99120121 `-ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
YOFCUPF.RTINO BUILDING-ELECTRICAL.
13UILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
A%DING ADDRESS: - 7N,1,IARY NO. =1CANITTAL DI
Q lCo 1JNxLti
WNER' ry4^E,: L PIIONE: CONT 0RN ME: hIC NO:
I V TAI V Q I IY1 (T S �e1V� �OI CONTROLpCHRECI'/ENGINEE LI NO: ADD SS
T •F' ei ,
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMBEl ID El
M. ECFy
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby nation that I am IicensM under provisions of Chapter 9(commencing JOB DESCRIPTION
CXZO with Section 7000)of Division 3 of the Business n deryltemax is
in full oto. and V�d/P PERMIT ISSUANCE RESIDENTIAL
FZW ¢erose Clas Lit.p eo ❑SFDWI. ❑KITCHEN REMODFI.
Dam Contractor C APPLIANCES-RESIDI?NTIAL
m6a ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p n Z . 1 understand my plans shall he used.,public records
OC Z'p UP TO 200AMPS MODIFICATION
F-�FW Licensed Poubs.iowl 201-Ipp AMPS [I INTERIOR 11 CHIMNEY REPAIR
IMPROVEMENT
ygaG' OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
I hereby affirm that I am exempt from the Centmctor's License Law for the OVER 10g)AMPS ❑BATH REMODIIREPAIR DEMOLITION—
SYU lidlowint"cown.(Sectlon 7031.5.Bootie's and Pollosinns Code:Any city or c umy SIGNS ELECTRICAL ❑OTHER
which requires a permit m cmmaum,alter,improve,demolish,or repair any sanctum -
pdortoitsissuance,atm rtquires the.pplicam for such oto file ass tied stammem
9yW m„1 Perris g SPECIAL CIRCUIT/MISC.
H 0 (cot menden sedwith
pursuant to the of D'vioosof the Contractor's and
ease Law(Chapter4
41rQO (commencing with Scninn7000)of UivisiOnJ of Business and Professions Code)or Tf?MP.METER OR POLE(NST. COMMERCIAL
a
at,
n y than he is exempt theafrnm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDD'ION ❑DEMOLITION
W�H Section 7031.5 byany.pplicwtfora pemdtsubjens Nezpplica,mucivil Nualtyof POWER DEVICES
EZno,...than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
80Loownerofthep...Nay,or any employees with wages us their sole compensation, SWIMMING POOL ELI!CTRIC IMPROVEMENT
aF will do the work.and thesancmreviral intended oroRered for sal,(Sm.704L Business ❑OTHER
3 and Professions Code:The Contractors License Law does not apply tow owner of OUTLETS-SWITCHES-Fl RES
property who builds or improves thereon,and who does such work himself or Brough
his own employees,provided that tech imN.'su ro,are not intended or offered for NEW RESI UENTIAL ELEC Icr.
mle.If,however the building or improvement is sold wilmone year of eampletionhc SQ.Fr.FLOOR AREA S/SQ.IT.
owner-loodder will have the burden of passing that he did not Mild ear improve for pur-
pose ofmle)
El I,as owner of the property,am exclusively enntrcrung with licensed contractors to TOTAL,
emomet the pasjmt(Sm.7044,Bminess and Professions C11:)Th<Counselor's I,i- /y
erose Law docs not apply tow owner of paspwy who builds or improves thereon.and QTY. PLUMBING PERMIT FEE fIJI
who contracts for.meh,agw s with n eo rawarrad licensed pumuwt m the Conaacmrs
License Law, PERMIT ISSUANCE DEC 21
I am exempt under Sec. ,H&P C for this reason
Owner
Date
ALTER-DRAIN&VENT-WATER(Ep) VAL A
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE p
I hereby.ffiran under penalty of pe Jury one of the following declarations: Bl/
Ihavewdwillmaintain a Certificate of Consent mself-insure for Workers Compm. DRAINS-FLOOR.ROOF AREA,CONI.
