S 0892 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEBh11T NO. O
APPLICATION/PERMIT PLUMB SIG `�`1
892
BUILDING DIVISION HUILDING FxOJELT IDENTIFICATION
�.
SANITARY NO. APPLICATION SUBMITfAI.DATI
•'
BUILDING ADDRESS:
b G e v 2-al
O NE S NAME: PIIONE: COMfRACTOx'S NAMELIC NO:
1 NIC CONTROLp
CHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLUI PLu�MB NIECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
DMZ with Section 7") Jofthe Business and Pmfwlions Code,and my license is RESIDENTIAL:
W O PERMIT ISSUANCE
F W in full force anJ effect.
❑SFDWL ❑KITCHEN REMODEL
�U License Class Lich APPLIANCES-RCSIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Q Dam Convenor
ARCHITECTS DECLARATION ❑MULT6UNIT ❑STRUCTURAL
t,Dy PANELS MODIFICATION
Z O n Z t understand my plans shall he used as public records
_ UP T0200AMP5 INTERIOR ❑S CHIMNEY
MINGPREPAIR
OL
{O�k Licensed Pndesxinert IMPROVEMENT SWIMMING POOLS
201-IOIFORAM
Y , OWNER-BUILDER DECLARATION OVER Ifpll AMPS ❑BATH kIiMODF.IJREP IK DEMOLITION'
�C 6 1 hereby aRnn that 1 am exempt from the Cessions Co License taw for the ❑OTNER
iNpi5 gs b6 which following mason.Permit
0 construct,Business and Professions h.or min ran or county SIGNS ELF.CTRICAI.
R+LL O t' which requires a permit m construct,alar,improve.Demolish,or repair any structure
mnrtoits issuance,vlsomepa estheapplicent fimench Penniuo fileasignNsamment SPECIALCIRCUIT/MISC.
y, y that he is licensed pursuant it)the provisions ofthe Contractors License Law(Chapter 9 COMMMFRsIAI:
`GO (commencing with Section 701()of Division J of Ne liminess and Professions Cock)or TEMP.MIR OR POLE INST.
6 Q.0 test he is exempt therefrom and the basis for the alleged exemption.Any violation of INST. -1 RLDG/ADDITION ❑UEMOLI'f10N
ern Sectio 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t,Z}
or more thin five hundred dollars(4500). IMPROVEMENT
G ❑I,es owner ofthe ampety,or my employees with wages as their stile compensation, SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the stmcmre is not intended or offered fnrsale(Sm.70UL Business
and Professions Code:The Contractor's License Law does not apply to an owner of OU I'LETS-SWITCHES-FIXTORES -
6 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intendN or offered for NEW RESIDENTIAL ELELTR SQ FT.
SQ.FT FLOOR AREA S/SQ.FL
sale.If,however.the building or improvement is sold whirairme yearofcontplaian,the
owner-builder will have Ne burden of proving that he did not build or improve for put-
, powlifsatry.
❑L as owr of the property,am exclusively contracting with licensed contners mla
ne9'OTAL:
�k pp
construct pmjecl(Set,7044,Business and Preassions Cnd[:)The CoWcm
nrs la- P N
cense Law does not apply to a owner of Property who build;or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjects with a commences)licensed purmanuo the Contractors D`V n
LicenU.Licari. PERMIT ISSUANCE a Palo
I am exempt under Sec. .B&P C far this.,air
At-R-DRAIN&VENT-WATER(E edit ser VALUATION
Owner Dam J fUYC
WORKER'S COMPENSATION DECLARATION BACK FLOW PRCUECT.DEVICE TI I INV
1 hereby affirm under penalty of perjury one of the following declarations:
I Ionic and will maintain a Cenificamof Consent to self-insure for Worked Compen- DRAINS-FLOOR,EDGE AREA,COND. STORIES TYPECONSTRUCf10
station,as provided for by Section 37M of the Labor Code,lot me performance of the
w' Is for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
W37 0)of the Labor Code.for the performance of me work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLETS OCG GNOIJp APN
My Wor ex Co n t. I sum�nucq��ffintto and Policy '�
Cnniee�{.•LI�ILMj- olicY NnGAS-EA.SYSTIiMOVERi(FA)
CERnMCATEOF EX ION FROM Wi)RKER$' GRHASMISDUSTRI,WASTE INTERCEPTOR
COMPENSATI N INSURANCE BUILDING DIVISION FELLS
(I his section need not becompletedIthe permit is forom hundred dollars($100) GRHASETRAP
a less. PLANCfINAK FET.
Iccnify that in the performance of the work(nr which thispennais issued,Is hall SEWER-SANITARY-STORM EA.200 FT' ENERGY FEE
not employ any person in any manner so as in become subject to the Workera Compen-
,Z sation laws of California.Date WATER HEATER WNENTIF.LECTR GRADING FEE
Applicant 1
fq NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WA'T'ER SYSTEM.PREADNG SOILS PER
'••t become subject to the Workers Compensation provisions of the Labor Code,you mu.d
Lakl forthwith comply with such provisions or this Permit shall M deemed revoked. WATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEWRP_SIDENTIALPLMB. SQ.PL Date R eiprg
U O l hereby affirm that there is a convection lending agency for the performance of
{L E the work for which this Permit is issued(See.304/,Civ.C.) OPAL:
O U larders Name - TOTAL:
W larder's Address BUTLDIN E
yI I certify that I have read this application and sate that the aMrve Information is
y correct.I agree to comply with all city and county onitunces and stem laws mining to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
U,2 building commit and hereby nuthorizerepreartatives ofthis city to enter upon'he
above-mentioned Property far inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liuhilitica,jt mems,ansa expenses w ich may in anyway tame against said City ALTER OR AUD'I'O MECH.' PLUMBING
canseque a of the 6 ti of xis per L
APPLICA UND R IS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.001 CFM) MECHANICA Al I
SOURCE EGl 1
AIR HANDLING UNIT(OVER](',.a'CFM) CONSTRUCTION X
Sig ImofAppli Co oar Date EXHAUST HOOD(WMUCU HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,010 BTU)
ahead by the Cupenme,Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100.000 LOU)
ode.Section 255320)? _
[]Yes ❑No VENTILATION PAN(SINGLE REBID) PAID
Da¢ Receipt p
Will the applicant or future building occupant use equipment or devices which HOR ER-COMP(JHP OR 100.001 BTU)
it mamdous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
istUcf' BOILER-COMP(OVER 110,000 BTU)
❑Yes ON.
I have read fee bricardousSe mattions 2 5 5,,meet Under552 1.1 pterand rsta of Ne Cali-
AIR CONDITIONER ISSUANCE DATE:
fornia gHealthdoer ffi cont Code.Sections 25505.255JJ and 2504.I understand Net if rte NEW R[SIDENTIAL MIiCN. SQ.14.
building Jces non currently have o tenan6 that it is my responsibility to notify the occupant
tribe regdrements which must W met mor to asuance of a Ceni icate of Occupancy.
Owner or aothodzN agent
Orae TOTAL' ISSUED BY:
OFFICE