S 3272 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITE OF CUPF.RTINO BUILDING-ELECI'RICAI. PE18IT No
`
BUILDING DIVISION APPLICATION/PERMIT v1.UXnnnc-MECHANICAL J 3272
IIUILDINX;PROJEcTinCrO ilund'iura
SANITARY NO. APPLICATION SUBMI'ITAL DATE
BUILDING ADDRESS:
0 S. An oa Mad
OWNER' ME: aA
411 1 /fA- PHONE CONT TIR:S NA - LIC NO:
II�YaMINi 'I NIC CONTROLp
tCHITECfIENGINEER: LIC NO: ADIV IDRE..I.: /TV El PHONE: OIOp - J BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE-C�TT PLUMB MECH
LICENSED CONMACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
X00 suint 5enion 70xXt1 ofnivixionlm me Bu<ineas nnJ Pramssians Coee,and my licenw ie RESIDENTIAL,
Op ) I'I3RMI'1'ISSUANCIi 3
LJ F 'roll force:rad etc` S p b15 1 r ❑SFDWL ❑KITCHEN RIiMOUfiI.
4Ur, License CPs Lou APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RH PIPE
FF..z W Dam Cn 1-1.1Ir 04 jedx__
+n6a ❑MULTI-UNIT ❑STRUCNRAI.
ARCtI1T1iCl'S DECLARATIONPANELS
z Ovt2z Iuulcrsund myplaio,led)beuscd as public fecunds UP T02f0AMP5 MODIFICATION
pz�.0 El ❑CHIMNEY REPAIR
Licensed Professional 201-INVAMPS IMPROV17MENT SWIMMING POOLS
$d�+ OWNER-BUILDER DECLARATION OV ER IfN)11AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
yiY 04 1 hereby affirm that I am exempt from the Contracmr's License Lvw for the
DC 316U following remain.(Section 7031.5,Business unit Professions Code:Any city.,..aty SIGNS ELECTRICAL , O ❑OTHER
ya which at uims a permit to curod.l,alter,improve,demolish,m repair any suucmre
�J prion.its issuance,Ms.mquirestheapplicant mrmth pemaino file.61mid statement SPECIAL CIRCUIT/MISC.
�V1 that he is licensed pursumtuo the provisions ofthc Contractor's License Law(Chapter 9
PaC (commencing with Section?000)dDivision 3 afthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
L y M rL that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
YLLl1 o, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE:
not more than five hundred dollars($500).�=6 Las owner of the ro norm In ees with wv cs as theirsole con tion, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ P Pe Y YenP Y 6 Tensa OOTHER
p. will do the work.and the swctum is not intundeJoralfemd for ade(So,.70i4,Business
a 3 m and Professions Code:The Contmetm's License law does act apply to an omni of OUTLETS-SWITCHPS-FIXTURES
property who huilds.r improves thereon,and who does such work himself or through
his own employees,provide)the such improvements ort not intended nr offered for NEW RESIDENTIAL 131.ECFRO Q e
sale.lf.hnwwcr,the M1ullding or lntpmvemcm is sold within ane ywfofrumpletinn.the - SQ,17.FLOOR AREA $/SQFIl
ner-hadder will have the burden alproving met he did ma build or Improve for lint,
paseofsaleJ.
❑1,as he,of the property,am exclusively contracting wita licensed cantrazmn to )TAE
construct the project(Sec.7044.Business and Professions Code:)The Commemrs—
cerise Law docs InA apply to an Owner of PMKOY who builds or improves dwafor,and QTY InGPERMIT FEE
who comment Ruttish projects with a commeor(s)licensed pursuant to the Cosnrucmr's
License Law. 1-17RMIT ISS CE
❑lam exempt under Sec. ,B&PCfarshixrwson
AFTER-DRAIN& -W :A) VALUAi'ION
Ow er Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT/--V
I hereby ill mai ander penalty of perjury one of the followingrkmnm: JA N
(have and will maintain nCenificme of Conxnn.elf-insure for W Worker'ssCompen- DRAINS-FLOOR,ROD F,ARE O S TYPE CONS'1'HUCfION
satin,as provided for by Section ONE of the Labor Cade,for the per amtunce of the
work for which this permit is issued. FI X'I'URES-PER TRX'
❑I have and will maintain W.rker'u Compensation Insurance,as required by Section
37M of the Labor Cash,for the perforromme of0he work for whichmis permit is noted. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC,G I AI'N
My Worker. o coxa- Ina antewme Poli Policy numherare'
Carrier. Policy Nn.; 372 '9��2 GAS-EA.SYSTEM-OVER 4(EA)
CCRTI CAfE OIC EXEMPTION FROM WORKERS' GHF.ASFIINDUSTRt.WASTF.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This nation needum becompletedlftheperamt ixforunohundreddollarx($10Xq GREASHTRAP
PLANCIfECK FEE
orlres.)
I cenifydat in the perfommm.ceof the work far which this permit is issued lsh.11 SEWER-SANITARY-STORM EA.200 IT
am employ any person in any manner au as m become subject to the Workers'Compen- ENERGY FINE
Z Sudan LwsafCalifouth.Date WATER HEATER WNENTIELECTR GRADING FEE
O Applicant
E4 NOTICE TO APPLICANT:IL ulet making this Cenifcmm of Exemption,you should WA'1'{iR SYSTEM/I'HIiATING SOILS FEE
F become xuhjcct nt the Worker's Compensation provisions of the Labor Code,you must
.�1 roue' forthwith comply with arch pmvixiomanhis Permit shall be decaned mvnkad. WATER SP,RVICE
Q
CONSTRUCT ION LENDING AGENCYncY for the performance ur NEW RESIDENTIAL PLEAD. SQ.FT PAID Jate ReceiptM
U O I herebyafmthe
firthere iso cansyuction Leadingage
{Tr the work for which this permit is issued(See.3097,Civ.C.)
L) lender's Name TOTAL:
Lender's Address T(rl'AL:
1y�s fy L certify than I have read this applienion and smtn that the above Intimnatian is tELEC
i..ah cameo l agree m comply with all city and county oNintences and state laws reining t. QTY, MECHANICAL PERMIT FEF.,Zbuilding cnmwction.and hereby numariee representatives nfthis citytoenmrupnn theabove-mentioned propeny for inspection fauT . PERMIT ISSUANCE(We)mire,t.save,indemnify and keep harmless the City of Cupertino againstliabilities.judgments,casts and expenses which may in any way accre against said City ALTER OR ADD TO MECH.Incousequcnceoflegmnlingol Oh lx it. 4
APPLICANT'I1NDE TANI1 ILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,WOCFM) EE
SOURCE RIiGU ONS.
AIR HANDLING UNIT(OVER 10.000CPM) CONSTRUCTION TAX
n
Sigruwrc�sl�ppl¢anr Dem EXHAUST HOOD Will HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe yfile Cupertinrfutureipal ode,Chap9ttormter 9.12.
handle Health asmmerial HEATING UNIT(TO IIN).1XN1 BTU?
vx dented by the Cupertino Municipal Gado,Chnptu V.12,and the Health and Safety
Cade,Section 25532(x)^ IIIIN'INC,UNIT FWI3R 11111,(X)0 BTU)
E]Yes o V13NTILATION PAN(SINGLE BESIDE PAID
Dam Heeeil
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(JEEP OR I W,lMlfl BTU)
tit hmarduus air can armair is as defined by the Be,Area Air Quality Management T TA
indct'1 BOILER-COMP(OVER 100,1100 B'WE
❑Ys boo
I have mad the haiultur;aamrias requirements under Chapter 6.95afthe Culi- AIR CONDITIONER ISSUANCE DATE
foram Health&Sa sty Csdc,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ,FT
' building Joesnw currently havemm�ant,dot it is my msptmsibility to nwify the occupant /�
ofth swhi moats met prior0o issuanceofx�a ific to of(k,trush .
Ow er ur nu0h� i dagent Datc TOTAL: ISSUED BY:
OFFICE It
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