S 2577 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.MECHANICAL C n C 7
BUILDING PROJECT IDL+MfIFICATION J GJ I
BUILDING ADDRESS: 1� SANITARY NO. APPLICATION$DRMfITAI.DATE
0/.2 C'�iNZ) V ism
OWy[a'S N'AMF:: ✓, PHONECI]y'fRAC Q NAME s ' LIC NO:
l/'•G- NIC CONTROL#
ARCHITECT/ENGINF:EIL AUDR .S: ❑
CONTAC'1'J) 7 _� PHONE. BUILDING PERMIT INFO
�L(LJJ y LC �C3^g DOO ❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I nm ueensea under provisions of Cbapmr 9(commencing JOB DESCRIPTION
QaZ with Beah,n9(1(n97 orDlvlston3onne Buxinexa and Pmmsal99
ons code,and my heen,ela RESIDENTIAL'
W O ERMI'I ISSUANCE
FU� in full forecind effect. ❑SFDWL [:1 KITCHEN REMODEL
IY U E" License Class Lic.#
6 U APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMB[NGRE-PIPE
F; WDate contractor
rn 0. ARCMrECFS DECLARATION ❑MULTI-UNIT ❑S DIFTURA
zo.z I underslandar,,hr ,torl be ned,omblic records PANELS MODIPICATION
OZ`30 UPTO 200AMPS 0INTPRIOR El CHIMNEY REPAIR
F�0.LW Licensed Pmfesaional 201-1000AMPS IMPROVEMENT L]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER I(HMIAMP$
following El BATH REMODEUREPAIR El DEMOLITION
Li
yO U (S
1 hereby affirm that 1 ren counpt&o.the Contract x License Law far the ❑OfHER xd$ LV ng reason Section 90315.Business mai Professions Code.Any city or county SIGNS ELECTRICAL M
W'3 W y
Much requires a permit to construct,alter,improve, I re qi h (it repair any structure / • l
prirrl toi'. o e,olo q ' .th sp,looll kastah,ormita.fl .'gnedawminrd SPECIAL CIRCUIT/MISC.
thorl 1 dpar n Ib p slim . fdr Collusion,L'e. Laos(Chapter 9 OMMFR IAL
0�0 (Commencing with Section Mtffiof Diviaon 3 of the Business and Professions Code) 'P.MP.METER OR POLE I NST. �`'
d m a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADOPTION ❑DEMOLITION
W Secmn1113 L5 by any applicant far a permilaabjcc¢too applicant to o civil penally of POWER DEVICES sem' ❑FOOD SERVICE
m—w tttnone thad live hundred dollars( AE.
[�. d I,as ownernf tiro norm Ioees with wastes ostneiraole cam lino, SWIMMING POOL P.LECf TITER ry1e"QT
Cy�O ❑ property, YetnP Y b' ,Buse TITER
C2 fist will do the work tlnJ lheslmqurc is ma afforded oroHemd furoate(Sec.]1144,Business
m and Mofessionx Code:'1'he Conducuu,License Law does not apply m un ewnor of OUTLETS-SWITCIIES-F S
property who builds or improves thereon,and who driven such work himself or through
his own employees,provided toot such impmvemems am not intended or olfered for NEW RESdDjN'PIAL ELECTR
sale.If,however,the building or improvement is sold within one year of completion,the SQ.' .I' ORI1Rr� 81SQ.FT.
