00010028 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 O 0 10 O�2L �
CITS'OF CUPERTINO BUILB NG-ELECTRIcA Pe ITNo f�fr
APPLICATION/PERMIT PLUMB INf,-MEGf1ANIGAI. p000l
BUILDING DIVISION - ,BUILDING PROJECT IDENTIFICATION - O 1
pUILU1NG ADDRESS: SANITARY NO. APPLICATION SU13M1'ITAL GAME
CA 1-15494-4- - l O 2, Do
WNER'S NAME: 'HO CONTRACTOR'S NAME: LIC bora
't S 3 2 /c corrrROL a
R )l;&44A1p AM
CHITECt/E G EER: LICNO: ADDRESS: ❑
ONTACT:_ PHONE: BUILDING PERMIT INFO
` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION Q'pY � ELUC RIC PERMIT FEF.
Ili byordainthtl licensed d p f Chapter 9(eonme ng JOB DESCRIPTION
HCOZ w;tns i Poco) rD'�alon3oftne pas' .ane Profe,x an,code ane ny bee,e is - - RESIDENTIAL'
PERMITISSUANCE
in Nllhome vnd effect. ❑SFDWI. El KITCHEN REMODEL!
�VF' License Class Lic.N APPLIANCES-RESIDENTIAL [_1 ADDITION ❑PLUMBING RF PIPE
nZ� Date Contractor ❑MULTI-UNIT ❑STRUCTURAL.
F5y ARCHITECT'S DECLARATION PANELS
v z p to z t 1 understand my plans,hal l be used as public.,,Nr MODIFICATION
Oz4- UPT0200AMPS [I INTERIOR ❑CHIMNEY RI7PAIR
F,.1q"; Licensed Professional 201-I010AMPS IMPROVEMENT E]SWIMMING POOLS
�+�2,
OWNERBUILDERDECLARATION OVER 1(010 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
d'�ff�y%Gy 1 hereby affirm that 1 vm exempt from the Contracts,License Law for the
iW5 y U following...son.(Section 7031.5,Business and Professions Code:Any city or runty SIGNS ELECTRICAL, El OTHER
lu Or which regnias n permit m co mover,aIle,,imp..c,demnlinh,or repair any onscome A
�' prior t t' ::uance,also requiristhe applicantfor such Formal t file a arguedstatement SPECIAL CIRCUI'I'MISC. r
that he licensedpursuant t they of of Communes L' I (Chapter9
u d'�' (aam g with Section 7000) fD tai 3 of the R ,' es
ns dP f P.
Code) TEMMBTERORPOLEINS'1'. COMMERCIAL:
Cy y�a flim he pt ll kf J Ili b ams f lh II gW ....par .Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 703156,.,applicant for apormil suhlcce,the upplicanl to a civil patvlty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
WF not more than Five hundred dollars($500), IMPROVEMENT
X50 ❑1......or of the property,army employees with wages as their sole cumpensntlnn, SWIMMING POOLELECTRIC ❑OTHER
F will do the wrnk,mal the sdmaureix not intended oroBered far sole(See 7(94,Buxiness
u�j mand Profession,Coda no Contractors License Law does not apply to all owner of OUTLETS-SWITCHES-FIX
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements aro or Intended or offered for NEW RESIDENTIAL 81ijiCIR
.It.If,however,the building or improvement is sold withinane year ofcompletioo,the SQ.HT.FLOOR AREA $/SQ.PC
ner-b rilder will have tint burden of proving that he did not Wallis improve,for par-
;p.,poe�sala). .. .
