99110052 :ARCHITEC`1YENGINEER:
CANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYCUPERTINO RWLDING ELECTRICAI,LDING DIVISIONAPPLICATION/PERMIT PLUMBING-MECHANICAL,BUILDING PROJECT IDENTIFICATION
aN/C
7INFO
NG ADDRESS:'S NA PH NE: C TRACTO ' NAM' LIC NO LIC NO: - DRF S:CONTACT: PHONE: Consultant Fees Paid by Applicant(Initial) BLDG ELU
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herebyaffirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�d'Z wiNSection]000)o Divixion3afthe Business vnd si C 'ease is RESIDENTIAL,
I+IO .Oft odd PERMIT ISSUANCE
W F in full tonic and of Zv / / C SFDWL C KITCHEN REMODEL
IOU License Clow F+p m
RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
QDam CoaAPPLIANCES-
ARCHITECT'S DEC fl LCMULTI-UNIT CSTRUCTURAL
MODIFICATION
O Z y Z I undemnnA my glare ro
shell be used as public reNs
UP T02W AMPS [I INTERIOR [I CHIMNEY REPAIR
F.FW Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS C BATH REMODEVREPAIR CDEMOLITION
EE C'W as I hereby affirm that I am exempt from the Cominamrx License Law for the C OTHER
OIs. following reason,(Section]031.5.Business and Professions Cole:Any city or county SIGNS ELECTRICAL
LL O E- which requires a pemdt to construm,aher.improve,demolish.or repair any struaturc FN
prior.its issuance.also acquires thmrpplicanl forsuchpermitm file anignedsmmment, / SPECIAL CIRCUITNISC.
ythat he is licensed pursuant in the provisions of the Contractor's License Law(Chapter 9
X00 (commencing with Senum.7")of Division 3o1fibe Busikenmal Pmfnsioks Crop)or TEMP.METER OR POLE INST
4 c that he is exempt therefrom and me basis for the alleged exemption.Any violation of C NEW BLDG/ADDRION C DEMOLITION
M Section 10115 by any applicant for a pormitsubjects the applicanno a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m no team than five hundred dollars(SSW). IMPROVEMENT
^ Q01,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered I'ar sale(Sec.]044,Business C OTHER
ams and Professions Cad,The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
6 3•- property who builds nr improves thereon,and who does such work himself or through
his own employees,provided that such impmsements are not intended nr offered Tor NEW RLSIDENTIA1.ELECTR SQ FT.
sale.If.hrvveve¢the building or improvement is sold within one year ofcomplmim,the SQ.FT.FLOOR AREA LSQ.FT.
wnerbuilder will have the burden of pricing that be did not build m improve for Pur-
)mse of sale.).
C 1,as owner of the pmumy,ten exclusively contracting with licensed contract..to TOTAL:
construct the project(Sec.]M4,Business and Professions Code:)Me Contractor's Lt
cense 7
Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a command(s)licensed porman to the COntostOrs
License Lo, PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this rcamn
ACLER-DRAIN&VENT-WATER(EA) VALUATION
• Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Ow
ner ^� O
thereby ul mo under penalty ofperjury one ofThe following Worker
declarations: t/
❑(have and for
mountain 37 a of CrmmatmCode,for the Worker's Compete DRAINS-FLOOR,ROOF,AREA.GOND. EWC.
ORI TYPE CONSTRUCTION
smirk,as provided for by Section J]W of the Ivbor Cade,Pon the pMormence of the
work for which this permit is issued. FIXTURES-PF,R TRAP
C I have and will ads,fan Workers Compensation Insurance,h required by Section
J]Wnf the labor Cade,far perfommnce of the work for which this permit is isxaed. GAS-CA.SYSTEM-1 INC.40UTLETS GROUP �"I - AP�
My Workers Compensation Insurance carrier and Policy number arc: GAS-EA.SYSTEM-OVF.R4(EA) 7 QQ7
Carrier: Policy No: 0 3 T
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(TTls,mationeed nor he completed tithe permit is forme hundred dollars5410) GREASEIRAP
or[CO,.) PLANCHECK FEE
I certify that in the perfminun,,of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 ET.
not employ any person in any manner so as m become xubjecno the Workers'Compete ENERGY FEE
Z ,Z nation L.—FC.lifornia Dme WATER HEAT ER WNENUELECTR GRADING FEE
Q Applicant
NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you should WATER SYSTEMRREA'FING SOILS FEE
became subject m the W..cr's Compensation provisions of the Lab.Cole,you must
r� forthwith comply with such previsions or this permitshall he deemed revoked WATER SERVICE
Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Pr PAID
rpt#
U O Ihereby affirm that there lsoamstmetion lendikgagency for per armermof m f
L[s H the work for which this permit is issued(Sec.3097,Co.C.)
Leader'x Name TOTAL:
W Lenders Address TOTAL:
ll I certify Not I have rend this application and sInto that the shove information is BUILD( FE
rF-r lA correct.l ogmem comply with all city and county onidences and state laws relating to QTY, MECHANICAL PERMIT FEE SEISMI EE
U building Construction,and hereby authorise representatives Ofthls city to enter upon the
above-mentioned property for inspection puryrseir PERMTT ISSUANCE ELE I E
(We)agree m save,indemnify end keep harmless the Ciry of Cupertino against
liahilities,judgmems,costs vnd expenses which may In any wayacemeaginmi aid City ALTERORADD TOMECH. PLUMBINGFEE
in consequence.1 the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE IONS.
i C'�I A AIR HANDLING UNIT IglIf10 CFM) CONSTRUCTION TAX
signature ol'ApplationfiContractor Dem EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARAZARD(1U5 MATERIALS DISCLOSUREhandle
Will the applicant or future building cupant nom or M1andlrdle hvurtlom memrial HEATING UNIT(TO 100,1100 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I W,000 BTU)
Code,Section 25532(a)?
El Yes ❑No VENTILATION PAN(SINGLE RESID) PAID Dam ReceigX
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 1 it BTU) //TT ee��
mit hazardous air contaminants as defined by the Buy Area Air Quality Management TOTAL: 0 G.
Central? BOILER-COMP(OVER 100.000 BTU)
E]Yes FI No
I have rod the haaudous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code.Sections 25505,25533 and 25534.1 understood that if the NEW RESIDENTIAL SUCH, SQ.Cr. /� 7
building does not Cu nI yhavn ssu
that it is my responsibility m notify the rampant 9' ~
of yt ea. ch muni meo iance of s Ce tiferal of Occuponal
w torauthL' nt s` Dote TOTAL: ISSUED BY:
OFFICE