S 1214 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH DING-ELECTRICAL - PF. NO
ILDING DIVISION APPLICATION/PERMIT PLUb1111NG-MECHANICAL '�IT � 1214
li BUILDING PROJE.Cf IDENTIF'IC'ATION
B ILOING ADDRESS /nSANITARY NO. APPLICATIONSUBMITTALDATE
/.Lr4 ud1+ fl
( NEB's NAME: I'HGNI4. CONTRACTOMS NAMF: LIC NO:
JANyct �.Gw)l.x, 1sr-SYY3 Co�I 3t/3
ARCHITECINIC corrl'ROLu
IIIkENGINEER: LIC NO: ADDRESS: yl/ ❑
CONTnCT: AA PHONE /T T - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLI ELECT PLUMB ECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby alarm that I an
licensed ander provisions of Chapter 9(mmmenefng OB DESCRIPTION
�aZ with Secamrlaaffof Division 3 ofihe Business and Professions Cale,and my license is RESIDENTIAL:
W O PERMIT ISSUANCE
awA in full force and effect. ❑SPDWI. El KITCHEN REMODEL
aUU License Class Lic.is APPLIANCES—RESIDENI'IAI. ❑ADDITION El PLUMBING RE-PIPE'
o elQ Dan—Can rancor ❑MULTI-UNIT ❑STRUCTURAL
'O m ARCHITECTS DECLARATION PANELS
v�Zz 1 understand my plans shall he used as public records MODIFICATION
UP TO 210 AMPS .RIOR 11 CHIMNEY REPAIR
I 4t:Q Licensed Professional 201-11108 AMPS MPROVIIDIENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
C —1 OVER I0AMPSP5 ❑ ATH REMODEUREPAIR ❑DEMOLITION
Q 1 hereby liffirm that I am exempt from the Contractors License Law for the
�yy�((O0.U
following reason.(Social 01131 S,Business and Pudesinnx Code:Any city or county SIGNS ELECTRICAL Of11E
LLl3,H which requires a permit m construct,alter,improve,demolish,or¢pair any suacture
FW_,O�
poor to its issuance.also requires the applicant for such peralit to rile a signed statement SPECIAL CIRCUIT'/MISC, s a
�� th.s he is licenser]pursoammthe provisions of lhn Conmamrsl.icemse Low(Chapter9
LIDNIMERCUL
W gaC (commencing with SicIkm OW(Oof Division 3 afthe Business end Professions Code)or TEMP.METER OR PULE INST
that he is exempt therefrom and the basis fm the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W y
Section 7031.5 by any applicant for aperat subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT FOOD SERVICE
tt more than five hundred dollars($500) IMPROVEMENT
❑1.an,owner of the property,army emmployces with wagesasdavoiila compcnsminn. SWIMMING POOL.ELECTRIC
will do the work,and the structure is not intended or offered forsele(See.7 W,Business ❑OTHER
63 m and Professions Cade:The Contractors License law does not apply to an owner of OUTLETS—SWIICOES—FIXTURES • !f Q 10
prolixity who builds or improves thereon,and who does such work himself or through r
his own employee.,provided thin such impfovcments are not intended nr offeredfor NEW RESIDENTIAL ELECTR SQ FT.
aa]e.If,however,the Mildingorimprovement is sold within one yenndntmplctual the SQ.P]'.PLOQRAR16 9Q.PE
"sne"Inadhir will boos the burden of previa,that he did not hail)or improve far par- FEB Y
pose of sale.).
