00010137 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: %' /' SANITARY NO. APPLICATION SUBMITTAL DATE
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KFA N Q ) NEC CONTROL#
CI ;CTBNGINEBI2: t LIC NO: ADDRESS
Oe{Y M1Y•I]:G ce/ ave on Cor ❑
CONTACT: _ PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
❑ 11 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CWZ with Section 7000)of Division�s.f the Business andP fesei sCafe,anJ Tense is
X00 ) / PERMIT ISSUANCE RESIDENTIAL:
FK�F mfulle ka and effect. ❑SFDWL ❑KITCHEN REMODEL
aUV License Class VV Lic.q APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING BETTE
y�ul Dara - Comracmr
ZOyz0.0. ARCHITECTS DECLARATION ElMULTI-UNIT ❑STRUCTURAL
lunderstand myplmvsshvll bemsedaspuble,records PANELS MODIFICATION
OZ-�0 UP1020I)AMPS El INTERIOR El CHIMNEY REPAIR
F(: W Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS.,44 OWNER-BUILDER DECLARATION OVER I0W AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
W fu:=6 I hereby.(firm that 1 am exempt from the(1mlmdCo License Law for the
jaj3�F following reason.permit
oto construct,
Business and improve,
demolish,
Come Aoy eeryorroomy SIGNS ELECTRICAL ❑OTHER
which requires issuance.permit re amswe aper,Improve,demolish,or repair any.ewment
pn.noilaensepursuant
theres thm,israsofcant for Cohperminmfile aicense ned Law(Chapter
SPECIAL CIRCUIT/MISC.
<� that be is licensed pursuant to the of ivionsaf them Business
License Laons Codmr9
(commencing xempthhecdmn andth basis for oftheeged exampt Professions Code)or TEMP.MET OR POLE INST. COMMERCIAL:
Ihnl he is exempt therefrom and Ina basis for the alleged exanplion.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant ma civil penalty of POWER DEVICES
^vs TENANT ❑FOOD SERVICE
not more than five hundred dollars yempl.
�'Z^6 (] Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
3 Sp will do the work,and the structure is per intended or offered rustic(So,.70",Business OTHER
w and Professions Cafe:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Ih avor.cad who does such .,it himself or through
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELP.CTR SQ FT.
sale.If,however,the building or improvement is sold within one year efcompletion.the Q. OR AR $/$Q.FT.
er-builder will have the burden of proving that he did nut build or improve for pur- �+p
poseofaale.). TOTAL: !/
❑ 1,as owner of the property,am exclusively contracting with licensed commners to
amsnuct Thep jce,(Sri.9M4,Business and Professions CWeOTheConvacmr'sLi-
nseLawdoesnolapplymanownerofpropertywhobuildsorimprovesthrown,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant o the Contractor s
License Law. PERMIT ISSUANCE.
❑ lam exempt under Sec. ,B&PCformis reason
'actALTER-DRAIN&VENT-WATER(PA) VALUATION
Date
WORKER'SCOMI'ENSAT]ON DECLARATION BACK FLOW PROTECT.DEVICE. 5-00-co IM1ad will irm
under Campyte perjury ofConenenflhefnllre for declarations: (f ��/
❑Ihave and will for
nection 700 of be Labto or Code,
Workersto of the DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
snl,kf as provided for by Ss km 3700 of Ore Labor C.tle,far the performeuce of the
rk for which this permit is issued. FIXTURES-PER TRAP
1 h d will maintain Workers Cmnpensminn Insurance,as required by Semina
.900 of the Labor Cade,for the performance of the work far which this permit is i sue I GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work 1F,.I ens m a d Polio,nu bar nt r /On1
T u tamer an V 7
Carrier: 5 Policy No. GAS-EA.SYSTEM.OVER 4(EA)
CERTIPI ATE OF EXEMPTION FROM WOR CERS'
COMPENSATION INSURANCE GRF.ASFANDU5'rRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(Thissectiou random recommitted iOhe permit is formal hundred dollars($100)
or less) GREASE TRAP
PLANCHECK FEE
toy any that in lie any mannrofliho .,it astbactrmr wubject to the rit isWorkers
Comer- SEWER-SANITARY-STORM EA.200 FP.
not employ any person in any manner so as m become subject the Workers'Compen- ENERGY FEE
oZ action Laws of Califmnis.hale WATER HEATER WNENT/ELECTR
z 2 Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Ceni6cale of Exemption,you should WATER SYSTENIG BEATING
a , became subject m that Worker's Compensation pmvimmns or the Labor Code,you must SOILS FEE
Lkl forthwith comply with such Provisions or this permit shall lie deemed revoked. WATER SERVICE
Q
Pr
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET PAID
C.) O thereby affirm that them is v construction lending agency for the prominence of Date Receipt
W
me work for which this ,air rs owned(See 3099,Civ.CJ
Q U Lenders Name TOTAL:
w Lender's Address TOTAL:
y 1 certify that 1 have read this application and state that the above information is - BUILDING PEE
fn cmi l agree to comply with all city and county ominence,andstwe lawarelano,or QTY. MECHANICAL PERMIT FEE
~ SEISMIC FEE
U imovengcoostrudpropert hereby calamine of this city upon the
above-memiun re property for inspection purposes. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH' PLUMBING FEE
't consequence of die granting of permit.
APPLICA T I ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,003 CFM) MECHANICAL FEE
SOURCE s TIONS.
AIR HANDLING UNIT I(L�HItI CFM)'Ip 'aD CONSTRUCTION TAX
Signawre of mramor Dale EXHAUST HOOU(W/DUCT) HOUSING MITIGATION PEE
aHAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as dented by the Cupertino Municipal Code,Chapter 9.12 and the Health and Safety
Cale,Section 25532(e)p �/l HEATING UNIT(OVER 100.000 BTU)
❑Yes -Apo PAID --
�`' VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant in future building by the Bt use ea Air Qnt or devices which
BOILER-COMP(IHP OR 100,000 BTU)
mit hamrdous ver contaminants as defined by the day Arca Air Quality Management TOTAL:
Dinnelp �.S
❑Yeso BOILER-COMP(OVER 100,003 BTU)
I have read the parer us materials requtremdm en�vnChapter GAIR CONDITIONER95 oRhc Cali- ISSUANCE DATE
fornie Hcaldb g ly Cnde,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
held,ng does anti,havealerear,that ilonty responsihilily to notify the.ccupam
,if the regti ichmostbe or
issumce.f a Certificate of Occupancy. /�/�(/) �. l
Owner or ambo' ge Dale TOTAL: ISSUED BY. — �iv����
OFFICE