as owner of the progeny,am exclusively connecting with licensed contractors to Tf
consumer the project(See.70TL Business and Professions Code,)The Contractor's Li- -Ir
cense Law does not apply it)an owncroflanqumy who buildi or amponves herear,and QTY. PLUMBINGPERMIT PEE
was cornets for such projects with a commetor(s)licensed pursuant to ore Conlmetors
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C 6 finis reason
ALTER VALUATION
&VENT-WATER(EA) VALUATION
7les")
WORKERS OMPGNSATION DECLARAIONBACK FLOW PROTECT DEVICE
veandwlansaentociiace ,df-iusefi ,CuImusand will forE neCion370of Consentrodef theWorkersreor th- DRAINS-FLOOR,ROOF,AREA,CONO STGRIE$ TYPE CONSTRUCTION
on,es provldod for by Section 3700 0[the L.bor Code,for the performance of the
rk far which this Permit is issued. FIXTURES-PEk TRAP
I have and will maintain Worker',.Cmnponsation insurance,as required by Section
IXl orthe Labor Cod,for the perrormance of the work for which this permit is Issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP A Ny Workers Cmnpensatien Insurance carne,anJ Policy number orerrier: Policy No.: GAS-P.A.SYSTEM-OVER4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASEIINDUSTRL WASTF.INTF.RCEI'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEE(Thls,ection need not be eompleled ifthe permit;,foroo baudred dallam(SI 00) GREASETRAP
PLANCHECK PEE
I certify that in the performance ofthe work l'orwhich this permit is Issued,I shall SEWER-SANITARY-STORM EA.200 PC
not employ any person in any manner so as to become subject to the Workers'CamperI ENERGY FEE
,7-s action",,of California.Date WATER HEATER W/VENT/ELECfIt
O Applicant l GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenifcare of Exemption,you should WATER SYSTEMITREATINO
become object m the Workers Compensation......inn,of the Labor Cale.you ma,,, SOILS PEE
m
Aforthwith comply with such provisions in,this ponnit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.VP. Ail>"'
z Ihereby a[Ethat m
here is a eonnetion on agency fon m
he perforan >w....
veof DJIeReceipt#
C➢ mt
the Werktit this permit is issued(Sec 3(197,Co.C.) TUrN
F' LenderName',Name
U Lenders Address TOTAL
� 1 candy that 1 have read this ppl t and state that thb rnarration Is11. 1 - =BU 'EE
t.-i rp correct Iagree m comply with II city a county d' dam 1relatingto QTY, - MECHANICAL PERMIT 4FEE IL007, buildng construction, dh Nbyap tatve.v I this city to ev3Mer upon the - $E1ICFEOPERMIT ISSUANCE(We)agree to civ,indemnify and keep harmless the City of Cupertino againstELECTRIC FEE
Habitides.judgmene,costsandexpenses which may ininy way accrue againstsaid CityALTER OR ADII'fOMF:CH,in asequence of the granting of this permit. PLIPMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNIT(TO10,010CFM)
SOURCE.REGULATIONS. MECHANICAL PEL �-
�7I o / AIRHANDLINGUNI'1'(OVER 10.om)CFM) CONSTRUCTION TAX
120007
ignmum ofApplieaI I Dune BXIiAUS'f HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS
US TRIALS comport
DISCLOSURE
Will
y(leCupertino Mure nicipal Cge,Chaptr9.12,noodlehaealth asd Safety HEATING UNIT(TO IOO,WO RTU)
as defined io 2e,Cupertino Municipal Conde,Chapter 9.12,and the Health and Safety
- otic,Section 25532(,)7 BEAT'ING UNIT(OVER 1110,(10)In
Yes ❑No PAID --
VENTILATION FAN(SINGLE RESID) Date Receipt N
Will the applicant ,,Entire hada ing occupant use equipment or devices which
:mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(THP OR 100,0011TH TO CA
District?
LJ Yes Cl No BOILER-COME(OVER 100,000 BTU)
I have...tithe hvzordovs materials requirements under Chvptcr 6.95 of the CWAIR CONDITIONERr ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.I undimmed Ibm if the NEW RESIDENTIAL MECH. SQ.PC
building does not currently have a scrum.Oat it is my responsibility to notify the occupant �' ®� z
of therunts which Y be me pdm m issuance osa enilir leof Occupancy.
1 �)
authonzed agent ate TOTAL ISSUED BY:
OFFICE