S 0949 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MBCIIANICAL S 0949
BUILDING PROJECT IDKN'1'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Iozo 9 lbyE�LV Cr cu Pf-Z -tN CA q ,5-o 1 y p
OWNER'S NAMf:: IIONE: CON'I'RACfOR'S NAME: LIC NO
fF I t d-0De O LE ¢O�2S'12-q197DvcKwok — NIC CON"1 Rlll,k
ARCHITECLENGINEER: LIC NO: AQDRE.SS:_ ,I� v�N R V E1 ❑
CONTACT: �^�P gw'+a"� C✓! (sec �I BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM} MECH
¢o g-9 8&-696 ❑ ❑ C�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
I hereby affirm thin 1 am licensed under provisions, Chapter 9(commencing JOB DESCRIPTION
DMZ with Section IINgB of Division 3 ofthe Business and Professions Code,and my license is
W O p tui PERMIT ISSUANCE ��"
FF in full force and effect. FDWI. C3 KITCHEN REMODEL.
JUUM License Class LIC.k APPLIANCIiS-RESIDENTIAL ❑AUDITION El PLUMBING RF:-PIPE
F Z U ❑ate Comracmr
NQa ED MULTI-UNIT El STRUCTURAL
�u,iK AR CHIT EC TS DECLARATION PANELS
C)C rn Z� 1 understand my plans xball be used as public records MODIFICATION
i OZ4 UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I r.,4C Licensed Professional 201-1000AMPS IMPROV17MEW (]SWIMMING POOLS
Q,W:, OWNER-BUILDER DECLARATION OVER 1000 AMPS
❑BATH REMODEUREPAIR El DEMOLITION
W Q 1 hereby M.that I am exempt from the Ci nwemr's License Law lion the
,SI5Ld 4 V following mason.(Section 7031.5,Business and Professions Cade:Any city tar coumY SIGNS ELECFRICAL CI OTHER
W 3 W F which requires n permit to constmct,alter,improve,demolish,or repair any suucturc I /J
prior to its issuance,do,requires the applicant for such permit to file a signed statement SPECIAL Cl RCUITIM ISC. '
C�QE thin he is licensed parxout to the provisions of the Contactors License Law(Chapler9 COMMERCIAL;
�CQC) (commencing with Section 7")of Division 3 of the Business and Professions Cod.Oar TEMP.MITER OR POLE INST.
6y Ibat he is exempt therefrom and the basis for the alleged exemption.Any violation of E3 NEW BLDGIADDITLON ❑DEMOLITION
it Section]031.5 by any applicant for a pcnnil subjects the applicant too civil ponulty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZNnot more than Eve hunJre dollaa(ESIXII. IMPROVEMENT
SQp ❑La.wntt of the propcny.or my employees with wages as Neirsolecompcnsntinn. SWIMMING POOL ELECTRIC
F- wdldo Newark,andthes0ucture is nmintcndcdmotEmdforsale(Sce.7D .Business ❑OTHER
W3 and Professions Code:The Contractor's License Law(fact not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny,who builds or improves thereon,and who ares such work himself or through
his own employees,provide that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Fn
sale.If.howewc.the building or improvement is said within one year ufeompletiun,the ` ' vSQ'�
ovioner-builder will have the burden of proving that he did not build or improve for par- RECEI V E
Q}(^mc a sale.).
owner of the property,am exclusively contracting with licensed convect".to TOTAL
wct the project(Sec.]IH4.Business and Professions Cee:)The Contracmr's Li- O 6 1f1[1�
cense Law does not apply to an owner of property who build or improves lhcreon.and QTY. PLUMBING PERMIT FF.F. NOVIY V 1.7.7
who contracts for such projects with a contractor(s)licensed pm uam.,he Cnmructor's
License I.uw. PERMITISSUANCE
(]1 am exempt unit Sec. - .B&1'C f tpr hiF reason 1
//la��„s^/�/- ALTER-DRAIN&VENT-WATER(EA)
O
W nderp COM of .ATI ON DfiCLARATION I f RACK FLOW PROTCCf.DEVICE -
I hand will ma under penalty of ofCon onecid of the following declarations
n,:
❑ Ibase and will far
eCmificatenf Ce Labto or Code.far the
Worker's Cooper- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TVI'ECONSTRUCTION
smirk,as provided for by Section d. of the Labor Code,for the peAormanm of the
work for which this maintain
is issued. FIXTURES-PER TRAP
❑1 have and will maintain he porf'a Compensation Insurance,h his pend by Section
3700 of the 1.ubnr Code,for the performance of the work for which this permit is lamed. GAS-EA.SYSTF1vl-I INC.O OU'I'LF:TS OCC.GROUP -APN
My Worker's Compensation Iint ance carrier and Policy number are:
Cartier. Policy Na.: GAS-CA.SYSTEM OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORK17RS' GREASI%INDUSTRL WASTE INTF,RCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This section need nm W completed if Ne permit is for one hundred dollars R l W) GREASE TRAP
or less.) 1'LANCHCCK FEE
I certify that in the performance ofthe work for which this Permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
rat employ any person in tiny instanter so as to became subject in the Workers'Comper- ENERGY FCC
O Z action Laws of California.DateWATER HEATER WIVENTMLEMR GRADING FEE
Z Q Applicant -
i.a y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENIG REATING SOILS FEE
abecome subject to the Worker's Compensation previsions of the Land Code,you must
{Ll forthwith comply with such provisions or this pcnnil shall hedcenreJ revoked, WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
Z [)-are
I hereby at that them is a construction lending agency fmthe performance of
iconstruction R e
LAthe work far which this permit is issued(Sea 3097,Cis.C.)
O V Lender's Num. TOTAL:
Lender's Address TOTAL.
r
L>. I certify that I have read this application and state that the above information is BUILDING FEE
correct.l agree to comply with all city and county ordinance,ending,lawsrelalingm QTY. MECHANICAL PERMIT FEE
building condonation.and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
condonation.above-mentioned property for inspection purposes. PERMIT'ISSUANCE(We)ague to save,indemnify and keep micaless Nr.City of Cupertino against ELECTRIC I'E'
liabilities,judgmenls,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE O
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL I M
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 111,0110 CFM) CONSTRUCGO TAX
Signature of ApplicanVContractor Date EXHAUST HOOD LWMUCIT HOUSING MITIGA ION HE
'HAZARDOUS MATERIALS DISCLOSURE
Wilida pplicnntorfnumbuilding occupant uouorhondle himadnus material HEATING UNITGO 100,0(1(1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100.0110 BTU)
❑Yos ❑Nn PAID
VBNTILATION PAN(SINGLE RESID) Dole Recelptp
Will the applicant or future building occopaat use equipment or devices which BOILER-COMP(31IP OR I W,pgl8TU1
emit hmmJous air contaminants at defined by the Bay Area Air Quality Management TOl'AL:
IVFJ
Ulstrict? BOILER-COMP(OVER 100.000 BTU)
E]Yes El No
I have mind the hazardmas matcrins requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.PT.
building does not currently have a tenant.that it is my responsibility to notify the occupant �reL
of the requirements which must be tract prior to issuance of a Criilicale of Occupancy. 5,5
'
Owner or aulhnriuJ agent Omc TOTAL: ISSUED BY: Tt
OFFICE