S 0274 APPLIUAN I IU PILL IN INYUHMAI IUN WI I MIN MGU LINtS-USt WALL PUIN I PIN ONLY
CITY OF CUPERTINO I BUILDING.ELECTRICAL PE.`V IT N0. O 1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINOO$5:� � SANITARY NO. APPILICAyON SUBMITTAL DATE
OWN E 'S Np /V4 NTRACTOR'S NAME: LIC NO: y`/9
I/ N/C CONTROI,tl
^CHITECT/ NE R: L DRESS:
CONTACT. ys E BUILDING PERMIT INFO
L `
// ❑ Consultant Fees Paid by Applicant(Initial) Dc ecr wM0 MECH
LICENSED CONTRACTOR S DECLAR T QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
wOZ with Section71100 ie'Division3of the Business and Professions Code,and my licensees
Fs'r is full force end ea PERMIT.ISSUANCE
�W /Q - - FDWL O KITCHEN REMODEL.
UzU License Class xLIC.M 6
yQ0. Date Contractor APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLA TION PANELS ❑MULTI-0NIT ❑STRUCTURAL
Z O VI7 0 runaround�ny plans shall be used as public records - MODIFICATION
024O UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
[=; {y iterated Profesatonal 2e11-1tl(N1AMP5 IMPROVEMENT SWIMMING POOLS
`JS` , la
a{ OWNER-BUILDER DECLARATION [I'
I hereby arm that I am exempt from she ContractorEl's License Law for the OVER 1000 AMPS BATH REMODF.UREPAIR 0 DEMOLITION
3 W F following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
p vv11 which requires n permit re nce.also requires
smeL alter,improve,such permit t fi repair any srucwre
CSO; pallicr toIflts ee edinuound mina mosixlicamfor CmdratrmlGoflen,Law statement SPECIAL CIRCUIT/MISC,
thallic is llansed pursoauvothe pmvisione oFlhe Contractor's License Law(Cbeper9
W AC (commencing with Sehion700o)of Division 3afthe Bra,messand Professions Code)on TEMP.METER OR POLE INST. OMM R IA
d y e eL that he is exempt therefrom and she basis far she alleged exemption.Any violation of ❑NEW BLDG/ADDITION ,EIDEMOLITION
W,^'vr Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICES ]TENANT 6��[alFDOD SERVICE
F y t mora then fve hundred dollars($500). �/ IyML.Yp,D
Oa ❑I,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVE
,pqy( isIt do the work.and the stocture is not intended or offered for sale(See 704q Business 00TH R
a a and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES rc' ur tI(}•
property who builds m improves thereon,and who does such work himself on through
E�I17Y�
his own employees,provided that such impravemcuts are not intended nr offered for NEW RESIDENTIAL ELECTR SQ FI'.
sale.If,however,the building or improvement issold within one yearofcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par-
po ,,awov e 1
se of sale J' IF /1C
0 1,as owner of the property,am exclusively contracting with licensed cantations to TOTAL: , /7
.same,the project(Sec.7044,Business and Professions Crxle:)The Comm na'a Li-
cense Law does not apply to an owner of property
i-censeLowdoesnotapplytoanownerofproperty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)Licensed pursuant to the Contractors
Licenxe Low. PERMITISSUANCE
C]1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER ) It r
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. VICE
1 hereby affirm under penalty of perjury as or the fallowing declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,ARElf.IIIN2Z Ali STORIES TYPE CONSTRUCTION
scion,as provided far by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP VAI/�
0 I have and will maintain Worker's Compensation Insurance,as required by Section Y
37011ofthe Labor CWd.forthepefformance ofh workfe w ich the permit is p d. GAS-EA.SYSTEM-1 INC.40UTLETS OCC.GROUP ,APN///
My Worker' ppyiot�wyy app-Poky No.:
ea AS-EA.SYSTEM OVER 4(EA)
Cartier: !Y'jV r J 7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES'
(Thissectionnwdna becompleted W ire permit is force It
dollars IS'
GRP.ASETRAP
or less) PLANCHECK FEE
I certify that In the performenea oRbe work for which this permit is issued,I shall
SEWER-SANITARY-STORM GA 200 PT.
not employ any person in any manner so as so become subject m the Workers'Compen- ENERGY FF.F.
,L) Applicant
Laws of Culifnrnin.Date Cd Z
Z
O A licem � WATER HEATER WNENT/ELECTR
PP GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenilicee of Exemption,you should WATER SYSTEMRREATING SOILS FEE
a become subject m the Worker's Compensation provisions of the Labor Code,you must
W F-t forthwith comply with such provisions or this permit shall h deemed rovoked. WATER SERVICE
Q
Dz CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT. PAID 7!4_V
U 0 l hereby affirm that here is a construction lending agency for she performance of Data Rec tN
LL F the work for which this Permit is issued(Sec,3097,Civ.C.)
0 Lenders Name V TOTAL:Lenders Address TOTAL:
I certify that 1 have read this application and state that the clowe information is BUILDING FE ps
�ID
nx fA emni lagreemcomply withal)city and county ordin9ncesandstnm lawsnchour,to QTY. MECHANICAL PERMIT FEE
V building eanswctusumid herebyoohorize represenmtives efthis city to eme,,am the SEISMIC FF;
shove-mentioned properly for inspection purposes. PERMIT ISSUANCE
(Wa)agree to save,indemnify and keep harmless the City(if Cupertino against ELEC'BIC
Iiabilities,judgmenls,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEV t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO IRIXIB CFM)
SOURC ULATI S. MECHANICA.FEE IIII
'O s AIR HANDLING UNIT(OVER O% ,WO CPM)
�d ` — CONSTRUCIION TAX �
7 ignawre Applicant/Contmctm 'Date EXHAUST HOOD(W/DUC) HOUSIN MITIGATION FEE
HAZARDOUS M RIALS DISCLOSURE,
Will the applicant or future buil mg occupant store or handle hazardous material HEATING UNIT('TO IOgWO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
s ❑Yes F1 No VENTILATION FAN(SINGLE RESID) I PAID
Will thea applicant or future building occupant use t or devices which ¢ Receipt N
PP 6 P ea Air n BOILER-COMP(3HPOR I00,000BTU
hazardous air contaminants as Defined by the Bay Area Air Quality Management )
Olsfricl? TOTAL:
1 ❑Yes ❑No, BOILER-COMP(OVER 100.000 RTU) _
1 have rend the hamfdons materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH.
building does not currently have a tenant,that It Is my responsibility to unify the occupant
of the requirements which muss lw met Prior In Issuance of a Certificate of Occupancy
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE