S 0971 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 0971
BUILDING PROJECT IDENTIFICATION
- BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
2 tgl"45G Averr
OWNER' A.• PONE: CONTRACTOR'S NAME: LIC NO:
tICONTROLp
RCHITECT/ENGINEER: IC NO: ADDRESS: ❑ vat`
CONTACT /yyykHH'ONE BUILDING PERMIT INFO
V /— 6& o ❑ Consultant Fees Paid by Applicant(Initial) LDG ELECT PL MECH
ie6.�
LICENSE ONTRACTOR'S DECLAR TION QTY. ELECTRIC PERMIT FEE
1 hereby affrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Op'Z th Section7")of Division 3 ofthe Business and Professions CME,and mylicenseis RESIDENTIAL.'
FWr infullfurricd effect PERMITISSUANCE �DWL ❑KITCHEN REMODEL
�U(I License Class Lick APPLIANCES-RESIDENTIAL ADDITION El PLUMBING REPIPEyah Date Contractor
ARCHITECPS DECLARATION [_1 MULTI-UNIT ❑STRUCfUkAI.
Z p r=an/+' 1 understood my plans shall be ueN as public records PANELS MODIFICATION
OZ49Z UP TO 200 AMPS �INN'TfFF�22It](2 P, ❑CHIMNEY REPAIR
r'3 t"{�r. Licensed Pnd'exsional 201-IOW AMPS TI117PR'&ENT L3 SWIMMING POOLS
Lt("+�jcyz"J•.t 'OWNER-BUILDER DECLARATION
6 I hereby affrm that I am exempt from the Contractors License Law for the OVER]Bob AMPS ❑BATH REMODE,1V�$`"��AIR ❑DEMOLITION
O d V followingreason.(Section 703 L5,Business and Professions Code:An t t H_ �[F� n ntt''"
yciynr couny SIGNS F.LECTftICAL
4 O F which requires o permit to construct,alter,improve,demolish,or repair any svuccum
yprior toits issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. _
that he is licensed pursuunfto the provisions of the Contractors License Loss(Chapter 9
ly ipO (commencing with Section 7")of Disislom 3 of he Business and Professions CMe)or TEMP.METER OR POLE INST.,
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ' ¢IEVTBLDG/ADDITION ❑DEMOLITION
xy WSection]03LS by any applicant for a permitsuhjects the applicant to acivil penalty of POWER DEVICES
W^e, ❑TENANT ❑FOOD SERVICE
p; not more then five hundred dollars($501l).- IMPROVEMENT.
6El1,os owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
S� will do the work,and the.structure is not inumdedoroffored for sale(Sec.701 Business ❑OTHER
and Professions Code:The Contractor's License Low dons not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through `
his own employees,provided that such improvements arc nm intended or offered for NEW RESIDENTIAL ELECfR SQ FT
sale.If,however,the building or improvement is sold within one year ofcompletion,the / SQ.FT.FLOOR AREA $/SQ.FT
owmerbuilder will have the bvNw of proving that he did not build or improve for purr- ��Q
dsolen)e
1 s r of the properly,nm exclusively oonlructing with licenced wotmcmm to
cons14)
on the project(Sec.7044,Bvdnesc and Professions Code)Tha Gontrdmov's LI-
c se Law does not apply to an owner of propeny who builds or improves thereon,and QTY, PLUMB NG PERMIT FEF. ��
who carriers for such projects with a cemuamm
cr(s)licensed pursuant the Contrdclor'a
License low. PERMIT ISS E
lame uSee ,B&PC'rthiv eason
m u ALTER– IN&VE WATER(EA) VALUATION
Date /�
WORKER'S COMPENSATION DECLARATION PACK FLOW PROT.CT.D 1/kI1;1l
I rd waffirmundo pevnhy teo(Cononeofthefollowingdeclarations: VV / `
Ihav rd will mainWina Certificule of Cnnsenun self-insure for Worker's Compen- DRAINS-lLOOR EA,C
cation, provided for by Section 3700 or the Labor Cnde,for the perfntmunce of the STORIES J1 TYPE:CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section J.
370(1 rifling Labor Cade,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OIIT T DEC.GROUP APN
My Worker's Compensmion losumoce carrier and Policy number are: /
Carrier: Policy Na: GAS-EA.SYSTEM OVER 4(EA) /Q'_I
CERTIFICATE OF EXEMPTION FROM WORKERS' -'
COMPENSATION INSURANCE GRFASErINDUSTRL WASTE INTERCEPTOR
B L DI SION FEES _
(Thio section meed not becomplered iRhe permit is fnrnne hundred dollars F6 IM) GREASE TRAP
ter less) PLANCHECK E -Fo
I certify that in the Performance of the work for which thisperunit is issued,I.shull SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Oz action Lt.,of California,Dote WATER HEATER W/VENT/ELECI'R
Applicant GRADING FEE
O
FN-t NOTICE TO APPLICANT:If,after making this Cerificate of Exemption,you should WATER SYSTEMRREATING SOILS FEE
F ' become subject m the Workers Compensation provisions of the Labor Code,you must
W ,-y forthwith comply with such provisions or this permit shallhe deemed revoked. WATER SERVICE
R 0
UD
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PT. PATO Date ceeiptk
1 hereby affirm thatpermit i Is s ed(Se,30 lending agency for the performance of
sr the work for which this permit is issued(Sea 9!197,Co.C.)
Lenders NameTOTAL'
LUkI Lender's Address A
Ps 1 certify that I have read this application and state Chet the above information is BUILDING FEE
lZi comet 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction.and hereby authorize representatives ofthis city mentor upon the SEISMIC fL
11617
above-mentioned property ror inspection purpnacs' PERMIT ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Cupertino against ELECTRIC NEE
In
liabilities,judgments,costs and expenses which may in any way accrue against said CityALTER OR ADD TO MECH.
in consequence of the gmmmg of this pe mit - PLUMBING F
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10, W CFM) MECHANICAL FEE
SOURCE REG LATIONS.
D, AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
vyl of/ plNmVCmntmcmr Date 6 EXHAUST HOOD OVIDUCT) HOUSING'MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
m de reed by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER Plat"BTU)
El Yet, FIN. VENTILATION PAN(SINGLE RESID) PAID —
Will the lieant or future building occupant useequipment or devices which Date Receipt k
)'. pp gra panBOILER-COMP LIKE OR I 0i BTU)
nit hazardous air contaminants as defined by the Bey Arca Air Quality Management TOTAL
IJistrict? BOILER-COME(OVER I Initial)BTU)
❑Yes [-I No '
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
1 fornix Health&Safety Critic,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
1 building does not currently have a tenant that it is my responsibility to notify the oucupam n
of the requirements which must be met prior in issuance of a Certificate of Occupancy.
Owner or autborized agent Dote T&LI, ISSUED BY:
OFFICE