S 0774 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
FBUILDINGADDRESS:
Y OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
ILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAI,
BUILDING PROJECT IDENITIF'ICAOON
SANITARY NO. APPLICATION SUBMITTAL DA
i r— drr
OI:R:S ME: PHONE: CONTRACTOR'SN AH LIC NO
NIC CONTROL#
I
�tNCHI'1'EC']'lE rINEF.R: LIC NO'. ADDRESS: ❑
-va (6 lilt FIKor>r -V (1/t.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRA )R'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby of ran hal 1 am ecen,ed der pmvisime,of chapter 9(commencing JOB DESCRI TION
Wnz with Section 7000)ofoivi.ion3 ofthe Business and Pmfesslamcode.and my l.cemm is RESIDENTIAL
1900 in PERMIT ISSUANCE
FLLF full force and effect. y� ❑SFDWL ❑KITCHEN RHMODE[
�VV Liccnsc Clu..r Ttic p— APPLIANCUS-RESIDENTIAL. ❑AUDITION ❑PLUMBING RU PIPE
NQa Unlc IZ-'Z2 /7 Contrminr
FDm ARCHEI LC'I'S DHCfARATION PANELS ❑MUI;I'I-UNI"T ❑STRUCI'URAI.
Z O r�Z I underhand my Plan,shot]be used u.public records MODIFICATION
OZ=� UPT0200AMPS ❑INTERIOR ❑CHINANEYREPAIR
F4.I Licemxd Prnfessimetl 201-1IXq AMPS IMPROVEMENT SWIMMING POOLS
C Q 1 hereby affirm hat I am exemp Efmm he ConueOors License Law for he OVER IflfglAMPS ❑BATH REMOVE EPAIR DEMOLITION
XO a V following renin.(Section 70)1.5,Business and Prafescions Cala Any dry nr county SIGNS ELF,CTRLCAL ❑OTHER
W 3 LL y¢
which mymne,a Permit to construct,alter,improve,demolish.or repair any hrucwm
0J prim to iu issuance.also rectuims the applicant h,rsuch period in file a signed statement SPECIAL CIRCUITIMISC.
E y that he in licensW Punuannnlhe provisiore oflhe Cnnvact.ex License Lass(Chapter v
y..COQ (commencing with Section 7IX1(B of Divirion3of heBmineu and Pmfm,innsCMc)ur TEMP.METERORPOLEINST COMMERCIAL
tL y m C that he is enempl Iherefrare and Ii me basis r the alleged exemption.Any violutlon of [_1 NEW BLDG/ADDITION E3DEMOLITION
X LL Sell 171315 hyany nppl...itti,rnlnnnl(,.hjcet,the applicmn tun civilpcmlllynf POW17R DEVICES
W•-on ❑TENANT ❑FOOD SERVICE
re than five hundred dollar.($51X).
`ZY it's IMPROVEMENT'
WSC wi Lo the work,the pnperty,structure myemplendes withwvges offectod rsalei(Sec. 044.8 Nalmn, SWIMMING POOL ELECTRIC
F. will dotnewor.Cosaftand heCioisnotinLicens,ed La.
to W.Business ❑OTHER
0.3 m Ind Professions Cnde:The Comment',License,w Law Jaen rid apply es if owner n( OUTLETS-SWITCHES-FlXTURES
prnpeny who builds or improves r such oral verve does such work dims,,or through for
nil own employees,provided r m improvement
impms soldwithin
are don intended oo o(@rtd for NEW RESIDENTIAL LLECfR SQ
NaIeJLhaweventhe building or of proving
is ml he did non Wild
icompletfor the So.FT.I'I-OOH AREA 9SQ.FT.
neol"alJer will have the burden of pmvin6lhat he did not hull,or impmvc far pur-
❑Mlas own.
h as owner of the property,mit exclusively contracting with:)Clad concretion,i- 1' j�q h
n,Lo the r,a,,,(See.7044,Business or and Professions Cade)The Cano:a:lo i. Li- r V
en,larw dxs nm apply to an owner,ofpropeny who nmles or impnmc,mercon.end QTY. PLUMBING PERMIT E
whit amvnc6 1'onuch pmjeas with u cnnmucbrt(s)IicnnsN pursuant m the Cunvuctorx n
License Law.oten PERM] ISSUANCE /CH ac
I um exempt under Sec. .B&P C for thin reason DECV ry�i1 °
ALTHR-DRAIN&vLNT-WATER(EA)
Owner CIrr U!' VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE H
I hereby affirm under pnahy of perjury Inc of he following dcdaralians: V
O l have and will maintain a Ccrtifcam of Consent to self-insu ,for Workers Compcn- DRAINS-FLUOR.ROOF AREA.COND.
