S 0791 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FILEC I RICAL PERMIT NO.
RUII,DING DIVISION APPLICATION/PERMIT PLUMBING-btF:cxANICAI" S 0791
BUILDING PROJECT'[DEIF'IC'ATION
SANITARY NO, APPLICATION SUBMITTAL DAT
DINGA DRESS: .�a � �I
NAME:
PHO N!?I CONTRA R'S NAME: \"I.IC NO: NIC CU
NT
AR( 'CIENGINEER; LIC NO: ADDRG4S: ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PW MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby altirm Ihat 1 am licensed under provisiass of Chapter 9(commencing
GKy with Section l(gBmfDmWan JafdW Business it Professions Code,end my license is RNID NTIAL
Win in full fares and effect PERMITISSUANCF. 0SFDWL O KITCHEN REMODEL.
ut! License Class APPLIANCES-RE ❑
Lic.A RESIDENTIAL ADDITION [I PLUMBING RE-PIPE
iC U;fn 6 a Datc Contmctar
ARCHITECT'S DECLARATION PANELS []MULTI-UNIT ❑STRUCTURAL
F Z_ 1 understand my plans shall be used us public records MODIFICATION
zo_ UPT02MAMN ❑INTERIOR [I CHIMNEY REPAIR
�y Licensed Professional 201-IWOAMPS ROVEMENT C]SWIMMING POOLS
OWNYeR-BUILDER DECLARATION OVER 1010 AMPS HREMODEUREPAIR [I DEMOLITION
G ee 6 1 hereby a1Rmt that 1 am exempt from the Cantmctnrx License Low for the - OTHER
yd0 is,UF fallowing remon.(Section 7031.5.9asirresnand Professions Code.Any city ar county SIGNS ELECTRICAL
613 a N which requires a permit to consaaa,dter.improve,demolish,or repair any structure
F,a.OQ prior to its issuance,also mquires Nc applicant for such Permit file o signed statement SPECIALCIRCUIT/MISC.
Shy that he is licensed pursuant the provisions of the Commences License Law(Charter 9 COMMFRCIAL'
GC (commencing with Section]0001 of Division 3 o(the Business and Professions Code)or TEMP. OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NEW BLDGIADDITION [I DEMOLITION
Wim SKtion 10JL5 by any applicant fora pelmhsohjects the applicant madvil penolry of POWER DEVICES, ❑TENANT ❑FOODSERVICE
t mom been hundred dollars(8506. IMPROVEMENT
five
� C SWIMMING POLL ELECTRIC
0 Las property.armmp
Perry employees with wages as theirsnlecacnsation,
s own ❑OTHER
Sys will do the workinlthe vwnam isnot intended or offered far sale(Sec.7N4.Business
Ii1 and Professions Code:The Contracto's License law dice,'not apply In an,caner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Thereon,and who does such work himself or through his own employees,provided that such improvements am not intended or all'er,1 far NEW RESIDENTIAL ELECTR SU
yd-
ale.If.however.the building or improvement is nalA within one year ofcompletion,the SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve lot pur- PAID
pone of sale.). TOTAL:
0 L M owner of the prapeny,am exclusively contracting with licensed contractors to
nstmcl the project(Sec.701 1.Business and Prolessions Cdr:)Tho Conuacmes nsLi- DEC MJ,w
Li-
came Law does not apply to an owner of property who builds or improves thereon, QTY. PLUMBING PERMIT FEE gZZI
whocomnacts farsuch projectswith scuntmctads)licensed pursuanttolhe Commcmr's - �4U
License Ww. PERMIT ISSUANCE Clly�r
I sal am! un rSce. B&P C fit this son
ALTER-DRAIN it,VENT WATER MA) ON
owner Date
. WORKE S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aRum under Mrsamy of perjury one of the following declarations:
❑Ihova and will mainminaCrnificote of Cnnunuoulf-inmra for Worlets ComPen- DRAINS-FLUOR,ROOF.AREA.CONI). STORIES TYPE CONSTRI1Cf10
