S 1836 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PESITNO. 1838
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL \/
BUILDING PROJECT IDENTIFICATION
BUILDING
ADDRESS: / SANITARY NO, APPLICATION SUBMITTAL DATE
/7 7 S Z_Y)n
OWNPJy NNAME: C I PHOI " I CON ACTOR'S NAME: - LICNO.
a/a/ll�� �]y �� 49 NIC CONTROL#
t ARCHITECTIENGINEER: LIC NO: ADDRESS I ❑
CONTACT: PHONE: BUILDING PERMIT INFO
f? ry� 3_�Ig ❑ Consultant Fees Paid by Applies at(Initial) BLDG " ELECT PLUMB MECH
TYr�. ❑ ❑ ^� ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 heresy alum that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FWWOO wee section mfNp of Oiviai0n3Orme9u,inert,and Professions Code,and my lian,els RESIDENTIAL:
O full force and effect. PERMI'TISSUANCE
�UV Licence Class Lie.# - ❑SFDWL El KITCHEN REMODEL
rH zuee Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION 1MBING RE-PIPE
ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
zonz Iunde..tand myplans shall bcnecd aspublic record, MODIFICATION
C z.. UPT02MAMPS
E 411....W Licensed Professional El INTERIOR ❑C14SWIMNEYMING
REPAIR
CJ 2U1-IINNIAMPS IMPROVEMENT SWIMMING POOLS
22 OWNER-BUILDER DECLARATION
CiaTION
�[y� 1 hereby affirm that 1 ora exempt Pram the Conaamor,License Law[or the OVER ION)AMPS El BATH REMOUEVRBPAIR 0 DEMOLITION
;2U
y U following beacon.(Section 7031.5,Bovine,and Pmfes,mr,Code:Any pity or county SIGNS ELECTRICAL ❑OTHER _
C y
which y Permit t t t her p d lkh p y ewemre A� : /
y�' prie t t :: cels y 'Ih ppli If hp miu fl :'g JsWleme.t SPECIAL CIRCUITIMISC.
�]y
that he licensed prt a the pricroons(if1h Contractor License L (Chapter',
61 l'•-1`00
(commencing with Section 7000).Thmmo.3ofthe Business andP f .' ns Cade)ar TEMP.METER OR POLEINST. # COMMERCIAL '
a y m yr that he is e.,.pt Iherefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC tr. Section 90315 by any applicant for a permit suhjeds me applicant m a civil perulty of POWER DEVICES
W^to ❑TENANT ❑FOOD SERVICE
y
not more than five hundred dollars($500).=� 1,as owner of the property,or my empinyeec with wagex as their sole compensation. SWIMMING POOL ELECTRIC 601 IMPROVEMENT
will do the work,and Restructure is not intended oroR'ered for-_sale(See.9044,Business ❑OTHER
p] m and Professions Cade:The Contractor's License Law does not apply[..an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such oupowements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,however,the building or improvemere is sold within one year of completion.the SQ.Ff.FLOOR AREA $ISQ.FIT.
ownecluoulder will have the burden of proving that he did not build or improve for per,
T o amarav JUL 13 AO'0
L ns,the ne the property,ora exclusively mmlrading with Ii in.,_conlranms 1. TOTAL:
oncnum the pmject(Sec 7044,Busincxe and Pndesinnn Code:)The Cnntracmr'x Li-
cenne law does not apply to air matter ofpmlwrlywho holds orimproves thereensaid QTY. PLUMBING PERMIT FEE CIIY Vr uUt CfiIINU
who contracts for such projects with a con0anor(n)licensed parsmmt m the Contmmors
License Law. PERMfr ISSUANCE S
❑ I am exempt under Seo. _ ,B&PCfanhisonwon
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following decurbab oic',
❑ I have and will maintain a Comficateof Consent mself-Insure nor Worker's Gnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TY PE CONSTRUCTION
saris.,u provided for by Section 3700 of the Labor Code for(he prum mane of the
work for which this Formal is issued. FIXTURES-PER TRAP
iL I have and will away man Workers Compensation Insurance,as required by Saiion
3900 of the Labor Code,fur performance ofthe work for which this permit is issued. GAS-EA.SYS I ENT INC.4 OUTLETS
My Wo r Cat or n It a d Policy n OCC GROUP APN
urdnw c n o and
Na: �G lis GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EX- PUON FRO WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
RQILDIN6 DIVISION
(This satien need not be aanpleled if thepemar i.Perone hundred dollars(11 NO PP.&S
or Ice,.) GREASE TRAP PLANCHECK FEE
1 unify Thal in the performance of the work for which this permit is issued,I shall
rnIo SEWEk-SANI'I'AkY-STORM EA.2lN11T.
p y an y person an any manner sn o,m hearth,subject m the Workers'ComFlen- ENERGY FEE ,
,7. not employ
satisn laws sPCalifornia.Date
Applicant WAT'Ek f{EA'fFk WNENTIELEC'1'R GRADING FEE
r7 vJ NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEM/TREATING
I"t became subject it the W.lace,Compcnsamen pre'llmns of the Labor Code,you must SOILS FEE
_
a U forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
WZ" I hereby affirm that there is a eonstmetion lending agency for the performance of Date Receipt#
O the work for which this permit is issued(Sec 3097,Ci,C.)
0 U Lender',Nunmh TOTAL,:
LS7 Lender's Address TOTAL: //y#2
yy I unify that 1 have read this appliwfion and statedad the shove information is BUILDING PEE,
�'. to emmot.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
L.) building construction,and hereby authorize mpmeemmives of this city to enter upon the SEISMIC FEE
above-menti.ned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Captions,against ELECTRIC LET
Ilaladities,judgments,cons and expenses which cony in any way acme against nail City
n consequence of the granting of this permil. ALTER OR ADD TO MECH. PLUMBING FEE //O•
APPLICANTUNDERSTAND: NDWH O PLY WITH ALI.NON-POINT AIR HANDLING UNIT p'010,000 CPM) MECHANICAL FEE
URCERE ON
:! —g AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Slgnm fAppliem Contra r [ Date EXHAUST f IOOD(W/DUCT) - HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will he applicaitm future building twer,an ,ormor handle mountains material HEATING UNIT(TO 100,000 BIT)
as defined by the Cupertino Municipal Cafe,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)f HEATING UNIT(OVER 100,000 BTU)
El Yes ❑No VEN'ELATION FAN(SINGLE RESID) PAID
Delo Rccelpt#
Will the t,pear or future defining by the B use co Air Qu m devices which BOILER-COMP DHP OR 10(1,000 BTU)
emit hmtrdnus air conmminems as defined by the Bay Arca Air Quality Management TDT L.
• District?
7Yc, FNo BOILER-COME(OVER 100,000 BTU)
I have read the hwnNourmatems requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Earn Health&Safety Code,Sections 255115,25533 and 25534.1 understand that if the NBW RPSIDP,NTIAL MECH. SQ.FT.
building does not com ody have a tenant,Nat it is my responsibility to notify the occupant
of the ace ormal which most he met prion.Issuance of a CeniOcam of Occupancy.
Owner or oulhor svid agent Date TOTAL: ISSUED BY:
OFFICE