S 2474 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING..MECHANICAI. S 2474
BUILDING PROJECT IDEM'IPICATION
BUILIIINGADDRISS: ET�E. MLF
ON SUtlMITI'AI.DATE
W sR'S AM: PHONE: CONTRACTOR'S NAME,: LIC NO',
+realNICTNol.0
( ARC( (ENGINEER: LIC NO: ADDRESS:CONTACT: PHONE: BLDINGPERINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Era it Imo. - ) ❑ ❑ Com' 1:1R
LICENSED CONIRACTODECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby dfrnt drat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OCz th Seaion](Ngphl'DivisionJof the Businear and Professions Code.and my license is RESIDENTIAL:
Wp wt PERMIT ISSUANCE
in full force and anec4L ❑SFDWL [I KITCHEN REMODEL
NtLicense Class ` Lic.q
U APPLIANCES-RESIDENTIAL ❑ADDITION +57I,6IBING RE-PIPE
FF..Z LJ Date Contractor
Herrn
ARCHITECT'S OECLAR O PANELS ❑MULT6UNIT ❑S•fRUCTURAI.
zOgHjz Iundo,oreanry Iloudiall be used apublic records MODIFICATION
Oz—Q UI'T02(XIAMPS ❑INTERIOR [I CHIMNEY REPAIR
P�2 LW Licensed Professional 201-11000AMPS IMPROVINENT L]SWIMMING POOLS
�l,:E; OWNER-BUILDER DECLARATION OVERIIXI(IAMPS ❑BATH REMODEUREPAIR DEMOLITION
p ar ,W Q I hereby atfirnh that 1 am exempt from the Cmmtraner's License Law for the
ryxx,,C W U Golowing rwson.(S-Chinn"!031.5,Burma x and Poxw,ximu Code Any city o,lau d, SIGNS ELECTRICAL El MITER
W'3 LL y which requires a peria
it to construct,alimprove,demolish,Or repair any sometime
l=LLOg prior to it issuance,also mquires the applicant for such permit to file a signed statement SPECIAL CIRCULUMISC.
�Gf that he is licensed pursuant to provisinns Of ac
the Contrtoes License Law(Chapter 9
CCOMMERCIAL'
be 7C (commencing with Section 7")of Division 3 ofthe Business and Professions Csd-)om 1EMP.METLRORPOLHINST.
Not he is exempt therefrom and the basis for the alleged exemption ArY violation of [I NEW HLDGIADDITION El DEMOLITION
Stalin.iG 4. Sin.7031.5 by any ii,iiwntfor a permit subjects the applicantto a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
LLI m t marc than fee hundred dollars WOOL
=q IMPROVEMENT
01,as mvnerofthe property or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC ❑OTNER
will do the work,and the structure in not intended or offered fnrsale(See.1044,Business
and Professions Gide:The Contractor's Licence law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
6 a^ roperty who builds Or improves thereon,and who does such work himself or through
his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.If,however,the building or improvement is sold within one yearsfcompletion.the _ SR 17.FLOOR AREA SsSQ.Ff.
ownburden-Builder will have the burden of proving that he did or
at build or improve div pasale.).
C] 1.as Owner of the properly,ten eecludvely contracting with licensed contractors to TOTAL:
onsuua the project(Sec.70D.Business it Professions Cods:)The Contractor's Li-
nm Law does not apply he an Owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cannonball)liscro d pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I at exempt under See. .B&P C tell this ancon
ALTER-DRAIN&VENT-WATER 11:A7 pTION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consant to self-insure for Worker's Compere- DRAINS-ILOOR,ROOT',AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3](0 of the labor Cade,for the per ,vermnee Of the O
work for which this permit is issued. FIXTURES-PER TRAP
-11 have and will maintain Workoex Compensation Insurance,m required by Section
3701 Of the Labor Code,for the performan¢nf the work for which this perran is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work um t nti flnwrt sew wrand Policy numb• 'y .aI
Canicr Olicy No.: 'WORK
ea[� GAS-IiA.SYS'fF.M-OVI!R4(F.A)
CERT(. ATE Op EX• Pr10N FROM ORKI!RS' GRFASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section nttdo.,The completed ifthe permit is furore hundred delta.($10B F GREASETRAP
PLANCHI!CK PEE
or less.)
I comfy be(in the perfourar.ol he work fur which thispomdt is osued,)shall SHWER-SANITARY-STORM FA.20()17.
not employ any person in any manner sr,as m became subject to the Wmkerd Compen- .NE Y FIRE
z2 wenn laws of California.Date WATER HEATER WNEYDELECEN
Q Applicant GPCIi
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SV STF.M/TRENI INGS ;1i
F^ b-com-subjen to the Worker's Compensation provisinns of the Latin Carlo,you most
UJforlhwithcomply with such prviom,or on, .or shall be deemed revoked. WATER SERVICE
Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. S PAID Date ReceiptN
U z I hereby allimt that there is a construction lending agency for the performance of
W F the work for which Nis permit is isoaed(Sec.30X97,Civ.O.)
TOTAL:
O ULender's Name
IcndcTI Addmss f
y 1 certify that have read this application and stem that the above information is p BUILDING ME
(A correct.I agreetn comply with all city and county ordinances and state laws relating to qry. MECHANICAL PERM By+ -.FEE
SEISMIC PUTU zbudding construction,not hereby radiance representatives affair city mater nam the
'--t above-mentioned properly for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to sure,indemnify and keep harmless the City of C.Nnina against
liabilities,judgments costs and expenses whiny yin any way uccroe again>t said City ALTER OR ADD TO MECIi. PLUMBING FEE
it quenrc ofthe gmntin Of thiryll'nty�
AP .ieANT UNUI' D.' D /l COMPLY "H ALL NON-POINT AB HANIILING UNIT To IO,Ofq CFM) MECf1ANICN.ME
SOU )N
�ze )7,...�.-9� AIR HANDLING UNIT(OVER 10.0110 CIM) CONSTRUCTION TAX
Signa nApplicnn nnuacmr `/ Doc EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MA'rERIAI,S DISCLOSURE
Will the upplicamor fair,-buildingsweupma n.rc or bundle hasrdouxnmmdul HEATING ON IT(TO 100,000 BTU)
as defined by the Cupertino Municipal/Code,Chapter 9.12,and the Health and Safety
Code.Saban 25532(a)P ury HEATING UNIT(OVER 11X),000 B'fU)
❑Yes o VENTILATION FAN(SINGLE RESID) PAID Dme RccelptX
. Will the applicant or future building Occupant use equipment or devices which BOILER-COMP(311P OR I W,WtI BTU)
emit havardous air contamlmmts as definad by the Bay Area Air Quality Management TOTAL:
Drum.? BOILER-COMP(OVLR 100.000BGD
❑Yes GlL'a_'
I have read the haardoos materials ro is under Chapter 6,95 of the Call- AIR CON ITT I TONER ISSUANCE GATE
825533 p
Inmiingdow&Sof /Code, nionc 25505.255JJend255311 undersfy the
thre at Ne NEW RESIIIl:Mr1AL MECH. SQ.Er
II gd ycyrey mi soot tit ianry responsibility mnmify thegency ret
�y�pyGef�mf(ms and macho n onnissnance ora rnir-ae or(xcnparer.
Ow uthoris mc TOTAL: ISSUED I1177r �
OFFICE