'I'URAI.
Z p Z 1 understand my plans shall be used as public records MODIFICATION
�+ UP TO 210 AMPS
pZ�p ❑INTERIOR ❑SWIMMINGP REPAIR
LL
Licensed Pmfessinnal 201-10(NIAMPS ,,,..�IMPROVEMENT SWIMMING POLLS
4 s�,•..I1 OWNER-BUILDER DECLARATION OVER IIX0AMP5 P4ATH REMOUELJREPAIR ODENOTATION
Og p OOyyffii U 1 herchy uflirm Ihot 1 am excmpl tram Iha Comrucinr's Licrnse Law for the
infuser,reason.(Section 9031 5,Raciness and Professions Code:Any city nr anumy SIGNS ELECTRICAL OTHER Air
I-
3 T. which requires a permit to construct,alter,improve,demolish,or repair any structure wI Do(
��p prior to its issuance,also requires the applicant for such Permit to rile v signed sd.ement SPECIAL CIRCUIOMISC.
f!7y that he is licensed Pursuant o the previsions adds,Commadon's License Law(Chapter 9 COMMERCIAL
ad..COQ (commencing with Section 700H of Division l ofdhe Business and Professions Code)or TEMP.METER ORPOLEINST.
Q.ty tY that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
lull 4• Section 7031.5 by any applicant fora Permit subjects the applicant In a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ZZ�'
.,It mora than five hundred dollars(55(0),
F C ❑ IMPROVEMENT
I,as owner of the prapertm
y,or y enlPlnyccs with wages ant
c their sole cn ,emation, SWIMMINGPOOL ELECT RIC
will do the work,and the llaxime is and intended oroffeted forsale(Sec 7044.Business [I OTHER OTHIiR
63�^ and Professions Code The Conlraam's License Law does not apply to as owner of OUTLETS-SWITCHES-FIXTUR
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided Nm such impmvemems me not intended on offered for NEW RESIDENTIAL ELECTR
ash.If.how,ver,the building or improvement is sold within one year a completion,the SQ.FT.FLOOR AREA SISQ.FT.
ownenbuilder will have the burden of proving that he did and build or improve for put
pa. f sale^), p
I,as ow r of the property,am exducively contracting with licensed contractors m TOTAL: #Y
nauuct the Eroject(Sec.7044,Business and Pmfessions GdeB•the Conmu<nsrs Li
se taw does not apply to an owner of property who builds or improves dherman.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cnntmmor(s)licensed pursuant the Contrdcmrx �o ���
License Law. PERMIT ISSUANCE
❑lam ndcr S,c. IFIt ef;:)
,B&PCforIjasx,n
ALTER-DRAIN&VENT-WATHR IFA) f"tf{ll VALUATION
er Ontoar- •(fly,
. WORKER'S CON41TASAfJON DECLARATION BACK FLOW PROTECT.DEVICE
I hereby.]firm under penmty ofperjury one of the following declarations:
[]I have and will maintain riCerificwe at Consedao wf--insure far
Worker's Camped- DRAINS-FLOOR.ROOF.AREA.GOND, s STORIES TYPE CONST RUCTION
nation,as provided for by Section 3700 of the Labor Cade,for the performance of the
xmk far a,hiah ads perrad ii issuW. FIXTURE-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M fthe labor Coda;for the performumeofthe work forwhiuh thlx Eemtil is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Workers Cmnpensation Insurance maria and Policy number are:
Carrico Policy No.: GAS-EA.SYSTEM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ORGSFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This s«Iion need and becompleted ifthe Permit is for one hundrMdmllars($I00) GREASETRAP
or IeasJ Pf.ANCTIECK FEE
I certify that in the pedanmanceof theworkforwhich this permit is issued,I shall SEWER-SANITARY-STORM 1A.200 FT. ENERGY FEE
nod employ any pesos in any manner soy ,�j{n�subjecnalheWnrkers'Cnmpen-
0 ,� swiim L. of 'fornia.Date P 99 J/ WATER HEXI'ER W/VENT/ELECfR GRADING FEE
GNOTICE TO APPLICANT.IL after mak. thisCeriEcam of Excmptinn,you should WATER SYSTENITREATING SOBS FEE
a; become subject m the Workers Com,ensmion provisions of the labor Code,you most
41I .-� forthwith comply with such provisions mun,permit shall be deaned rev.ked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET. PAID
I hereby affirm that them is a amstmction lending agency for the Performance of Date Receipt#
U 0 the work for which this permit is issued(Sec.9007,Civ.C.)
Q U Lenders Nan. TOTAL:
�.t WLenders Address IOTA[,:
y 1 certify dh.1 have read this applie.inn a d state that the above inon formatiis BUILDING FEE
Fy coca.l agree to comply with all city and county nNlnames and rate rows mining. QTY. MECHANICAL PERMIT FEE
U building construction,and hereby aulhoriu representatives nflhis city to enter upon the SEISMIC FEE
serve-mannered noway for inspection pugnscs. PERMIT'ISSUANCC•
(We)agree ,I save,indemnify and keep branded;the City of Cupertino against ELECTRIC FEE
Iinbilities,judgnlvnts,costs and expenses which may in any way asecme against said City ALT ER OR ADD TO MECH.
PLUMDING FEE
NPLIC NT Nthegranting Sthis permit.
APPLICANTULATIO UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO IBgX)CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.10(1 CFM) CONSTRUCTION TAX
Signature a J'ApplicanVCmaractor Date EXHAUST HOOD DVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous mumriul HEATING UNIT(TO'00,000 BTU)
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Seaton 25532(x)^
HEATING UNIT(OVER 100,000 B'TU)E]Yes Vivo VENTILA TION PAN(SINGLE REMITPAID pee Receipt
Will the applicant or future building oecupall use equipment or dwices which BOILER-COMP OHP OR 100,0010 BTU)
,mil hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District? �./ BOILER-COME(OVER 1110,1110,0100XI H'I'U)
El yea p#No
(have maJ the hvxardous materials rtyuiremems amen Chapter M1.95 of We C.li- AIR CONDITIONER ISSUANCE DATE
Radia Health&Safety Code.Sections 8505,ISS33 and 8594.1 understand that if the NEW RESIDENTIAL MACH. SQ.ET.
building dress.enrnemly Mve also Ihxlilis my responsibility to smify fiececupam
of the menu whic t mel, iamisauanceofe Ccrtificateo cup cy.
Ow r rumharizeJ ngen n etc TOTAL: ISSUED BY:
OFFICE