S 0237 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EIAF RICAI, PERMIT NO.
T
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL Q On
BUILDING PROJECT IDEN'TIF'ICATION v L
BUILDIN37
G ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAPI
oaa� b � s �Pl, o
OWNER'S NAME: PHONE. CONTRACTOR'S NAME: C �p NIC CO TR01.a
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ARCHITECT/ENGINEER: LIC NADDRE! m
❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fiscal Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing
aa9Z with Seeian70M)nfDivision 3afthe Busirs.,ind Professions Cods,and my license is PERMIT ISSUANCE RESIDENTIAL
Falb in full force and effect / OPb Si' ❑SFDWI, OKI HEN REMODEL
�V(U,,) License 1 4 Lie.N C APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RGPIPF.
Z W Use s Carom,
Isis GS 0MULTI.UNIT UCTURAL
ARCHITECT'S DECLARATION MODIFICATION
F a 2 1 understand my plans shall be used as public records PANELS
OZ4o UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Prorexsional 201-IIXMIAMPS IMPROVEMENT OSWIMMINGI'OOL.S
gyE-i OWNER-BUILDER DECLARATION OVER I00)AMPS O BATH RF.MODEUREPAIR 0DEMOLII')ON
K K 6 1 hereby alarm that I am exempt fmm the Contractor's License Law for the
K N U fallowing reason(Section 707 L5,Business it Pmom fessiCode:Any city or county SIGNS ELECTRICAL ❑OTHER
RM
a,{� which requires a perm.,m construct,stet.improve,dental Isla.or mica,any nrocturt
Fp�0 prior to its issuance,also requires the applicant for.such Permit to file a.signed statement SPECIAL CIRCUIT/MISC.
2 } that he is licensedpufxua.I came provisions of the Co&nmetnr's License Law(Chapter 9 COMMERCIAL,
W��O (commencing with Bunion 7(XFp of Division 7uf lM1e Business and Professions CWe)nr TEM METER OR POLE(NST.
d d e tY that he is exempt thereGom and the basis for this alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
on Section 703 LS by any applicant(car a permit .him,the applicant m a civil pereltyof POVjHD VICES ❑TENANT ❑FOOL)SERVICE
rent more than five hundred dollars($500). IMPROVEMENT
FZC 0 Las owner oftheproperty.ormy employees with wagesn Their unnpenswiom, SWI POOL ELECTRIC
F will do the work,and the cre is not intended or olTeeed for sole lSecJ(W4.Business ❑OTHER
swm
of and Professions Code:The Cor acme License Law does net apply ut an owner of OUTLETS-'SOWHP-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 RhSENTIAL E SQ FT.
sale.If,however comilmagor inpravemenr is sold within one yearmfemonction,the S ICiggREA $NQ.PT.
ewmer-hudder will have the burden of proving that he did not hold or improve for pur-
poseof sale.). TOTAL: Jv
0 1,as owner of the properly,am exclusively enamoring with licensed contractors to to M 3,0 ZCw
mtmet the project(sec.70,14,Business and Professions Cale:)The Connactor's Li- II
cense Law does not apply to an owner of properly who builds or improves themon,and QTY, PLUMB( PP�1IT FEE Y
who contracts for such pointers with a commctonO licensed pursuvm to the Contractors ry
License low. PERMIT ISSUANCE Vh �Ur�N(IIV()
0 l an exempt under Sec. ,B&P C for This mown
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aRrm under penally ofpcoml be of the fill-in,declarmium:
❑ I have and will maintains Ccdificamof CmeammcolFimme for W..Ime,Cempen- DRAINS-POOR.RO(OF,AREA,COND. STORIES TYPECONSTRUCf10
,anion,as provided for by Section 37004 the IoMm Code—the petormanm
work for which this permit is tissued. FIXTURES-PER TRAP �<V
0 1 have and will amntsn Workers Compensation Insurance,as required by Section
37o0ofthelohm Cora foier: ,in perton{'once ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Wake nm isnri�yrsuruncrJ:unierand Policy My Wcv Policyolic MS-IiA.SYSTEM-OVER 4(EA)
CarCERTIFICATE OF EXEMPTION FROM WORKERS' GREASI%INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCEHUILDING DIVISION F17ES
('Otis senionnad a.. m
becompleted ifthepetit is for onehundrod dollars($IN)) GREASETRAP
or loss.) I'LANCH[CK FIiE
I codify that in the perfnneenetwOm work for which this permit is Issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so n to beenmc subject to the Workers'Compen- ENERGY FEE
Z,Z maim Laws of Celiferm.Dare WATER HEATER WNENTIELECTR GRADING FEE
O Applicant
NOTICE TO APPLICANT.IL after making this Conificme of Exemption,you should WATER SYSTEMI TREATING
on became subject To the Workers Cempcnsmem provisions of The Labs Cade,you must SOUS FEE
IgI G forthwith comply witb,uch provision or this permit shall he deemed revoked. WATER SERVICE
OPAID
CONSTRUCfWN LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. Date ReeeiptY
V7 Ibomby af<rmtha0here is acorioune,ion lendingagency for the pertsuncome of
(•+ the work for which this permit is issued(Ser.3097,Civ.C.) 'TOTAL:
Q ULenders Name
W Lenders Addrem T
Ly, a I certify that I have read this application and&rate that The above information is
BUILDING FEE
Ir y correct.I agree to comply with all city and county ordinances and Into laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC HE
L) z building ecnstmetion,and hereby authimorrepteamaiives oftbis city mentcrupon the
above-mentioned pmNny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
ee
(We)agrto wmtl
ve,indemnify and keep haess the City of Cupertino against
1. lia—
liabilities,judgments, smandexpeconswhichanayinany way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
inconsequence th ndngof tspermit.
APPLICA TSTAAND WILL COMPLY WITH ALI, ON DINT AIR HANDLINGUNIT(TO 10,000CFM) MECHANICAL FEF.
SOUR P
AIR HANDLING UNIT(OVER III,gq CPM) CONSTRUCTION TAX
S' a (Applicant/ oatrey a EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAMAR US ATERIALS DISCLOSURE
Willtheapplicamtorfuturch Idingstccupamxtorc orhrrdle hazardous mmemit HEATING UNIT(TO 100,000 BTU)
vs defined by the CaNi inn Municipal Cale,Chapter 9.D.and me Health it Safety HEATING UNIT(OVER 100.000,BTU)
Cede,Section 25532(.)'
❑Yes No VENTILATION PAN(SINGLE RESID) PAID Date Receipt is
Will the applicant or future buildin,eccupant use equipment or devisc,which BOILER-COMP OHP OR 100. 00 BTU)
•emit hassamou,air contaminants as defined by the Bay Area Air Quality Manmen
aget AU
District'! BOILER-COMP(OVER[00.000 BTU)
❑Yes �No
I hvso rex h azo 417 �13�3
nent under Chapter 6.95 of the Cuh AIR CONDITIONER ISSUANCE ATE
fomia Health C .SmJ 534.1 undetst J tb if the NEW RESIDENTIAL MECH, SQ.PT.buildin reneslbility ronmlfheof estfa Ccrtifi<m o
r u o z t D e 9'OTAL: ISSUED BY:
OFFICE