00010111 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ✓ Doc) I U I
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT'NO.
BUILDING nIVISIDN APPLICATIONIPERMIT PLUMBING-MECHANICAL.
/BUILDING PROJECT IDENTIFICATION 011.71,".
BUILDING ADDRESS: SANITARY NO. APPLICATI N SUZIIMI�AL DATE
ANI,LOWNER'S B: — PHO ' CONTE DR'S NAME: LICNO:
NIC CONTROL#
ARCHITF HR: ADDRESS: ❑
CON'TAC'T. PHONE fjf,�,gjn ';1BUILDING PERMIT;MFO!/'I,�' -
❑ Consultant Feet,Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
&i
LICENSTIJ OMI RACTOR S DECLARATION j.. r tl'+•• 1 fj" ❑ ❑ ❑ ❑
QTY 'IT li CLECTRIC PERMIT I I FEET
l herehy alrrmt ,lam l' n.edud p fChapte 9(mmme g I I", ., -r.l•I ji sa• easrer, JOB DESCRIPTION
'aZ th Scafon9sM01hfD '�13efdrolbue,ii os.si Ieandmylie< r RESIDENTIAL:
FOO in Iforce.at ellen PERMITISSUANCF,
=Hr U '" 0 SFDWL 0 KITCHEN REMODEL.
aUZU License Cl' Lia.#Dme APPLIANCES-RIi51UFN'I'1AL OADDITIDN OPLGMRING RE-PIPE
NL
FOy ARC111TOR PANIiLS ❑MULTI-UNIT ❑STRUCTURAL
Z O r�dZ 1 undersunderstand my plans sl be,used
used as public records MODIFICATION
pZ=q UP TO NM AMPS OINTERIOR El CHIMNEY REPAIR
Niicensed l'rofes.cinnal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
,^,^�� OWNER BUILDER DECLARATION OVER WMAMPS O BATH REMODEUREPAIR ED DEMOLITION
O G I hereby elfin that I am exempt form the Contranor's License law for the
?1$O y U following reason.(Semina 70316.Business and Professions Cale:Any city or county SIGNS ELECTRICAL C OTHER
FO y which requires a permit to consumer,alter,improve,dem akla,or repair any xteunme
4 prior to its issuance.also rac fres the applicant(orxuchpermit to lileasignedxtmemunt SPECIAL CIRCUI I MISC.
y, mode is licensedpurstmnno thc,owisinns of the Contractors Licence Law(Chapter 9
00 00 (commencing with Season 700()nf Division 3ofthe Business and Poolessions Code)or I'EMI'.MITER OR POLE INST. I
a q M f� that he is exempt themfrnin wJ the kavis for the ullegul excmntion.Any vinlmion of NEW BLDG/ADDITION 0 DEMOLITION
% W Section by anyapplicaut for al cro iE subjects the applicant a civil penalty of POWER HEVICIS
W..y ENA ❑FOODSERVICE
t more than five hundred dollars(S50E O IM L'MENT
' Q 0 Las as net of me property,no my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
[.. will do the work,and the structure is notmucnded oroffered for sale Der.7044,nosiness ❑OTHER
L�' end Prolessions Code:The Camara, s Licanse Law does not apply to nn owner of OUTLETS-SWITCHES-FI%T'ORF.S
property who builds or improves thereon,and who does such work himself o1 through
his we employees,provided that such Improvionem,are not intended or offered for NEW RFSIDHN'I'IAL ELECTR SQ ET
sale.IL however,the building or improvement is sold within one yeerrfcomplcnirn,the SQ.PT.FOOR AREA $/SQ.FT.
r-build,,will have the bunko of proving that he did not build or improve for pur-
posenfsowrac
1,as owner of the prrpxty,um exclusively contracting with licensed<nmmemrs to TOTAL:
construct the project(S 1144 Business nd Proassionc Cok:)The Contractors Li ..
coast,Law d :notPPY it) f property who milds ot- p :marcran.and QTY. PLUMBING P1ERMIT
who contracts(rsuch p jnwith nummnrKs)licensed purrocant tothe Contractors Nr 3,
License
Licen: Law.