sation.an provided for by Section 30110 of Ne IaMr Cale,home performance of the
work for which this permit is issued. FIXTURES-PER TRAP
0 I have and will maintain Workers Compensation Insurance,as required by Section GAS-F.A.SYSTEM-I INC. 0UTLF.'fS -
3000ofmaUninrCale,for the performanceofthe work far which this permit is issued. OCC GROUP APN
My Workers Compensation Insurance carrier and Policy motivators: GAS-EA.SYSTEM-OVER 4(Eie
Carries Policy Nu.: '
CERTIFICATE OF EXEMPTION FROM WOR KERS' GRE ASM NDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCI? BUILDING DIVISION FEES
(This section need molbe completed ifthepeonan is torose hundred dollars($100) GREASETRAP PLANCHECK FEE
Toy any Ihminthe performance as he
for which this me Wosissued,I shall'Comfen- SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any manner s0 us m become subject m the Workers Camper- ENERGY FEE
Z smion Laws of Calif raia.Date WATER HEATER WNENTIELECIR GRADING FEE
O Applicant t
C Tq NOTICE TO APPLICANT.If,after nuking this Csi ifcam of Exemption,you should WATER SYSTEMiT EATING SOILS FEE
(✓ ^� become subject m the Workers Campanian..Provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE
0
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
1 hereby affnot thw there is u constrvnion lending agency for the performance of Dam
W Fthe work far which this p.it is issued(Sec.34197,Co.C.) c TOTAL:
V Lenders Name
Lenders Address TOTAL:
y1 certify that 1 have read this application and state that the above information in HUILDINC
fit correct l agree to comply with all city and county ordinances and state lows totaling to QTY. MECHANICAL PERMIT FEE SEISMIC IEE
U Wildingcons0uctibn,and herebyvummize rel)resemmivcsoftbiscitymemer upon the
ubav-countomed property far inspection purposes PERMIT ISSUANCE ELECTRIC Ii
(We)agree to save,indemnify uad keep Worries,the City of Cupenum against
lubidaurs,judgments,enmsand expenses which may in any way aceme against said CityALTER OR ADD TO MECH. pLUMBIN
in conseque a of the grunting of this Permit.
APPLICA UNDERSTAN SAND WIL :OMPLV ITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FE
S U Sr ULAT )NS.
AIR HANDLING UNIT IO,IMIOCFM) CONSTRUCTION TAX
' 7'!
Signamreof Applic Contractor Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Wi[I the applicant or ficaura Wilding occupant store orlardle hazardous material HEATING UNIT(TO 10,000 BTU)
ax definealby the Cupertino Municipal Cade,Chapter 9.12,and the Health unit Safety HEATING UNIT(OVER 10,00)HTU)
Code,Section 25532m)0 _
❑Yes [IN. VENTILATION FAN(SINGLE RESID) PAID
DaIC RKeiplp
Will the applicant or future building occupant use equipment or devices which BOILERCOMPIJHP OR 100,071 BTU)emit haznNous air comaminaap as defined -
by the Bay Area Air Quality Management TOTAL:
"Datim" BOILER-COMP(OVER 10 ,a)(OBTU)
El Yea; ❑No
AIR CONDITIONER ISSUANCE DATE.
1 have read the h Can,
Se mmaids 5,2553 a 255Dadic,Chapter b to 0(the Caltime
Tondo Health o Safety Code,Seniors dons is my and255]4.Iunderstandthat ifthe NEW RPSIDF.NTIAI.MECH. SQ.FT.
Wilding dna currently which havenm met
it ism.re of
birtycanotifythe osecuption
sses"
of the requirements which must be and prior to issuance of a Certificate of Qcupency.
Owner or authorized agent Dove TOTAL: ISSUED BY:
OFFICE