S 0051 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEIT RICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICALn
r
BUILDING PROJECT IDENTIFICATION
NOILUING ADD ES 'SANITARYNO. APPLICA'I'IONSUNMITTALDATI
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O N" A P NE: CONTRACTOR'S AMI:: LICNO:
xllp� NIC CON TROL#
ARCHITECT/ENOWEER: LIC NO: ADI PSS: ❑
CONTACT. - PHONE: BUILDING PERMIT INFO
❑ Consultant Fess Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEC
1 nerenr amrrn mm 1 am licensed ander provisions of chapter 9(commencing JOB DESCR PTION
1P1�oo with Section 7(1011)nfDivision 3tftha Buenesnnd Profession,Gdo,cadmy license is
FOD 11 force and care PERM)IISSUANCE RESIDENTIAL
aUF ;omen Cl s. -fie Lic.N 3��� JS ❑SFDWI. ❑KITCHEN REMODEL
Dam— k \ Contractor APPLIANCES-RESIDETG AL ❑ADDI'f1ON
L ❑I'LUh'IHING RE-PIPE
y ARCHITECTS DECLARATION PANELS ❑MULITUNIT ❑STRUCTURAL.
Z w Z 1 unJersW and my plans shall he used as public mttiNs
024-O UP TO Zoo AM PS MODIFICATION
1--4 t:; Licensed Professional 201-Igl(IAMI'$ ❑IN'I HItIOR ❑CHIMNCV REPAIR
yeJ yw..I OWNER-BUILDER DECLARA'T'ION IMPROVEMENT I]SWINI,NING POOLS
y 0 W 6 1 hereby affirm that 1 am exempt from the Contrncmr's License Law for the OVER 11MAMPS ❑BATH REM DEL/REPAIR ❑DEMOLITION
'ag 3 0.UfNlowing reawn.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL OI'IfliR
F`O� which regit m mou a permconsumer,alter,improve,, molish,deof repair any drucmte
Eno`
priorm itsissuam fi
nce,alsorequims Ne applicant forsuch Permit le a signed statement SPECIAL CIRCIADIMISC.
'Eno` that he i,licensed pursuant to the provisions orthe Contractor's License Law(Cbuptcr9
O po (commencingwith Section 7o(lo)of Division 3 of Ne Business and Professions Cale)or TEMP.METER OR MIX INST COMMERCIAI:
6 q o y that he is exempt omrefrom and the basis for the alleged exemption.Any violation of ❑NEW fl1,DG/ADDITION ❑DEMOLITION
Section 70315 Saint any applicant far a permit Sainthe applicant)a civil penalty of POWHft DEVICES
not more than five hundred dollars(SSW). ElNANT ❑hOOD SIiRVICE
SQ ❑Las owner ofthe pmpeny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the emcmm is not intended orofTend for ale(Sec.]044,Rosiness ❑OTHER
and Professions Code:The Contractor's License Law does not apply m an owner of OUTLISTS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself m thmugh
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL RLECTR SQ FT.
sole.II,however,the building or improvement is .to wi thin one yc.rofcamplmion,the SQ.FT.FLOOR AREA $/SQ.ITT
owner-builder will have the burden of proving that he did not build or improve for pun
ryrseafsale.).
❑ 1,as usner of the propeny,am exclusively convecting with licensed contractors in - - 'TOTAL: A� '
consumer the project(sec.](94,Buand siness Professions Carded The Contort Li- - D
cerew Law does not apply man owner ofphopeny who builds or improves Ramona,and QTY PLUMBINGPERMIT ��
who contracts for such Projects with u contmctor(s)licensed pursuant to the Contractors . Y,�g
0 lamnse Lamexempt
PERMIT ISSUANCE ` nr.,
❑ lam exempt unJtt Sec. ,R&'PCfor chis reawn ; /�.4p
Owner Dec ALTER-DRAIN&VENT'-WATER(EA) UI,�.VALppUA I'1(T
WORKER'S COMPENSATION DECLARATION BACK ROW PROIECR DEVICE CH/�Ar�
.• I hereby affirm under penalty of perjury one ofthe following Eclamtiore: ,1r'
❑Ihdv and wi ll omintdn.C,mr...tc fConsent toed-imine far Worker'.Compen- DRAINS-FLOOR:R0017 AREA,COND.