tos ter-builder will have the burden of proving that he did not build or improve for par
-
pese of eule.)' '1 I
El L as owner of the property,am exclusively contracting with licensed c.tractors In ❑11
construct the prefect(See 9044.Business and Professions Code:)The Contractor's Li-
cert
,e Law does not apply no an owner of property who builds or improves thereof,and QTY PLU C PF.RMI
who contracts for such projects with.utntructor(sl licensed pursuant to the Contractor
License Law. PERM]IISSUANCE
❑ lam exempt under Sec. ,B.@PCfnr this rcvaun
ALTER-DRAIN te VENT-WATE VALUATION
Owner Dune
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIC O
1 hereby affirm tinder penally of perjury one of the following declarations
I have and will moment a Certificate of Consent loself-insure for Workers Cmapen- DRAINS-FLOOR,ROOF AREA,GOND. ST RIES TYPE CONSTRUCTION
smion,as provided for by Section 39W of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 hove and will maintain Wedoefs Compenailion Insurance,as required by Section
3700 of the Labor Code,for performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
M Worker'sfjyrlpenpllon Insurance carrierolicy ll GAS-EA.SYSTEM-OVER 4(F.A)Her
LC/EERRTIIFI�
CERTIFICATE OF EXEMPTION F ORKERS' CRF.AS[IINDUSTRL WASTF.INTERCEP'fOR
COMPENSATION INSURANCE BIJIED_MG DIVISION FEES
(This section need not beco.pletad ifthe permit is forone hundred dollarsCSIW) GREASE TRAP
mires) GREASE FEE
I certify that In the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT
not employ any fiction in any manner so as to become subject to the Workers'Cotnpen- ENERGY FEE.
OZ cation laws of California.Date WATER HEATER W/VENT/ELECTR GRADING FEE
0 Applicant
.zl (�/)
NOTICE 10 APPLICANT:If,afrer..kid,this Ccnificate of Exemption,you should WATER SYSTEMaREATING -
`.� nc.ome xobject le he Worker's oma,or Im, ennil shal of the Labor Coda You must
SOILS PEE
forthwith comply wish,uch pravixions or this permit shall he Deemed revoked. WgTER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMB. SQ,FT PAID
Z Ihereny affirm that there is.construction lending agency for the perfonnonce of Date Remipt#
U
0eweak for which this pdamil.issued(So,.3097,Co,.CJ TOTAL:
Lender's Name
WLenders AJdrcss TOTAL'
y, 1 certify that I neve recd thisapplication and stem that the above information is BUILDING FEE
Com. h
copper 1 agree.comply with all city and county ordinances and stale laws miming to QTY. MECHANICAL.PERMIT FEE
U building conumution,vad hereby umhorise representatives of this city m enter upon be SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino stolon ELECTRIC P58
liabilities,judgments,costs and expenses which may in any way accme againu said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of tad granting of this pennn.
APPLICANT UNDERST&NDS AND W MPLY WIT 1.NON-POINT AIR HANDLING UNIT(TO 1o,WBCPM) MECHANICAL FSE
S( CE REGULATIONS.
9 AIR IIANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
rco Applictin ont'ac(.' Dom EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS UIS .O 1 E
Wilidmapplicallor future nuilding occupant atomo .nAlehoeardco uraterial HEATING UNIT(TO 100,00ORTU)
m defined by the Cupertino Muniapal Code,Chapter 9J2, ad the Health and Safety
Cede,Section 25532(a)p HEATING UNIT(OVER 100,000 BTU)
❑Yea ❑Nu VENTILATION PAN(SINGLE R55ID) PAID pore accountp
Will the applicant or future building occupant nw equipment or do',.,which BOILER-COMP(3HP OR 100.Of1f1 BTU)
mil hueardnus air ammmiwnla as def tied by the Nay Area Air Quality Management TOTAL:
District? B0ILPR-COMP(OVER Inputs)B'I'U)
El Yes - [-I No
I have m.dnhe he...far,maleriola reciirentena under Cnapnerfitsof the Cali- AIR CONDITIONER ISSUANCE DATE
fnmin HenhM1&Salary Cal Sections 8505,25533 and 25534. understand that if the NEW RESIDENTIAL.MECH. SQ PC
F, ilding do-ourn c..mdllynave te it is myreaponsibility notify the oecupam
II requirmnema hi 1p c e,I t
or or o dm ood a t Dnm TOTAL: ISSUED BY:_
OFFICE