S 1628 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIT x'�P CUPERTIN0BUILDING-ELECTRICAL PE IT NO
B - INGDIVISION APINIP$ER PIAMBING-MECHANICAL : 1628
,�. BUILDING PROJECT IDENTIFICATION
BUILDING AIIDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
' � � 9' OWNERSNAME: CONT ACTOR'S N E: LIC NO: N/C CONTROL#CHI FFCI'/ENGINEER: ADDR S'. z s .CONT y �` /��`p�, UILDING PERMIT INFO
�/ 1e PAM I-/Ie.•/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
S C� 2'L C SED ONTRACTOR'S DEQTY. ELECTRIC PERMIT FEE IOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions Of Chapter 9 g
9004 with Section 7")of Division 3 of the Business and Professions CWe,and my license is - �!T RESIDENTIAL,
-Or PERMIT ISSUANCE t YJ
l0� in full force and effect ❑SFDWI. I�TCITGHEN REMODEI.
IUU License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION 'PLUMBING RE-PIPE
F IZ W Date Contractor
rcgQa' ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
zc,olz Iundersmndmyplans,hail heusedaeprblewsorda PANELS '/ ' (� MODIFICATION
CZ4- UP TO 200 AMPS {� L `- El INTERIOR [_j CHIMNEY REPAIR
C44tly Licensed Professional 201-IOMAMPS IMPROVEMENT ❑SWIMMING POOLS '
OWNER-BUILDER DECLARATION �' 'BATH REMODELEEPAIR El DEMOL TION
WQ I hereby affirm that 1 am exempt from the Cnnlmetnr's License Law far the OVER L AMPS C
�d�(O G U following reason,(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
ul 3 W y which requires a permit to construct,alter,improve,demolish,or repair any swoons
!Fq�"�yy0Q prinrm hs issuance,sten requires lheapplicvnl for such permit to ole asigned slamment SPECIAL CIRCUUUMIS i,arp
y'-� that he is licensed pmmantm thepmvisinnsofthc COntmemrs License Luw(Chapter9
e'� (commencing with Section 7100)of Division 3 of the Business and ProfessinnsCode)er TBMP METER OR POLE INST. OMM R IAI'
oC that he is exempt therefrom and the hams for the vlleged exemption.Any vloladon of ❑NEW BLDG/ADDITION ❑DEMOLITION
4: Section 7031.5 by any applicant for a permit subjects the applicant to penuhy of POWER DEVICES - ❑TENANT EI FOOD SERVICE
r� art marc than five hundred dollars($500).
AZO ❑1,as Owner of the property,army employees with wages us theireole compensmiten, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or Offered for 14
sale(Sec.94,Business OTHER
Wand Pmfesoors Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES O
Q' property who builds or improves thereon,and who does such work himself or through
his own employees.Provided bat each improvements arc our intended m offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If,how'ever,the building or improvement is sold within one year of completion,the
SQ.FT FLOOR AREA $ISQ.F1'.
owner-hullder will have the burden of proving that he did not build or improve for pur-
pose of WL)
E]1,as owner of the property,am exclusively contracting with licensed contractors be TOTA
constrict the projen(See.9044,Business and Professions Cade:)The Contractor's Li-
sense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wrn
who contracts for such projects with a metor(s)licensed pursuant to the Contractors
License Law, PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this rcacnn I
ALTER-DRAIN&VENT'-WATER(EA) VALUATION
net I'A emDore
ORKF.R'S C ENSATION DECLARADDNS,MBACK FLOW PROTECT.DEVICE j`3^O
I hereby affirm under pen cryofperjuryonccodsfiOl.O....a clvmtiom: DD
❑I have and will maintain a Certificate Of Consent toself-inure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTIOI
cation,as provided for by Section 3770 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
3]W of the Lab or Qrde,for thepenbnnenceof the work for whichthis perm%iais.sred OAS-EA.SYSTEM-1 INCA OUT] OCG CROUP APE
My Workers Compensation Insurance wrier and Policy nu s
Carries Policy No.: GAS-EA.SYSTEM-0VBR 4(EAJ
CERTIFICATE OF EXEMPTIONFROM ORKERS' GREASE/INDUSTRL WASTE INTERCG
COMPENSATION INSURANCE BUILDING DIVISION FEES
GD,,cairn need not ba,comFlood if]he pemtity for one hundred dollar,41 W) GREASETRAPUt l-Leel
orlosc) L V PLANCHECK FEE
I cerify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as to became subject to the Workers'Camper- BNEROY FEE
Z a.,am Laws of California.Date WATER HEALER WNENFULLECTR
O O - GRADING FEE
Applicant
t^. NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should WATER SYSTEMGREATING SOILS FEE
(~ heucme subjna m the Workers Compensation provisions of the Labor CoU,you most
forthwith comply with such provision,o,,he,pamit shall be deemed revoked. WATER SERVICE
Q
a Zoo) Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELSIE SQ,FT PAID In Receipt#
1 hereby offirm that there is a con6tmCtiten lending agency for the performance of
WF the work for which this permit is iesaed(Sec.3099,Civ.C.)
OU Lender's Name TOTAL.
4k1 Lender's Address TOTAL: 'O
y 1 certify that 1 have read this application and state thatthe above information is BUILDING F B
rF-t fn
enter,I agree to comply with all city and literary ordinances and state law,relatingm QTY. MECHANICAL PERMIT FEE SEISMICF 8V
building constriction,and hereby authorize representatives of this city to enter upon the - �1
above-mentioned property for inspection purpows. PERMIT ISSUANCE ( ELECTRIC FE V
(We)agree to save,indemnify and keep harmless the City of Cupertino vgninst
linhiliries,judgmenu,costsand expenses which mayinany way coouna,mam#aid City ALTER OR ADD TO MSCI{. PLUMBING FF.
I. mo,tencc of the grwningof this permit. - r
APPLICANT UNDERSTANDS AND W;kqOMPLY WITH ALL -POINT AI R HANDLING ON I'rpro I QaIII CFM) MECHANICALF '
SOURCE REGULATIONS
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature Of Appll Comm or Dar EXHAUST HOOD(WIWCT) HOUSING MITIGATION FEE
ALAR SMATERIALS .CLOSURE
Wlaws, pplicam or future building Ocerpem store or handle hazardous material HHA'rINGUNIT(TOI0ff000BTU)
as defined by the Criterion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Stettin 25532(x)7 HEATING UNIT(OVER 100.000 BTU)
E]Ties VENTILATION FAN(SINGLE RESID) PAID Dote Receipt If
Will the applicant.,future building occupahow equipment ordevices which BOILER-COMP(3HPOR 10k000BTU)
mit haaardeus air contaminants as defined by the Bay Area Air Quality Management
District?
' BOILER-COMP(OVER 101"BTU)
.0 oYna
I have reaidan hazardous material,w hirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
mando Health&Safety Code,Section 505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff.
building doe,hol cu ntlyhavelf, n,that it lsmynx ruesibilityto ifytheoecupanr IVV.J
of the require n met ptiormissuance of nil sof Occupy
Owner or rued age t Da TOTAL ISSUEDBY: •\J\
OFFICE