S 0967 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY lfF CUPF,RTINO BUILDING-ELECTRICAL PERMIT'NO.
- BUILDINGDIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL Q O (�C
BUILDING PROJECT IDENTIFICATION J J o
BUILDINGOBSESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
WN, 'S NAM.: •1�/P��� CONTR NO:
N/C CONTROL,
WACHITECTENGINEER: LIC NO: A ,: / ❑
JJRC
CONTA : PHONE: V J BUILDING PERMIT INFO
�79 -3 3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ z � ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 ten licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QUO, with Section 900 of Division fine eusinessa Professions Gxle..n Ylicenscis
FWE !,Rhee and C S PERMIT ISSUANCE El SFDW.NTIAIL
<Ul{C'J"J -icenso Cl SLic V D / ❑SFDWI. [I KITCHEN REMODEL
yQL Die Contmcfor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F.Dm CHITECPS DECLARATION PANELS [I MULTI-UNIT E)STRUCTURAL
z 0 to Z I un lcrsmn my pleas shall be usN as public reandx MODIFICATION
O" M UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1"'faj Licensed Professional 2n1.10WAMPS IMPROVEMENT E]SWIMMING POOLS
C6�( 3 OWNER-BUILDER DECLARATION OVER 1000AMP5 ❑13AT41 REMODEIJRF.PAIR D OLI ON
C 6 1 hereby affirm that 1 am exempt from the Commas is License Law lot the
fiYS 6 U following reawn.(Section)031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Ia 3 4.j which requires o,.mill to comtma,alter,improve,demolish,otfi repair any swcwrt
k.WC and beislcevencgako alto he rox,mohe ro for suchprtni'foicenseaw(Chmmem SPECIALCIRCl11T/MISC.
"y (comm)camel pursuant loth)pmvisionsn oft Contractor's License Loons Code)at
W p0 thane,is(commencing Section 7000)and
of basis for the
Business and
on.Anyvilaude)or TEMP.METER OR POLP.INST. COMMERCIAL:
Q.pp,,a pf that he is exempt Therefrom ami the basis for the zllegcJ exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
><^1L Section 9031.5 by anyupplicanf far.pemmifsubjes'ts thr,dicamm.civil pereatyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
LLLL11 N. nm more man five hundred do[]..($5000. IMPROVEMENT
C ❑I,as Iscariot the properly,or my employees with wages a their sole compereamr. SWIMMING POOL ELECTRIC I
will do the work,and the mruaure main imcnded moRered Bn sole(Sec.70,14.Business ❑OTHER
and Professions Code:The Commutes License Law dos not apply to an owner of OUTLETS-SWITCHES-FTXTUR
,miserly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECfR FT.
sale.If.however,the building or improvement is sold within one yecrof completion.'he SQ.FTfF RFA VSQ.FT.
owner-buider will nava the burden of praying mat he did not twin or impmvc for par.
".°f own ANSI
❑1, f owner of the property,ten exclusively convuding wish licensed comr.curzs to TOTAL" JUL'u`
construct the project(Sec.701 L Business and Pmfessiom Ctde:)The Con- hors Li- v
Cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FE
who contracts for such projects with a contmemnd licensed pursuant to the Contractor's LILY Vr vvt-ChI LNU
License Low. PERMIT ISSUANCE 3
❑I am exempt under Sec. ,B&P C for this as.son
ALTER-DRAIN&VENT-WATER EA) VALUATION
wrial hate
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Ccnifcam of Consent to self-insure for Worker's Contact- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provide t for by Section 37W of Bac Labor Core,for me performance of the
work for nichihis permit is issued. FIXTURES-PER TRAP
sm and will maintain Workers Compensation Insurance,as required by Section
00 ofthe Labor Code,for the erfnrmancc of the work for which this Ostssu GAS-F.A.SYSTEM-1 INCA OUTLETS OCC GROUP APN
My Workers ens tion 1 ranee ca er and Policy numb) . f
Cartier. �Pnlicy GAS-FA.SYSTEM-OVER 4(EA)
E ]PICA FEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section aced not becomplaN i(the pemtit is for one hundrcddollsrs lS 1001 GREASE TRAP
or lexsJ PfANCHECK FEE
I certify fault in the performance oflhe work for which this=i,,'-ad.. GF,WER-SANITARY-STORM PA.2NlIT.
.or em,Iny any pimsm in any manner so as nt hacome subject 1.the Worker.'Compen- I,- ENERGY FEE
C Z sarin.laws of California.Dae t WATER HEATER WNENTB?LECTR /OROV
Z Applicant GRADING FEE
y NOTICE TO APPLICANT,IL error making this Certificate of Exemption,you should WATER SYSTEM/IREATING
a become subject 10 the Workers Compensation provisions of the Labor Code,you most
SOILS IEE
{il forthwith cam,),with such provisions.,,his permit shall be deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V0 l 1 facrabywhichithithauhcre i.sacd(Sea.onlendgency for the perfnmmnw of Data Receipt,
V. the work fur which 1his,tnlif is issued(Sec.3057,Co,iv.C.)
0 f' Lenders Name TOTAL: TOTAL:
W Lemlers Address '
1 eerily that I have read this application and state that he above information is BUILDING FEE
V) correct.]agree to comply withal]city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
U z
building construction,and hereby aothorim represenmtivexofth]s city menmrupn the SEISMIC FEE
above-maninned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
Iiahifities,judgmenls,costs and expenses which may in any way acemeag.Lnsf said City ALTER OR ADD TO MECIL
in consequence of the granting of this permit. PLUNKING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBW CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCOON TAX
Signature of ApplicandContmnor Date EXHAUST HOOD IW/DUCT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant since or handl°hmmJous material HEATING UNIT(TO 100.001)BTU)
is defied by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safe,,
Code,Scclion 255J2(mr, BEATING Dist r(OVER 100.00s)BTU)
El Yes ❑No VEN'TILA'TION FANS INGLE RESID) PAID -
Data lieceiplX
Will the applicant or fata building oant ccupuse equipment nr devices which BOILER-COMP UHP OR 100,000 BTU)
emit hezmdoos air contaminantss as defined by she Bay Arta Air Qualify Management TOTAL.:
District? BOILER-COMP(OVER 100.000BTU)
f
F)Yea, ❑
YeNo 9
I have ma the limitations materials tcyuiremenks ander Chapter 6,95 AIR CONDITIONER95 of the Cali. ISSUANCE DATE
fonds Health& fn of on 25505,25533 and 255311 undemu 'nd thatthe NEW RESIDENTIAL MECH. SQ.17.
building does not a lmyh.v•umne ,haifismy respwsibility f9 ami
quifarm
the oxc p.
oflherwhi farm) p onnissu ce ofeCrnif¢a
Owner or uu nrizeJ agent Date TOTAL: ISSUED BY:
OFFICE