20103 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBINGMECHANICAL 20103
BUILDING PROJECT IDENTIFICATION Waim
BUILDING ADDRESS: �'i/ SANITARY NO, APPLICATION SUBMIITj�A/�NL DATE
OI ER'DN M i C tJY(INE: C NT CI'UR:ti NOAME: ^I N `- LI
I W NIC CONTRO(L�p
ARCHITECf/ENGINF.ER: LIC NO: S: �M ❑ /I J� 5 J(
CONTACT: PHONE'. BUILDING PERMIT INFO
C —� ❑ Consultant Fees Paid by Applicant(Initial) In
DO •L�-J
El PLUMB niCH
L CENSED CONTRACTORDECLARATION'S QTY ELECTRIC PERMIT FEE Lri�l/ ✓ LmK/
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
M�Z with Section7000)Of Division 3.fthe Business and Professions Code.and my license is RESIDENTIAL:
W p PERMITISSUANCE
�ty2 in fu111 ,,'a nd rfl S ❑SFDWL ❑KTTCH17N REMODEL
QUU license Cl,cs _ Li0.N APPLIANCEti-RE5IDGNTIAI. ❑AUDITION C1 PLUMBING RE-PIPE
v~iQa Doc Coolant., ❑MULTI-UNIT ❑STRUCTURAL
F=y ARCHITECTS DECLARATION PANELS
Z O y Z I uadenund my plans sh ill be meed iNp iblic records UPTO 2(MI ANDS MODIFICATION
El ❑CHIMNEY REPAIR
P 41:w licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
9. 2d OWNER-BUILDER DECLARATION OVER IINN)Ah1P5 . 1_4trH RF,MODELIREPAIR 0DEMOLIIION
p.C C Q 1 hereby affirm(but 1 am cxen+Pt Irmo the Cm mtelvn's Licerne Lew for the OI IILR
x O L U following recon.(Section 7031.5.Business and Professions Code Any city m county SIGNS ELECTRICAL
n1 LLy which nc mms a IKOnit to consumer,ulm,improve,demalolr or minor any SmilitIrC
"i priormi¢issuanco el-requires the applicant for such Permit file a signed sediment SPECIAL CIRCUIT/MISC. a
$ — that he is licensed pursuant to the provisions of the Contractors License Law(Chapter9
u1?00 (commencing with Semion]00(0 of UivisianJofthe Business and fndessions Codchsr TEMP.METER OR PULE INST. COMMERCIAL'
p y o aa that he is exempt therefrom saidthe had,for Ne alleged emmption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLl'1'ION
N
Section]031.5 by tinyappheant fill a peront stil the aPplicentm a civil I'll of POWER DEVICES ❑TP.NANT ❑FOOD SERVICE
not more than live hundred dellnas($5118). IMPROVEMENT
=O ❑Las ownernf the property,nr my employees wiN wages usthcir sole c.mpensatior, SWIMMING POOL ELECTRIC
F., will Bothe work and thesmlimm isms membldmaHered formle(Scc.]t144.Business [101 HER
W 3 m and Rofecsions Code The Contractors License Law doez not apply,o an owner of OUTLETS-SWITCHES-FlJCTURFS .00
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are not intended or offered for NEN'RESIDF,NTIAL ELECTR SQ FT
sale.If.h.wever,the building or improvement is sold within one year ofcnmpletion,the SQ.FT FLOOR AREA 5/,SQ.19'.
