S 0965 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO A
TRICAL - PERMIT NO.
BUILDING DI VISI ON APPLICATION/PERMIT ANICAL S 0965
NTIFICATION
BUILDING ADDRESS: /l/ SANITARY NO. APPLICATION SUBMITTAL DATI
OWN'RI NAME: : '` CONTRA OLIC NO: ,lx
OV NIC CONTROL#
•ARCHITF T/F.NGINHER: LIC NO: �VES e� ❑
CONTACT PHONE: Y 6 BUILDING PERMIT INFO
44� _L,6-7q 36 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION �/ QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
,Q IZZ with Section](KKpnf Division 3aflhe Bminespand Professions CNe,andmy license is RESIDENTIAL-
00 in full forceand t PERMIT ISSUANCE
�U: License I s ���Lic.p 7 Q ( - - ❑SPDWL ❑KITCHEN REMODEL
yZ8 Dare Comracmr APPLIANCES-RESIDENTIAL DADDHHON El PLUMBING RE-PIPE
'Don ARCHITECT'S DECLARATION PANELS _ OMULTI-UNIT []STRUCTURALZ O y Z I understand my plans shall be used as public records MODIFICATION
OZ�M - UP TO 20)AMPS ❑INTERIOR El CHIMNEY REPAIR
[..a,.,1"61Licensed Professional 201-100TAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Hok)AMPS D BATH REMODEUREPAIR ODEMOLITI N
y GG I hereby 41firm that 1 um exempt from the ConrractAC,License Law for rhe
x O p,U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. D OTHER
W a F which requires a permit ra construct,alley,improve,demolish,or repair any structure
�404nn prior to its issuance,also requires Ne applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC.
P. 'hal he is licensed pursuant to the Provisions of the Comracmds License Law(Chapter 9
CO (commenting with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
C. c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
Section 7031.5 by any applicant for armh
pesnbjscts he applicant to a civil Penalty of POWER DEVICES
rota [I TENANT ❑FOOD SERVICE
t more than five hundred dollrn y employees
IMPROVEMENT
F Q O Lasowner k.the Pealmi or mye ireendes with wages eyed o stheir sole yki,B cation, SWIMMING POOL ELECTRIC
FO adl dothework,ande:ThCountumeieter',License
dos ct imlly I. a,Bualness - OOTHER
RJ m and Professions Code:The improve,
then Licence Law does ml apply to if owner of OUTLETS-SWITCHES-PIX'NRF.S
properly who build,or improves thereon,and who docs such work himself or Ifigough - tJ
shisal own employeese providnl that such improvements are not intended or olfered for NEW RESIDP.NTIAh P.LECTR SQ FT. S
sale.ILhowevegrhevethburding den fpravintithat hewithin.,wild or improve
- SQ.FT.FLUOR AREA Nass QR
owner-builder will have the burden of proving that he did not build or improve Int put- u
Pose of sale). 1 -
❑s as owner of the property,,B exclusively contradict,with licensed na ens's i- TOTAL: V
prise La the project(Sec.o an Business and Professions Code:)The Contractors Li- V Jf,-V1111i�
cense Lawdoesfor
apply toan with
anfpropeny who
sedpogimproves therem. QTY. PLUMBING PERMIT PEE G`"y Ur
who contracts for such projects wilhaamlramar(s)licensed pursuant to the Conlrecm8s I License Law. PERMIT ISSUANCE �I
D I am exempt antler Sec. ,B&P C forrhis reason J
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE
L hereby affirm coder penally of pedury one of the following declaralion.e
El I have and will maintain a Criifican of Consenuo self-insure far Workers Comped- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
work far which this permit is issued. FIXTURES-PER TRAP
and will maintain WorkeYs Compensation Insurance,as required by Section
3/00of the Whar Code,for the performance of the work farewp.hri{cWh pNeis permit is is.sued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Cooco. 'slCompen�f�n�lns pot cy NloY nu[)//b �0�7 GAS-EA.SYSTEM-OVfiR4(EA)
Carrier I(��./T� fiance comer an
F ICERTIT O'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Tinton,ction need oar beenmpleedif Ne permit is Intone hundreddollars($180] GRBASB'TRAP
or lexsJ � PLANCHECK FF.F;
I certify that in he performance ofrhe work for which this Permit ix.oind,Ishall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so ex to became subject m the Workers'Comped- �O ENERGY FEE
0 z satimn Laws of California.Date WATER HEATER W/VF.NT/ELECTR GRADING FEE
Applicant
ti NOTICE TO APPLICANT:11 after making This Cedificme of Exemption,you should. WATER SYSTEMIREATING
h became subject to the Worker.,Compensation provisions of the Labor Cade,you most SOILS FEE
Ok
{aTa i fonM1wiN comply with such pmvisimnsmlhia permit shall be deemed revoked. WATER SERVICE
aQ
z
CONSTRUCTION
rnGAGENCY NEW RESIDENTIAL PUMP. SQ.FT. PAID
Iherehy affirm Na there isaconswimion leading
nding agfof ency the performance of Dam R etpl
V the work for which this permit is issued(Sec.3897.Civ.C.)
Us F" Lender's Name OTAL:
V Lender's Address TOTAL'
' I certify that I have read this application end awe that the aMve information is BUILDING FEE
Fr VI correct.I agree to comply with all city and county ordinances and stare laws relating to QTY MF,GHANICAL PERMIT FEE
U building construction,and hereby authorize representatives aRhis city to enter upm the SEISMICFF.E
above-mentioned property far inspection purposes. PERMIT ISSUANCE
(We)agree In save,indemnify and keep harmless the City of Cm er int against ELECTRIC FEE
liabilines,judgmems,cnah andexpenses which may in any wayeccmeagainclseid City ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO TO,fI )CPM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 18,008 CPM) CONSTRUCTION TAX
Signature of Applicant/Contrector Date EXHAUST HOLD(W/DUCT) HOUSINGMITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
0011 the applicant or future building occupant amrcor handle Taormina material HEATING UNIT GET 10001)BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(m? HEATING UNIT(OVER 100.00)BTU)
❑Yes Otho VENTILATION FAN(SINGLE RESID) PAID -
Dae Receipt
Will the applicant or furore refund
occupant use equipment of devices which BOILER-COMP(3HP OR 100,0(10 BTU)
emit haaardnus air contaminants as defined by the Boy Area Air Quality Management T03'AL.
Dishicfl
❑Yes FIN. BOILER-COMP POSER 100,000 BTU)
AIR CONDITIONER
I Teva gild he haeardous Mamrials requimmems under Chapter 695 of the Cali- ISSUANC-DATE
fames
Dead'
&B fiery Code Sections 5505,25533 and 25534.I undersmnd that if the NEW RESIDENTIAL MECH. SQ.FT.
huiWing dttev nn urgently eaten ,that it is my sPansibiliryI Ify the�xcu ant [�
nfthe teyuire n w 'c prior 11.1 e: c ofa Ceitifwte of cu / <T/�
Ownerorathoriudagem - Dor TOTAL ISSUED&9,04`7UBY: —0
OFFICE