.µ.oto is provided for by Section 370()of the Labor Calc,for the serromnance ofrhe STORIES 'TYPE CONSTRUCT ION
for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
J7 1the Lebu-Code,for the performance of the work for which this permm is issued. OAS-[A.SYS'1'EM-I INC.4 OUTLETS OCC.GROUP ppN
y WalacejCampertati Inxurunce carie,and Policy number am'
Carrier: RC eaV of Policy Ni Ion 5--":Z-7 CAS-EA.SYSTEM-OVER4(EA)
C17RTIFICNI'E OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
or he's.)(This section need nm be completed if the permGREASETRAP it is for one hundred dol lam IS 111) BUILDING DIVISION ES
' FE
FEEI certify that in the Performance mance of the work for which this permit is issaed,lshdl SEWI?R-SANITARY . W
not employ any perwu
n in any manner so as to become subject the Workers'Coarsen. -STORM EA,2IT. ENERGY FEE
O zsation Laws of Califomia.Date WATER IIIiA'fER W/VEN'fIELEC'I'R
z Applicant ) GRADING PEE
H NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM EATING
a ; become sobject o the Worker's Compensation Provisions of the Lecher Cale,you aunt SOILS FF.E
LkJ forthwith comply with such provisiman,this permit shall be dcenmdrevuked. WATER SERVICE
d
U
CONSTRUCTRN LENDING ATINCY z Ihercb aftirmthanhere isummswminn leading ue for the NEW RCSIDENTIAL PLMP, SQ.FT PAID Dole, Itccciptk
U P the work Tor which this Iamb;is issued(Sec 3091 CI¢C.)ncy performance of
U.ULenders Name
U TOTAL:
Leaders Address L
Fa I certify that I have mai this application and state that the No,inbmmation is Ii UILDING FEE
Vicorrect l agree w comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FTiE
U Z building construction,and hereby authorize representatives of this city mw
eer uponthe SEISMIC PHe
above-nmmioaed moiperty fit,inspection Purposes. PEBBLY ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
behilitics,judgmem,.costs and expenses which may in any way active agoinstsaid City ALTER OR ADD TO MECH.
inum nsaluence of the grounng of this permit PLUMBING FI7E '
A PP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT frO loch CFM)
S 'R'G REGULATIONS. MECHANICAL IPE
M Z�I 1 AIR HANDLING UNIT(OVER 1I,000CFM) CONSTItCUT10N TAX
Signatum ol'ApplicarraContiffichor Dam EXHAUST H60D(W/DUCT)
HAZARDOUS MATERIALS UISCIASURE HOUSING MITIGATION FEE
Will Iheapplieantor Ilnnre building uectmantsmrcer handle huzallous material HEATING UNIT'fro I WAIT B U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heahh and Safety
Code,Section 25532(ap HEATING UNIT(OVER 100,000 BTU)
❑Yes C]No
VENTILATION PAN(SINGLE RFSIU) PAID Dam Receipt
Will rhe apPlicour or future building occupant use equipment or devices which
-nut hamrdous air containments its dinned by the Ray Are.Air Quality Mtmagemmd BOILER-COMP(3HP OR 100.0f)(11ITU)
O"W"L TOTAL:
❑Yes Fl No BOILER-COMP(OVER IBo,IX10 RTU)
I have read the hazedous mmanels requlremems under Chapter 6.95 of the Cali- APR CONDITIONER
funis Health&Safety Code,Sections 2550.5.25533 and WM.I understand that if Ne ISSUANCE DATE .
building dreg not currently have a tenant,that it is my responsibility m notify the rocurynt NEW RESIDENT JAL MF,CIL SQ.FT.
or the rojame eat,which most license Into to Issuance of a Certificate of Occupancy.
Owner or aumser ied agent pate TOTAL: .
SSUED NY'
OFFICE