er-builder will law.the burden of proving that he did nm build or impmve for Pun
pose of sale.). /'1
I,as owner of the property,am exclusively contracting with licensed conmicmrx to TOI'Al.i GJ
consumer the project(See 7Oq4.Business and Pmfessions Codl The Contractor s Li-
aseLasvdoes no,apply,.an mmer.f pol who builds or improves Thereon, it QTY. PLUMBING PERMIT FEE
Odw conuacts for such pmjec¢with a communist licensed pursuant m the Contraerms,
License I.aw. PERMIT ISSUANCE
El 1 am exempt under Sec. .B&P C for'his
ALTER-BRAIN&VENT-WAfITR(EA) VALUATION
Owner Date / i /
. WORKER'S COMPENSATION,lin,on DECLARAT Ing RACK FLOW PROTECT.DEVICE C(.f J
I hand w affirmai under penalty of perjury one noftym
self following declarations:
I have and will maintain aCenihcam.f Consemmsclf-insure for Workers Compcn- DRAINS-Fl,OOR.ROOF AREA,CUN0. STORIES TYPE CONSTRUCTION
.aloo,as provided for by Section 37O0 of the Labor Code,for the{rrf.munce of the
work for which this peront is issued. FIXTURES-PER TRAP
El I have and will maintain Worker's Con+pens aian Insurance,as required by Section
3700.f the Labor Cuda for the perfnnnttec of the work for which lhispemnit is issued. GAS-ITA.SYSTEM-I INC,4 OUTLETS OCC GROUP APE
My Work C......,arm Inwrancecanierand Policy f+ i hntre 1 GAS- +
Carie,_ k� - Pull,No:{�I�, fa321171— GAS -OVER4WAI
CERTIWCATEOFE �MIUIONFRO. VO KERS' GREASI%INUUSTRL WASTEINTERCEPTORCOMPENSATION INSURANCE BUILDING))]VISION FEES
(Thi,,wOiun need not be completed ifthe panni,Isfor.ne hundrNdollan($IW) GREASETRAP
or less.) PLANCH[CK FEE
Ieenit'ythat in the perfort Of tire work(orwhich this wrmit is issued,l shallSEWER-SANITARY-STORM nA.2uo FT.
no(employ tiny pent nnym nnun..+s to Mcome snbj¢tmlhe Workers'C( pro- ENERGY FEE
Zi section Lawsof California.Data WATERHHAFERVINEN"FIIH,ECI'N
zC) Applicant 1 GRAVING FEE _
NNOTICE TO APPLICANT:IL after making this Cenificem of Exempd...you should WATER SYSI`EM/TREAT'ING SOILS FEE
b
..
a > ecome subject to the workers Compensation Prorisions of he Lahr Code,you must
f.novals comply with such powistuna or this permit shall be deemed revoked "All Ell SERVICE
F' CONSTRUCTION LENDING AGENCY NEW RP.SIDEN'1'IAL LMN. .FT LAID Ilam RccciPt p
I hereby alttrin that here isa Cmsme,lla i lending it,ney lira be peoformm¢col' -
he work for which this permi,is issued(See 3097,Civ.C.) TOT
0 U Lenders Name ✓I
G.1 Lender's Address J` +� +fOTA r,/ O
} 4 1 certify that 1 have read,his application and sum that the above inf.mtaion is BUILDING FEE / Q
F' N correct-I agree to comply with all city and county ordinances and state laws relating to QTY MECO'A ICAI PERM IT FEE
U Z building consuuc,ion,and hereby authorize representatives ofthis city m enter upon the N" ^ SEISMICFEE _
above-men6.ncd prapeny for inspection Purposes. PEEMANDIANG
NCE r V./ BLUE TRIC FEE ( O
(We)agree m save,indnnnily end keep harmless the City al'Cuperin.against
li.OIdics,judgmems,costs and expenees which may in any way accme again.asawl City ALD TO MECIL PLUMBING FEE ^� S O
to nos,,times of the gramm,ointo permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRG UNIT(TO IILUNICFM) MECHANICAL PBE SOURCE REGULATIONS.
AIGUNIT(OVERIO.OWCFAI) CONSTRUCTION TAXSignaturedApplicunt/Contrect.r Dat EXOD(W/DUCII HOUSING MITIGATIONIlli
HAZARDOUS MA'I ERIALS DISCLOSURE
Will the applicant or future building Occupant store.,handle h ondmolnatcrml HT(TO I W(OF lirIU)
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
Celle.Section 25532(0)? HEATING UNIT(OVER 100.000111 U)
E)W, 71 No VENTILATION FAN(SINGLE RF_SID) PAID --
Date ReceiP,k
Will the applicant o,future building.ccupant use equipment or devices which BOILIiR-COMP(3HP OR 100.0 0i)BTU)
Jemit baxaNans air contaminants its defined by the Boy Area Air Quality Manuganenl )Tt r
Distort! BOILIiR-COMP(OVER 100,0 N)11'PUT
I]Yes E]No
I have mad,he hvurdoas materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
fomia Health&Safety Code.Sections 25505.25533 and 25524.L understand that if the NEW RESIDENTIAL MECIL SQ.EL G( ^ Z
building does not currently have a tenant Nat it is my msponsibility to many the occupant
of The requirements which moa be met prior to issuance Of Cenificr a of Occupancy.
ants 'non
Owner or suit lord agent pateTOTAI' ISSUED BY'. ru��
OFFICE