C] 1,as owner of the pntpny,um cadin ivdy contnating with licensed smahme ns,to TOTAL:
construct the project(Set.IlW4.Business and Prnf.mons Gde:)The Contractors la- lb1TY'0F UUrrri LINO
cense law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEF.
who commcts for such projects with a conuanm(s1 licensed purnuanlao the Compactor's
License law. PERMIT ISSUANCE
❑I am exempt under Ss. .R&P C far this rcawn
Date
ALTER—DRAIN&VT:N'1'—WATER(EAI /O VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑Owner Ihaveand will maintain.Cenilicaeof Cnoscnuowlf-insure for Workers Contain- DRAINS—FLUOR.ROOF,AREA,C IND. STORES TYPECONS'fRUCTION
smian,as provided for by Satins 301q of the LaMn CnJc,for LM1e peRnrmunce of the / Yi
work for which tPermit his peit is issued. FIXTURES—PER'I'RAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Labor Code,for the performance of the work for whichmi,permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLFT OCC.GROUP N
Cameer�/ mmlpenyylAlnytrcnce curtie it lint cY
No: yt,M[Lr_:9L_orWE
SYSTEM-OVER4(EA
CERTIFICATF:OP li%IiMP1'ION FROM WORKERS' UUSTI2L WASTE .RCFPTOR
COMPENSATION INSURANCE W BUILDING DIVISION PF.IkS
('Ihissation need nm be nmmpinul if the lemth is fortune hundred Jollnrs(Eton) RAP
or less.) PLANCHRCK PEE
I cenify that in the performance ofthe work for which this permit is issued,I shut] ANITAR —S1TYRMEA.2W FT.
not employ any person in any manner so as m become subject to the Workers'Comlmen- ENERGY FIiE
,Z cation Lows of Cali tori..Dam .ATE NENT/ELECTR
zO Applicant GRADING IELr
y NOTICE TO APPLICANT,It,Mier making this Cenificam If Exemption,you should EMITREATING SOILS ME
(~ hecome,a ov,m,he Workch Compensation pruesion,of the Licar Code,you mast
ai fonhwitb comply with.wch provisions lir this perm.it.1,11 be deemed revoked. RVICE
+ n
CONSTRUCTION LENDING AGENCY DENTIAL PLMB. SQ.Iq'. PAID
U 0 I herebya0inn that there iso construction lcommlitgency auraeparrormanaof a Receipts
the work for which torsla t�('s isucJ(Sec.309],Cie C.)
Of�
he
Name�2-A TOTAL.
Lender's Address T(TTAL:
y 1 cenify that 1 have mad this.pp]Icmmn and note than die.Mee information is BUILDING FEE /
V) confect.l a gree In comply with.[]Oily end county ordinances and...tctins,a]mingm QTY. MECHANICAL PERMIT FEE"HOUSINGM11
L) 2 building construction.and hereby authoriu reprc>enmtives of ibis city menmrupmoho above-mcmioned property fur inaPeNn purposes. MISSUANCENCE EE(We)agree to save,indemnify and keep hmmlcss the City of Cupeninn agninm]iabilities,judgmems,costs and expenses which may in any way accme against said City D TO MECH. 'BEnsequenceoflhegmntingofthis t.APPLICANT UNDF. ANDS,,,,,,���)WILL C PLY WITH ALL NON-I'OIM' G UNIT(To 10,0(111 CFM) L FEEs Rc r n.n o s. �iG UNIT(OVER I0.11(%I CFM) f10N TAXSignature ofApp]ieanUCommmor Doc OD(W/DUC'Y) ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthenpplicantor faare building occupamsmrc or handle hamrdolonmenal IT(TO 100,o(N)RT U)
as]OF cd by the Cupertino Municipal Cade,Chapter 9.12,and the Health anti Safety
Code.Section 25532(a)? - HEATING UNIT(OVER IW,IA)BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
r Dae Receiptp
Wil]the applicant or future building occupant use equipment or devices which BOILER—COMP(311P OR 100,00it emit hueardnus air containment,as defined by the Nay Arca Air Quality ManagementTOTAL
District? BOILER—COMP(OVER 1011,000 BTU)
L]Yes El No
Ibavo road the ;n"Nom tareVl �.iencs umkr Chapter 6.95 o1 the C.li- AIR CONpIT1UNER ISSUAN E
tomia Ileahh&Sof ale,Seco and 25534.I undemxmnJ tt if the NEWRE.SLUEMIALMECH. SQ.FT.tlhavenrespomibilitymnoodythe t.Wt
hickneeofa Ceniacmeo' p Icy.
Owner or aothonu4a m Dam TOTAL: • ISSUED BY:
OFFICE