S 0980 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING-ELECTRICAL PE$MITNO. 0980
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J`
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10sqIt ZIVKC kwu-e t
W ER' NAME:/� vaJ '\CV PHON''� b/ TOPS NAME: LI7]�
NO:
/V�`.''.✓ AAVVII C O I__ �� I �,� CONTROL%
TECT NGIpIEE LIC NO: ADD SS�,,q•
I/
Co cT: 0- ( PHONE: - BUILDING PERMIT INFO
COT(_ rt` 43- -P_ ❑ Consultant Fees Paid by Applicant Haiti a BLDG ELELI un ME'CH_
LICENSED CONTRACTOR'S ECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am Reemaea nnaer viscous of chapter 9 eedmmenemg JOB DESCRIPTION
0%z with Scalum70N))of Division,a,the Boniness and Professions Core.and mYllcenseis
�OO cur PERMIT ISSUANCE
�UUin fall force and,Beat.
License Class Lic.K Ile,DWL L1 KITCHEN REMODEL
F Dam Contractor 'APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL
PANELS
a
[Or t7/rZ londerstand my plans shall named as public records MODIFICATION
9
oz-n UP TO 200 AMPS
F4E'W Licensed Professional El INTERIOR ❑SWIMMINGF CU
ad OWNER-BUILDER DECLARATION 201-IfNN1AMPS IMPROVEMENT SWIMMING POOLS
a C a 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER law AMPS [_1 BATH RF.MODEL/REPAIR 0 DEMOLITION
iq5
W'30,U following reason.(Section]031.5,Business and Profess inns Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL y¢ which requires a permit 1.construct•alter,improve,demolish,m repair any suucmre �' p
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M ISC.
}
that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9
LL Q0 (commencing with Section 701011 of Division 3 of the Business and Professions Code,or TEMP METER OR DOLE INST. ,.
d qo IL that he is exempt therefrom and the hasis for the alleged exemption.Any violation of a permit EINE / RIO DEMOLITION
fi Section]0,1.5 by any applicant for peit wit acts the applicant to a civil penalty of POWER DEVICES
NT OOD SERVICE
not more than love hundred pmpt dollars y amp. �Z �
CyQ ❑ Las othewrk,the propeny,Onnyet intended with wages erect fothei(Sec.compensation, SWIMMING POOL ELECTRIC R�i'/EMENT —
CiG 0 will dothewons and the The [ore is char's kende offered s not apply to an Business ❑OTHER IrVY
4 'm and property
who
Code:The Con thereon,
License Law dreg not apply s an owner Of OUTLETS-SWITCHES-Po%TURES
his owy who builds or improves thereon,and who does such work himself or through
his own employees,e provided that such improvements are nor intended nrpleered for NEW kESIDENTIAL ELECTR SQ PT.
ovener-Ihowevecthbsethburdding car en ofp.in issold he lid mn build
r of I a,improve
the = SQ.FT.FLUOR AREA $/SQ.PI'.
r-builder will hove the burden of proving ohm he did not build or improve for par- `�
�
Pow cof sale.). -
❑ I,as.,our of the property,am exclusively contracting with licensed amumsons to
construe[the project(Bee.7IW4,Business and Professions Code:)The Contractors LI-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, LUMBING PERMIT FEE
who contracts for such projects with o comractod s)licensed pursuant o the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason PERMIT ISSIfA E
Own Data_270ALTER-D N&VENT- TERRA) /tom VALUATION
�
WORKER'S COMPENSATI DECL ATION BACK FLOW PR .DFVI
y affirm under Penalty of. one of the all .e owing declamrionits—
E]
�
❑I ve and will maintain a Certificate of Consent m self-insure for Worker's Compen- DRAINS-FLOOR,BOOP, ND. STORIES TYPE CONSTRUCTION
.sation,as provided for by Section 3]00 of the Labor Code,for the performance of the -
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
73700 of the Labor Code,for the performance ofthe work for which this permit is issued GAS-F.A,SYSTEM-1 INC 40UTL S OCC.CROUP APE
My WOrker'p Co an tion Insureeaeea cam' d Policy nm sai
Carver: F pgTONFRO GAS-EA.SYSTBh1-OVER4(EA)
CERT I I ATE OFcogR,E EX rTON INSURANCE
WORKERS'
COMPENSA'f10N INSURANCE GRF.ASFIINDUSTRL WASTE INTERCEPTOR
(This section neW not be completed if the permh Is forone hundred dollars($100) I I IVISION PEES
or less.) GREASE TRAP PLANCHECK �
I certify that in the performance of the work for which this permit is issued.Lsball
not employ any person in an mannerso as to become subject m the Workers'Cum SEWER-SANITARY-STORM EA.201 FT.
y , pen- ENERGY FEE �
C) Z sound Laws of ColJomia.Data WATER HEATER WNENT/ELECTR
Q Applicant - GRADING FEE
0 NOTICE TO APPLICANT.If,after musing this Certificate of Exemption,you should WATER SYSTEM/TREATING
abroame subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions Or this permit shall be deemed revoked. WATERSERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
U0 ..,it
rwhich that Front iisseomuudion lending agency for the performance of Data ReceiptM
[Iw H the work for which this permit is issued(Sec.3097,Ci,CJ
O U Lenders Name - w. TAU
W Lenders Address _
I certify that I have read this application and state that the above information is BUILDING FEE
Lit) correct.1 agree to comply with all city and county ordinances and Wadi laws relating to QTY. MECHANICAL PERMIT FEE
building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE It
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep handless the City of Cupenino against ELECTRIC
liabilities,judgments,crusts and expenses which may in anyway acedia against said City ALTER OR ADD TO MECH.inconsequence of the granting Oflhis permit. PLUMB GFEE
APPLICANT UNDERSTANDS AND WILLCOMPLY WITH ALL ON DINT AIR HANDLING UNIT(TO IB,aw CFM)
SOURCE GULATIONS. q MECHANICA tEE
I/(,
(, AIR HANDLING UNIT(OVER IQtw)CFM) CONSTRUC ONTAX
, r fA,dicent/Cmararor Data EXHAUST HOOD GVMUCT) HOUSING DATION FEE
HAZARDOUS MATERIALS DISC SURE
Will the applicant r future building occupant store or handle hazardous material HEATING UNIT(TO 100.00)BTU)
as defnul by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? HEATING UNIT(OVER IOn"BTU)
El Yet, ❑NO
' VENTILATION PAN SINGLE RBSID) PAID '-
Will the applicant or arts.,building occupant use equipment or device.'wDam ceipt Nhich BOILER-COMP(3HPOR 101,000BTU) '
'nutiel'i ue air conmminenss as defined by the Bay Area Air Quality Management TCI.
Uistrid?
❑Yes Fl No BOILBR-COMP(OVER IW,(%w BTU)
AIR CONDITIONER
I have mad the hazardous materiels requirements under Chapter 6.95 of the Call- AIR
p71TE
tonic Health&Safety Code,Sections 25505,25533 and 25534.1 to notify
that if the NEW RESIDENTIAL MECH. SQ.FT. i'- (l'•(�jJ(
building does not cunemdy have n tenant.that it is ua responsibility Certificate
ro notify the Occupancy.of the m;uiremcnss which must be met poor roissuance nfa Certificate of Occupancy.
Ownerorauthorized agent Data T L. ISSUED BY:
OFFICE