S 0548 1.
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pi5i r NO. 0 5 4 8
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL. V\
gU11.DINC PROJECT IDEM'IFICATION
TSANITARY NO. AIWLICA'I'ION SUBMITTAL DATE
BUILDING ADDRESS:
Joodo .8 fya
OW SNA � PHONE: CONTRACfO 'S NAMG. LIC NO: CONTROL.p
foCHIT /ENGIN LIC ORES
'ONTACT. PHONE: � BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B", ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECFRIC PERMIT FEE JQg DESCRIPTION
I hereby oNrm that 1 em licensed under provisions of Chapter 9(commencing
0%Z Ih Stttiun]Wlp of Divisinn3ofthe Business end Prnfessinns Cale,a dmylicenseis RESIDENTIAL'
I 00 wt PERMIT ISSUANCE
FX W F, m full Gece end eget ❑SFD WL ❑KITCHEN REMODEL,
aUU Licenv Class
Lit. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
g.Za Data Commemr ❑MULTI-UNIT ❑STRUCTURAL.
s'nn G ARCHITECT'S IIECLARATIf PANELS MODIFICATION
0Z7.NZ. I understand my plans shall W used as public records
t UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
LaLmxed Profession.) 201-113IIAMPS IMPROVEMENT ❑SWIMMING POOLS
S I OWNER-BUILDER DECLARATION OVER IIKKIAMPS ❑BATH REMODEUREPAIR El DENOUTION
L 6 I hereby ati m that I am exempt from the Contractor's Liceme Law for the El OTHER
U following reason.(Section 7031.5,Business and Professions Code:Any city or countyIAMER
ELECTRICAL
which reyuimsa permit r construct,epee improve,demolish, file
repair any slmcmrc
pnormiocensecenlsorequiree previsions o me such Conaccure License ned Law(Chapter
L CIRCUIT/MING.
that he is pursuannolheprovivisionf Ne Cnntsiness License Law(ChMc).r COMMERCIAL'
C (commencing with Sution 11X31 of Divisinn3ofthe Business and Pmfessiuns Cale)arMETER OR POLE INST.
d y m tY that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/AUDITION []DEMOLITION
uX1 By Section 1031.5 hyany applicantfar.permit subjects the applicant a civil penalty of DEVICES []TENANT ❑FOOD SERVICE
rn more than five hundred dollars($500). IMPROVEMENT
�=Q (]1,mowmmof,W pmpeny,or my employees with wages mNeir sole compensation, ING POOL ELECTRIC ❑OTHER
willd.the work,and thesh ant.is not intendedmoffered for.,.l.(Sea 1044.Business
a 3 12
and Professions Cole:The Contractors License Low does not upply m an owner of 'f5-SWI'TCHLS-PI%TURKS
property who builds or improvesthereon,and who Lines such work himself or throughESIDCNTIAI.ELECTR SQ FL
his own employees,Provided that such improvements ort no intended or CffetW far SQ FT AM $/SQ,FT.
I� sale.If,however.the buildingm improvement is sold within yearifcompled.n.Jhe I
owncr-holder will have the burden of Tossing that he did not build or improve for put- A /�
on.of vie.). TOTAL.: Uj�
C]1,as owner of the property,son exclusively contracting with licensed con recturs m M 12 /1Mras
conn ort the project(Sec.1044.Business end I4ufomime,Crdc,)The Crumbs ar's Li- - -I'T�IV-/V)
cense Law does not apply man owner of property who builds or improves thereon.andP NG P' T FEE
who contracts for such pojeax with a eontmctor(s)licensed pursuant to no Contractor's Ur "Je
License Law. IT ISSUANCE tK�INV
❑I am exempt under Sec. .B at P C far Nis reason
-DRAIN&VENT'- A f") VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION Fl.OW PROTECT.DEVICE
1 hereby.lZo.under penalty of perjury one ofthe following declarations:
Hermandwill maintainaCeniflcamofConsentmmlf-insumfor Workers Comrn- DRAINS-FLOOR.ROOF AREA,COND. .STORIES TYPE CONSTRUCTION
tion,as provided far by Section 37M of the Labor Cale,for the perfnrrmance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as retained by Section GAS-EA.SYSTEM-]INC.60UTLIiT$
3100of the Labor Code,far he performant.id the work for which thispcon,is issued. OCC.GROUP APN
My Wmkcrs Cnyt pemntlon Insurance carrier and Policy ngyD 'l GAS-EA,SYSTEM-OVER 4(EA)
Carrier, AR Policy
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IP,ES
(This semina need not hecompined if the permit in forms,hundred dollars($In)) GREASETRAP PLANCHECK FEE
or less.)
I certify that in the Performance of the work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA 200 W. ENERGY FEE
no employ any peman in any manner so nzJn becpyc�ub,aa m the WmIms Cnmpen-
sm,.. va of Calif n.Dam Ota/Ira WATER BEATER WNENT/ELECfR GRADING FIDE
7� Q Applicant --
q N NOTICE TO AT5MCANCE If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING SOILS FEE
I••' r become subject to the Worker's Compensation provisions of the Ubor Cade,you must
W Q forthwith comply with such previsions or med T
his permit shall be deerevoked. WAER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDINGRAL PLMB. SQ.PT. PAID
Doc Receipt
USO I hereby affmm that hem N.cr..trat ion lending agency for the performance of
I'4"'�. the work far which this Permit is issued Sec.3091,Civ,C.) TOTAL:
NIL lender's Name TOTAL;
U Lenders Address BUILDING FEF.
LS
s I certify that I have read this application and state that the above information is
N comet,l agree m comply with all city and county ordinances and stale laws relmingm QTY. MECHANICAL.PERMIT FEE SEISMIC HE
V a building cnnamoion,and hereby no,h,mm representatives of Nis city to enter uponthe
abovementioned property farimpaction Impi PERM IT ISSUANCE ELECTRIC FEE `.
(We)agree m save,indemnify and keep harmless the Ciry of Coperti no...ins,
habilities,judgmena:costs and expenses which may in any way accrue agoimtvid City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of Nis pcmtit.
APPLICANT UNDERSTAN 5 AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT('40111,(311 CFM) MECHANICALFEE
SOURCE REGIR, 0
AIR HANDLING UNIT LOVER 10,M)CFM) CONSTRUCTION TAX
ImJa",,, p e .or Da EXHAUST HOOD OVIDUCT) HOUSING MITIGATION PEE
A RI�US MATERIALS DISCLOSURE
ill,a applicant or future building occupant store or handle hazardous matenal HEATING UNIT(TO 100,000 RTU)
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,33 BTU)
,We,Section 25532(a)1M Yes CNo VENTILATION FAN(SINGLE RESID) PAID Dua RCceipt#i #
Will Ne applicant or future Wilding occupant use equipment or devices which ROLLER-COMPOHPOR 100,000BT'U)
it hazardous air connotations as defined by the Bay Area Air Quality Management
soict'!❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I
I have mad the h rade, c matenaE 5.TSO
annts unlet .I and 695 of the Gli-
AIR CONDITIONER ISSUANCE DATE
fomi.Health n Safety Code,Sections 25505.25533 atd 21534.I understand that if the NEW RESIDENTIAL MECH. SQ.FI'.
buildingdnes na c which have a,meas Nv o is my responsibility m e.notify the oce.porey.m
of Ne mauirements whish mux W and poor m iosuunce of a Certificate of Occupancy.
ISSUED BY:
Owner or amhonxed agent Dam TOTAL:
OFFICE