Nation,as provided for by Section 3700 of he LaCade,for the performance of the STORIES TYPE CONSTNUCEI(
hr
work far which this permit is issued. FIXTURES-PER TRAP
I] 1 have and will maintain Worker',Cnmpemmlion Insurance,as ev ailed by Section
3700ol the Lwo,Code.for the pc,facronequf the work for which this permit ix issued. GAS-i?A.SYti TIiM�11NC.40UTLETS
My Work's C,mRensetion i ar nmd Polity OCC,GROUP APE
s[� p py
Carrier: VILUA I�V�"lYlxc ncP iuy Ne.:1ry Yl�'�97 CAS-EA.SYSI'i?MOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASUINDUSTRI.WASTE INTERCEPTOR
(This section need not he completed ifhc permit is for Inc hundred dollars(5100) BUILDING DIVISION FEES
ss
m le ) GRLASE TRAP PLANCI IECK IEE
lecoLythal inthe pdformamc ofhc work forwhich lhispsmut isissuid.I shall SEWER-SANITARY-STORM EA.2(X114
.in employ any permit in any manner so w m bccome,ubjeci m the Workers Co.,.- . . ENERGY FEE
ZZ cation Lassof Califomia.Dam WAT17R HHA14R WNENT/ELECTR
O nppbcam GRADING FEE
% NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTIiMG REATING
a ; Mm
coe.,ubjecl to the Worker's Compensation provisions of the Labor Code. ue,yomud SOBS THE
W fimhwith comply wihauch provision,it this proon,holl be dr.ored revuked. WATER SERVICE
= z CONSTRUCTION LENDING AGENCY NEW RESIDEN"I'IAh PCMB, SQ.lel'. PAID
Us 0 I hereby effort that them isamd(Sit.3niending agency Tia nhc perfitmwncc of Date Roecipnp
F` the work for which his permit is issuN(Sec,309],Civ.C.)
O 1,cnder',Name TOTAL:
} Isndcr'.Address TOTAL:
y I ccnify that I have read his application and slate that the aMwc information is BUILDING FEE
F h correct.I agree no comply with all tiny and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 2 building convection,and hereby authorize representatives ofhiscity memer upon the SEISMIC 193E
almic-mentioned pmpcny for inspection purples. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
linbililics,judgments.costs and expenses which may in any way scenic against said City ACIER OR ADD TO MECH.
in lsequenm of he granting of his permit. PLUMNING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('r010.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IO.gX1 CFM) CONSTRUCTION TAX
5lgnmurc ofof AppLcunVContmc(nr Dam EXHAUST'HOLD(W/DUCT') HOUSING h11"fIGAT10N FEE
HAZARDOUS MATE, IRIS SCLOSURE
Will the applicanmrfmum huilJing nccupam score or handle hazardous minimal HEATING ON]1'(TO 100.000 BTU)
as defned by the Cupertino Municipal C st.Chap¢r 9.12.and the Health eml Safety
Code.Section 25532(x)? HEATING UNIT(OVER 100,000 RTU)
❑Yc. [-I No
VENT'I LATION PAN(SINGLE RESID) PAID
Will he applicant or fnuuc building occupant use equipment or devices which Date Recap k
tnit hxeordous ai r contaminants as def mrd by hm
e Bay Area Air Gust by Monagcmnl BOILER-COMP OLTP Uk IIXI,fXX18'I'U)
District! TOTAL:
( �Yee, [3No BOILER-COM 11(OVER 100.000 BTU)
]have rwd he hazardous mamna9 mquifcmerm under Cooper h 95 of he Cali- AIR CONDITIONER ISSUANCE DATE
frmia Heald&Safely Code.Sister as 25505,25533 ami 25534.1 mtdcmund Ihun if the NEW RESIDENTIAL MECH. SQ.14.
building hes no currently have a heard.that it is my rtspnnsibilily to notify the recupmn
of the nyxbemems which must W men prior to ismence of Cenifica c of Occupmrcy.
Owner or mhorizcd agent Date TOTAL: ISSUED BY:
OFFICE