1 PFRMI I ISSUANCE
❑I am exempt under See. ,H&PC[or this r<vsnn
Is
{ Owner Dan ALTER-DRAIN&VENT-WATER(HA) VALUATION
WORKER'S COM PCNSAI'[ON DECLARATION BACK FLOW PROTECT DEVICE - / I 0
w❑ I hereby ulfn,under penalty of p Tone of the following d,damm:
tinf. V
I have and will nmlnmin aCertiGcme ofConsennn self home,for Workers Compen- DRAINS-FLOOR,ROOF AREA,COND, STORIES TYPE CONSTRUCTION
scion,as provided for by Section 3]00of the Labor Chale,for the pcfif ami nce of me
work far which his pa'.it is issued. FIXTURES-PER TRAP
0 I have and will maintain Woker,Compensation Insurance,as required by Sworn
3700 fthe Labor Code.for the fK 'mance of the walk for whichthis permit is issued. GAS-EA.SYS EM-I INC.4 OUTLETS OCC.CROUP MIN
My Worker' pensation ins arand P licynunt��a GAS-EA.SYSTEM-OVER 4(EA) _�
none
CE IFI (l 10, FI )M w _,#A�r�I OREASUINIIUSTRL WASTE INTERCEPTOR
� 'F k plT and"rtd doll" r ,I1UILDING DIVISION FEIiS -
Chi-.¢��tihpAcyd / /t(Jfor"rte a.(SIM) GREAMiTRAP
orlers.) II I/�V - PLANCHECK FEE
Ic'tifythulinthe pafurmnncentt ewer fol hi chthisparmaxissueQlehall SEWER-SANITARY-STORM EA,2IM FT.
not employ any person in any manner so as to become subject the Workers'Conifer- ENERGY FEE.
O z stolon Laws cCidifrrnis,Data WATER HEATER W/VEN'P/ELECI'R
Z O Applicant GRADING FEF.
rj) NOTICE TO APPLICANT,If,after making this Certificate of Exemption.you should WATER SYSTFMITREATING
paranoia mbprat m the Worker,Contpenxalinn pm,odoes of the Lab'Code,yon must SOILS FEE
fill forthwith comply with such provisions or this penin tledl The deemed revoked. WATER SERVICE
Q
pz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
V Q I hembyoh(hi thanhem issued(Set.30 lending agency for the performance of Dom Receipt#
U the walk for which this permit is issued(Set.3091,Civ.C.)
p Lender's Name TOTAL:
U F 4nJer' Address 'TOTAL
I :G certify that 1 comply
this pplbt t d state hitt the shove information x -t - , , - c BUILDING PEE
w+ to correct 1 agree m comply Ih II sly and countyordinancesand store laws minting ht QTY MECHANICAL PERMIT I " i-'(',FEE' '
C..) Z building constitution,and hereby authorize representatives options city m enter upon Ore I - I" 1 e Is, SEISMIC FEE
abnve-mentional property for I"xnection purposes. PER s
(We)agree to cave,uncannily and keep harmless lbs City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,casts and expenses which may in any way acme agninet said City Ala ER OR ADD TO MSCI I.
s men rf the granting of this Permit. PLUMBING F'EE
APPLICR INDERSTANDS AND WILL COMPLY WITH ALL NO POINT AIR HANDLING UNIT TO 10,000 CPM) MECHANICAL TEE
SOU ,ERI ILATIONS. \ n r-�-- 1��
/\Q/�11.J1'll//lJ!-1/_sem-•7/ AIR HANDLING UNIT(OVER 10,000 CFM) CONS'1'RUCTION TAX
Signmure ofApp6<LnVCummw
[)me EXHAUST HOOD(W/DUCJ HOUSING MITIOA'1'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi111heapplleant nr moo,building occupant score ndbundle[,a...dnuxmaterial HEATING UND(TO IW,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532NC HFATING UNIT(OVER IMist)If FID
I-]Y" PAID
VENTILATION CAN(SINGLERR51U) Date Receipt#
• WILI the applicant or future building occupant use ea Air Qin o1 devices whish BOILER-COMP(311P OR 100,000 BTU)
emit District?
us air c'nntnminuntya;oklined by the Buy Area Air Quality Management TOTAL:
Disvia7 VALTN.Nv. BOILER-COMP(OVER Pak000 BTU)
❑Ycs _ I
I have read the hasardous mmerial.+rcyuirements under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
fumi I leul Safety Code,Section,25505,25533 and 25534.1 midectnnd that if the NEW RESIOEN'PIAh MIiCH. SQ.T"L
huildin ore ty have s,a t ,nus ryrecpnnsibibt to notify eoxcupmht
rfthe i •nbTM'chrah in nauance otic Cer t tin
9PJ;1y
Owneihn gem at 'TOTAL:
ISSUED BY:
OFFICE