moon,u provided for by Seedon 37M of the Libor Code,for the perfamwce of Ne STOR TYPE ONSTRUCTIOD
work for which this permit is issued. FIXTURES-PER TRAP _
_ ❑I hove and will m adorn Worker'Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OU'I LETS OCC GROUP
Mas�r1�TS Co . tion In Twee canierwlcy Na.Policy l'�t�f bIyN� GAS-EA.SYSTEM-OVER 4(EA) (S6f�O`J
CERTIFICATE 0 EXEMPTION FROM WORKERS' J N
COMPENSATION INSURANCE GREASDINDUSTRL WASTE INTERCEPTOR
(This.sectlon need not M completes]if the permit is for one hundred dollars(Sl OB BUILDING DIVISION FEES
or less,) GREASETRAP
PLANCHECK FEE
(certify rM.the comperm erce m,In a,no bekforwhbjM1 this perthe W iksxred,ICmn hall SEWER-SANITARY-STORM EA.200 FT
.11,court,Laws
any Colorado
any manna so as m bensme object the Warkcrs'Comps.' ENERGY FEB:
O Z moan Laws nr cmrramrn.Dam '
ZO Applicata \ WATER HEATER WNENT/EL[LTR GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
a ; beerme objeal to the Worker's Cour,me em provisions of the Labor Gude,you must SOILS FRE
Q forthwith comply with Inch provisions or Nis prrmit shall M deemedrevoked. WATER SERVICE
a
� z CONSTRUCTION LENDING AGENCY NEWRESIDENIALPLMB SQ.Fr. PAID
U 2 I hereby afimt that is o wotmedan lending agency for the performance of Date Rmeiptk
F the work for which this permit is issued(Sce.YN7,Civ.C.)
Leaders Nome
O W Lenders Address TOTAL: TOTAL:
gy I mail,that I have read this application and state shot the above information is BUILDING FEE
A nnrmt.l agree mcomply with all city and county ordinances and smote laws relating to QTY. MECHANICAL PERMIT FEE
t)z Milding crowemal.and hereby moderiu repasentons"of this city to enter upon the SEISMIC FEE
above-mentioned pmpeny for inspection pmtpoms.
(we) to rove.indemnify p City pe g' PERMIT ISSUANCE
( agar yes which
harmless the Cit fcu nota mist ELECTRIC FEE
incoitiesjrceor recons and expenses which may in any way wcme against said City ALTER OR ADD TO MECH.
consequence orate grwting ohhis perm PLUMBING FEE
APPLICANT UND� STA DS ILL C PLY WITH AI NO -POINT AIR HANDLING UNIT TO 10,(X10 CFM)
SOURCERI' MECHANICAL FEE
�� qq AIR HANDLING ONTr(OVER 10,000CFM) CONSTRUC'rIONTAX
Sigwma ofApplicamu Contractor Date EXHAUST HOOD(WMUCn
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applieum or future building occupant store or handle hazardous materiul HEATING UNIT(TO I00.010 BTU)
m defined by thu Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Seetloo 8532(x)7 HEATING UNIT(OVER 100,000 BTU)
❑Yeas ❑Na
VENTILATION FAN(SINGLE RESID) PAID -_
Will the applicant or future building occupant use equipment or devices which Date Receipt a
it ha-duus air contaminants m defined by the Bay Aren Air Quality Manegemem BOILER-COMP DHP OR 100.010 BTU)
ivuiet7 - TOTAL: O
[:I Yea El No BOILER-COMP(OVER 100.000 BTU)
- 1 have read the hazvd0o mutcdals AIR COMB rIONER
requirements under CTapar 6.95 of the Cali- ISSUANCE DATE
(endo Health&Safety Cade.Seri a 850.5.SSJJ wd 8534.I urrdersmnd that if the NEW RESIDENTIAL MECH. SQ.FI'.
baldingdoe a nil tenwL Nat" my responobilityt notify he sccupwI
o(th ust term l'manceofnC Ifo 62t;31
of u cy.
Owneraroathomaxi'am f Dae TOTAL: ISSUEDBY:
OFFICE