S 0457 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF GUPERTINO
Bull 1)NG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT DI.UMBINJECTIDENTIFIC S 0457
BUILDING PROJECT IDENTIFICATION V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBAIITTAI.DATI
b / Ave- 1173
OW ERS N PHONE: �� CO ACI' 'S NAME: LION
NIC CONTROL g
HI CT/ENGINEER; LIC NO:r ADDRESS: ❑
AA h
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
❑ ❑ ❑
LICENSED CONTRACTO"LA
QTY FEE•
1 hereby etfinn that 1 van licensed undpter 9(commencing JOB DESCRI ION
O�Z c.and myliccnse isRESIDENTIAL'
p� � nfull form vnd / ❑SFDWL ❑ ITCHEN REMODEL
QUU Lmense Lic.gIAMB ❑ADDITION RING RE-PIPE
IADass Conw
[]MULTI-UNIT STRUCTURAL.
ARCHITECT'S DECLARATION
p.pm - MODIFICATION
Z p v�'� 1 undcamnd my plans shall he used as public records
I OZ�O ❑INTERIOR ❑CHIMNEY REPAIR
1-y�W Licensed Pmfessimtal IMPROVEMENT ❑SWIMMING POOLS
Sys OWNER-BUILDER DECLARATION ❑BATH REMODEUREPAIR El DEMOLITION
rr��y fY a I hereby alfrm that I am exempt from the Contractors License Law for the
hd�gU following reason.(Section]RJL5,Business unit Professions Code:Any city or county ❑OTHER _
L'B[71`•3 u,�ej which requires a Permit to construct.alter,improve,demolish,or repair any structure
R�.] prior to its issuance,also requires the applicant for such permit in file a signed statement SPECIAL CIRCUITIMISC.
ythat he is licensed pursuant o she provisions of the Commcmrs License law(Chapter 9
0i �C (commencing with Section 901]0)ofDivision 3 of Buand sinessProfessions CwR)or 'TEMP.METER METER OR POLE.INS OMMFR IA
q q pt that he is exempt therefrom and the basis for the alleged exemption.An,violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
hYl1 tv Section 70315 by any applicant for a permit subjects the applicant to a civil penulry of POWER DEVIOUS 7 ❑TENANT ❑FOOD SERVICE
y t marc than Eve hundred dollars($500).
EFC SWIMMING POOL ELECTRIC IMPROVEMENT
❑OTHER
will dothewon,and the he Cm Taman', union,Law
far tfOw.Business
4�1 � and Profensinns Code:The Cnntructots License Law does not eptly m an owner 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 are not intended or offered for NEW RESIDENTIAL.ELECTR SQ PC V.A SISQ.IT.
sale.IL hoomegtbe building or improvement is sold within nuc year ofcompledon,the gQ. LI ( 0y
wna,bolder will have the burden of proving that he did not build or improve for par. Q /�
pars of sale.). TOTAL: FP' D
C]1,ss owner of the propeny,am exclusively contracting with licensed comracvm m v
com uct she project(Sec.]1114,Business amt Professions CMc:)The Contractor's I.i-
ecru,Law does nos apply In an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT Ft/ (fit, L,
who contracts for such projects with acomacums)licensed pursumn m the Cri uncon, E UNr b
Licence Law. PERMIT ISSUANCE X111/11T'U
E]1 am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT—WATER RRA) VALUATION
Owner
Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under Penalty of perjury ane of she following declarations:
❑Ihavc and will maintain uCertifcmerf Consnnn telt-insure for Workers Cramped- DRAINS—FLOOR,ROOF.AREA,COND. STORIES 'TYPE CONS'1'RUCTIOI
sation,as Provided for by Section 37W of the Labor Cale,for the performance of she
work for which this permit is issued. FIXTURES,—PER]BAP
❑1 have and will maintain Workers Compensation Insurance,m mquiml by Sminn
3700 of theLa,TE�r adc.forthe pc xmance nl she work far which this permit is issued, GAS—EA.SYSTEM-I INC.40lITLLTS OCC.GROUP APN
My Woo clo nsmir Inmrm emrrictoli Policy N e .m: GAS—EA.SYSTEM OVER 4(CA)
Carrier. IT policy No.:
CERTIFICATE OF EXEMPTION FROM WO KERS GREASEBNDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE —BUILDING DIVISION FEES
(This section need not becnmpleted ifshe permit is town,hundeddollan(SIM) GREASETRAP
' or less.) PLANCHECK FEE
I cmif,that inshe perforrommifthework fnrwhich thispermit isissued.].hot) SEWER—SANITARY—STORM F.A.200 FT.
not employ any person in any mannerist,as to become subject to the Workers'Comped- ENERGY ME
sation Laws of C.lifamin.Date WATER HEATER W/VENT/ELECR GRADING FEE
z O Applicant
NOTICE TO APPLICANT:IL after making this Cedificare of ExemMion,you should WATER SYSTEM?RGTINC
f•' "iZI'� hecnme subject to the Wnrkefs Compensation provisions of the Labor Cade,you must SOILS FEE
wforthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDLN'1'IAL PLM). SQ.EL PAID Date Re oidia
UQ Thereby sffrm shed them is aconstmdinn lending agency for Ne Nifmmvam of
F'+ the work for which this permit is issued(Sec.300],Civ.C.)
O U Lenders Name 'f T L. TOTAL.
{✓a Lenders Addrcas ov
1 cedify that I he rwd this application and mate that fr
the above inmmtlon Is BUILDING AEU
htorted.I agree to comply with all city and county ordinances unit state laws relatingm QTY. MECHANICAL PERMIT FEE SEISMIC MEz building conarmtiom and herebyauthorire reprcmitiivescronscityrremer uptmshe
above-mentioned prnpedy,for inspection purposes. PERMIT ISSUANCE ELECTRIC IM
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmems,met unit expenses which may in any way deems,against said City AL]'ER OR ADD TO MECH. PLUMBING FEE101 U
Of
f ego ting of shin it.
E 'TANDS WILL COMPLY WITH ALL 0 POINT AIR HANDLING UNIT fTO 10,10X1 CPM) MF.CHANICAhIrIRE
A NS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCfIONTAX
]icant/CmurararDate EXHAUST HOOD(WMUCI} HOUSING MITIGATION FEE
HAZARDOUS MAY
S DISCLOSURE
WdltheapPh__... fuwre building ntt tam marc mhandlehmallous nwteriul 1 IHATINGUNIT(TOIW,0001ITU)
as defned by Ne Cupedino Municipal Code.Chapter 9.12,and the health and Safety
Cods,Section 25532m)' HEATING UNIT(OVER 100,001 BTU)
❑Yea ❑No VENTILATION FAN(SINGLE REBID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILBR—COMP OHP OR 100,1%X1 BTU)
mit hazardous air conmmidants as defined by the Buy Area Air Qualify Mvnagenteni TOTAL:
DIsalSrt BOILER—COMP(OVER 100,000 BTU)
❑Yea ❑Nr
I have real the han rdoaterials re,mo meats under Chapter 6.95 of she Cdi- AIR CONDITIONER ISSUANCE.DATE
us m
fomia Health&Safety Cole,Sections 255115,25533 and 25534.1 understand that if the NEW RESIDE IAL MECH. SQ.Fr.
building doestom currently have a senate,that it is my respnnsih 11)notify'he saeupant _
of the requirements which must In met prim In issuance of a Cedilicate of Oompamy.
Owner or andomied agent Da¢ TOTAL' ISSUED BY:
OFFICE