S 0365 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITV OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDITIFFIFICATION 3 0365
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAME: + PHONE NTRACTOR' AME: S CLIC NO:
1 x O-Sp/ NIC CONTNOLp
.ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
/ l� Z2—
CONTACT: PHIO/NE:�i BUILDING PERMIT INFO
`j 0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Jr 0"4T7� 2q-yg33 ❑ ❑ ❑ 2-�
LICENSED CONTRACTOR'S DECLARATION QTY_ ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�04Z with Section 70Dd1ofDivision 3ofma Businsssand Professions Cssde,and my license is RESIDENTIAL;
p PERMIT ISSUANCE
� � in full force stet 3� ,Ss��/yl ❑SFDWI. ❑KITCHEN RF.MODEI.
QF.UZE Date Liccna ClassL Lic.N—�t-�—/ 1� APPLIANCES-RESIDENTIAL. []ADDITION El PLUMBING RE-PIPE.
yQp, T [I MULTI-UNIT ❑STRUCTURAL, i
F=y ARCHlhatealptiITECTS DECLARATION PANELS
I understand my plans shall be used ax puhlic records CHIMNEY
REP
' 02�Q UPT020(1AMPS C3 INTERIOR ❑CHIMNEY RIiPNR
rot:ata Licensed Priae,ional 301-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 100)AMPS ❑BATH REMODELfREPAIR El DEMOLITION
I hereby elfirm that I am exempt from the Contractor's License Law for rho
O U following reams(Section](131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3[L which tediums a pmi
ert m construct.alter improve,demolish,or repair any structure '
gSSSym prmi-mitsissua.1c,.Io requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
than he is licensed,ursr m loth,provisions mine Courtrooms License Law(Chapser 9
CQ� (commencing with Seon7030)of Divisian 3 of the BusinessamP.
nd Profe,,iss Cod0ra TEMMETER OR POLE(NST. COMMERCIAL'
N
a q^eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any,applicant for a permitmhjecs the applicant a a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m t more than five hundred dollars IS500).
Xq Las owner oT the prop,ny,arm roto rh wv their m4 cam urian, SWIMMING POOL ELECTRIC IMPROVEMENT
ye p intended
tui dfus pcm ❑OTHER
p. will drthe work.
n,and c:The Curersnots siren nralvdoesm mu apale ply
Business
W and Professions Cale:The Commamrs License law does not app1Y m un miner of OUTLETS-SWITCHES-FIXTURES
G.'3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided than such improvements ore not intended or altered far NEW RESIDENTIAL ELECTR SQ FT.
sale.Thowever,the building or improvement is sold within one year ofcompletion.me —5� RAµF:A LSQ.FI'.
L
owner-builder will have the burden of proving that he did not build or improve for put. Iul 1
pose of sole.).
TOTAL:
I,as owner of the pmpeny,nm exclusively conauding with IicenscJ contractors uo � n
construct the pmject(Sec.7044,Business and Professions Cade)The Contractors Li- IYI AY 041999
cerise Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
Who oxamac s for such projects with a commetin(s)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
Iamesemptunder Sec. ,B&PCforthismason
ALTER-DRAIN&VENT-WATER(EA) V VAI UATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
1 hereby affirm under penally de perlury one of the following declarations:
ns:
(have and will maintain vCcrtifcam ofCanmmmsdLinsure for Worker'x Compete DRAINS-FLOOR,ROOF,AREA.GOND, STORIES TYPE CONSTRUCTION
.Bart,as provided for by Section 37M of the Labor Cale,far the performance of the t)
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insumbec,as required by Section
3700 ofthe Labor Code,for the performance attic work for which in,pcmrit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My War R Compcmation lnsu�gr pre unmoral PoC Rule, licy py Olyg:-'�./ — GAS-EA.SYSTEM-OVER 4(EA)
CERT(dCIIaATF:OF EXEMPTION FROM(WORKERS'Y GREASrANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION LEES
finis section needmm be cnmpletW ifthe permit is formic hundred dollars(SURE GREASETRAP
or jx..) PLANCHECK FEE
I certify that in the performvneeofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner m as m become subject to the Workers'Compton- ENERGY IEE
ISIZ�Z smion Laws of California.Dam WATER HEATER W/VENT/ELECTR GRADING FEE
Applicant 1
In NOTICE TO APPLICANT:If,after making this CeniBcate of Exemption,you should WATER SYSTF.MITREATING SOILS FEE
a ; income s.bjecuo the Workers Compensation provisions of the Lahr Cade,you most
Da r4 forthwith comply with such provisions or this permit shall he disclosed revoked WATER SERVICE.
0 PAID
i 4
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FI'. Done Receipt g
I hereby alfrm that there is a construction lending agency for Ne perfom
rmnce of
the wank for which this Permit is Lamed(Sce.3097,Civ.C.) V
QV Lenders Name
{LI Lender's Address TOTAL:
I cenify that I have read this application and state that the above information is
i-4 rA correct.l agrte to comply with all city and county ordinances and state laws rclotiogm QTY. MECHANICAL PERMIT FEE
(„) building contraction,arta hereby authorize representatives of this city to enter upon Ne
above-mentioned property for inspection purposes. PERMIT ISSUANCE 3 Q
(We)agree m save,indemnify and keep harmless the City of Cupenind ngainn
hadlines,judgments,casts add expenses which may in anyway accrue ugainsnsaid City ALTER OR ADDTO MECH.in cosequence of Ne gunning of Nis permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT(TO BLOW CFM)
SQURCF.REGULATIONS.
pf'�yt-(q a � 5/�/•//99 AIN HANDLING UNIT(OVER 10,050 CFM) CONSTRUCT( NTAX
^!�4pl
�amre of Applsont/Commem Dam EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store o (TO r handle hazardous material HEATING UNIT O I00,M)BTU) . 2
—/a
as defined by the Cupertino Municipal Cada,Chapter 9.12,and the Health and Safety HEATING UNIT(LIVER 100,011 BTU)
Coda Section 25532(a)9
(]Yes VENTILATION FAN(SINGLE RESID) PAID Dam Receipt#
_ WII the applicant to future building..pool use equipment u111-1-1 which BOILER-COMP f3HP OR 100,000 BU)
T
emit hazardous air contaminates as defined by Ne Bay Area Air Quality Management TOTAL:
DistrictP Yu IO.No BOILER-COMP(OVER I00.000 BU)
T
❑
I have readme Intonations materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE.
fomia Health&Safmy Cal,Sections 25505,25533 and 25534.1 undeauuM Nat Bthe NEW RESIDENTIAL.MECH. SQ.IT. r^ Q
badmngdcesnoncurrentlY an tcnanL Nat itis my responsibility no notify the acupoit — /
of uirtmcnaw 'h st be me eofaCenilicatc of Occupunc.
outhorzcd ag 1 Date TQ I^ ISSUED BY:
OFFICE