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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE MI NO.
BUILDING DI VISION AFPLICATION/PERMIT PLUMBING-MIiCI1ANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APPI.ICATION SUBMITTAL DATE
Z7-17o kl-re s, 6A- 4
OWNER'S NAME: ''�� 11 PHONE: Q CONTRACTORS NAME: LIC NO:
/JSL>`(�r l�'1 />-IY I� ((�.�� 7 G; -of 41 eT�J/�'Nr Cb �/�� NIC CONTROL#
ARCH fids'✓NTECl/ENCIN TT G� C LL'S tJ-/ �. 2'L�/O p�r� 4T; ter /rV/IC NO; ADDRESS ❑
CONTACT: PHONE: ''/ RUILDING PERMIT INFO
CEEvnI yorl �� Ca d yg� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
s ❑ �! ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I um licensed under previsions of Chapter 9(commencing
Q=z with Section 7000)ofDivision 3arlhe Bosinessand Professions Gde,and my license is RESIDENTIAL.
FF++ full force and eflem. PER IHISSUANCE
C F nt ❑SFD W L ❑KITCHEN REMODEL
aUyU License Class Lich APPLIANCES-RESIDENTIAL []ADDITION [_1 PLUMBING RE-PIPE
h4 W Date Contractor
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
,zOnz I understand my phow,hallM used as publicrosmids
MODIFICATION
OZ-- UP T02W AMPS [I INTERIOR El CHIMNEY REPAIR
P 4 I[] Licensed Proressinnal 201-100 AMPS IMPROVEMENT
9 9 9..I ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEfJREPAIR ❑DEMOLITION
I hereby affirm sure 1 um enemas from the Contractors License Law for the
W 3 tf following mason,(Section]031.5,Business and prnfessinns Cgxle:Any city or county SIGNS ELECTRICAL ❑OTHER
o y which requires a permit to construct,alter,improve demolish,in ropalr any structure
y6� prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Qthat he is licensed pumuanTto the pmvisits,.fda,Contractor's License Law(Chapter 9
OC (commencing with Section 700M of Division duffle,Busincasand Pmfesslons Cola)or TEMP.METER OR POLE INSI COMMERCIAL;
M q o C quit he is exempt therefrom and the basis for she alleged exemption.Any violation of F ❑NEW BLDG/ADDITION ❑DEMOLITION
W..y
Section 7031.5 hyanyapplaost rnupanno d atslheapplicamm acivil aa.liy.f POWER DEVICES El TENANT ❑FOOD SERVICE
not more
CQ i] thanfvehundedda.llan,1110), , IMPROVEMENT
efeprpUnsow
SWIMMING POOL ELECTRIC
will do lie work,and messmomm isnq intendedmufficred forsula(Seo.7dD,Businesx ❑OTHER
W m and I4ofesoners Cade:no Committees License Law does not apply an an owner of OUTLETS-SWITCHES-FIXTURES
propery who buildsor improves thereon,and who docs such work himself or through
his ow.employees,provided ghat such improvements are nm mal, led or offered fm NEW RESIDENTIAL ELECTS SQ Fr.
sale.If,however the building or improvement is sold within one year ofcompletlon,the FLOORAREA
caner-builder will have the harden oT proving that he did not build or improve for pur-
pose of sale). y
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL'
aconstruct the project!See 7044,Business and Pndessians Cod,)The Coomustons Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. NG P RMIT FEF,
who contracts for such projects with a contrectogs)licensed pursuant to the Contractors
License Law. PERMIT ISSUANC
❑ Ismexem oder Sec. ,B&P C far miareason
ALTER-DRAIN 4 VENT- (EA) VALUATION
Owner Date
W tKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. VICE
I hereby affirm under penalty of perjury one of the following declarations:
El I have and will maintain a Certificate of Cnnsem to scluinsam for Worker's Compen- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3]00 of the Labor Cale,fortheperformance of the
work for which this permit is issued FIXTURES-PER rRAP
❑ I have and will aviation Worker's Compensation Insurance,as required by Section
37100o17tbe Labor Code,for the paformence.f the work far which this permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP +I APN�
My Workers Compensation Insurance peation Insurancarrier and Policy number are: L(p Z
Carrico Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 `�
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTER
(This section need not he completed ifthe Norman,Corona hundred dollars(5100) BUILDING DIVISION PEES
nr lex,) GREASE TRAP
PLANCIIECK FEE
(certify that in the any manner ofthe work for which this permit ises'CoI shall
not employ any person in any manner so as to become subjecno the workers'Compact. SP.WP.R-SANI'T'ARY-STORM CA.21M1 FT. ENERGY FEE
Q Z action Laws of California.Date WATER HEATER WNENT/ELECTR
y O Applicant I GRADING FEE
a ) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSIf ITREATING
aE became subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS HE
LLl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
L.l0 T here by affirms Nord,
lssued(Sa30 leading agency fbnM1eperf rmanceof Dam kaeipgb
QH the work for which this permit ix lamed(Sec 309],Co.C.)
ULender's Name - To FA L:
Lender's Address TOTAL:
1 certify tint I have revtl his applicntinn and erase that the above inmrmetion is BUILDING PEE
sr (g) abroad.1 agree to comply with all city and county ordinances and state laws adding to QTY, MECHANICAL.PERMIT FEE
V z building construction,and hcrebyamhorize representatives of this city to enter upon the SEISMIC FEE
'-' abuse-mentionW propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.casts and expenses which may in any way reame against said City ALTER OR ADD TO MECH. PLUMBING FEF.
to consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE.REGULATIONS, MECHANICAL FEE
A.. (, AIR HANDLING UNIT(OVER I0.0POCFM) CONSTRUCTION TAX
Signmurc of Apphcant/Contactur Dam EXHAUST HOOD(W/DUCp) HOUSING MITIGA'T'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store or handle hnendnns material HEATING UNIT(TO[(In 0(1 BTU)
as defined by the pupation Municipal Code.Chapter 9.12,and the Health and Safety
Cod,Section 25532(a)? HEATING UNIT(OVER 100,000 BTI])
❑Ycs F1 No VENTILATION FAN(SINCLP.RESID) PAID r
Date Receipt q
Will the it cotta or future buildingby the B use equipment Quality
Management
which
emit licentious air mmvmiuems as dolined by the Buy Area Air Quality Menagcmem Rf31LER-COMP(3HP OR 1(0,0K0(1 BTU)
District? TOTAL:
❑Yes El No BOILER-COMP(OVER 100,000 BTU)
1 have read the treated.,ordered,requirement,under Chapter 6.95 of tfic Call- AIR CONDITIONER J ISSUANCE DATE
(amid Health&Surety Code,Sections 25505.25533 and 25534.1 understand met if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently haves tenant,that it is my resl.msihility m notify the acs vart
of the requirevten ichmust;met pno,w o,came ofa Cenificate of Occupancy.
Owner m sachem agent Date _ TOTAL: ISSUED BY.
OFFICE