S0068 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY //ss �+ /�
CITY OF CUPERTINO BUILDING-ELECTRICAL. OR
PERMIT NO. /^ ^ may`,.
BUILDING DIVISION APPLICATION/PERMIT PING isuoG MECHANICAL 1 '1 1 lJ �
BUILDING PROJF,CT IDENTIFICATION
BUILDING ADDRGSS: SANITARY NO. APP.ICATION SUBMITTAL DATE
�oZL Gent tin.
OWNER'S NAME PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONI ROL#
JIfa/�NDGINBERADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
JJA&A R�n(V'� ZYp � ❑ Consultant Fees Paid by Applicant(initial) I. , ELECT PLUMB MECH
P
LICENSED CONTRACTORS DECLARATION 1 1 V QTy ELECTRIC PfiRMIT FEE
I heresy atfrm Nm l am rt
foe..ud under npoisma,of Cmpmr 9(commencing _ JOB DESCRIPTION
Mod with Sc 1117100)Of Divisionlnf the Business sand Prol<ssi.nsCWc,and mylircnse is RESIDENTIAL
W O PERMIT ISSUANCE
F-W� in full force and effect.
❑SFDWL ❑KITCHEN REMODEL
�U�j Liecom Class Liae VSRFSIDLFEf ..CES—RESIDE •� ❑ADDITION ❑PLUMBING RE-PIPE
In6L Dam Commcmr ❑AD ADDITION
❑STRUCTURAL.
F.7m ARCHITECTSDECLARATION MODIFICATION
OZ`y�'� Iundersmnd my plan.v shall beused os public records 0 PS ❑INTERIOR ❑CHIMNEY REPAIR
4 µjLicensed profcadonal AMPS IMPROVEMENT E]SWIMMINGPOOLS
OWNER-BUILDER DECLARATION ECASTS ❑BATH REMOI]"UREPAIR EI hereby anion that 1 am exempt from the Convaaor's License Law for theemswQ—W following reosnn.(Senn..7031.5,Businessand Professions Cask:Any cityorcomityECTRICALERLLI- which requires a permit to consnum,lifter,improve,demolish,m repair any structureos prior m it issuance,also ueryires then,iunt forsuch,molt t.fileasigned smmmenr CIRCUI S} that he is licensed pursuant to the Provisions ofthe Connectors Licedu Law(Chapter9COMMERCIAL:mpcommencngLE INST.that he i.s exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIAUUITION ❑DEMOLITION
Section)03LS byany applicant forapermit whjectx the epplicom mucivil pcnvlty ofI? 0TENANT ❑FOOD SERVICE
?Gnot inure than f sae hundred dollars Stan), IMPROVEMENT
❑Las mvamr of the property.or my employees with w�gesazNeirsole compenvatinn, SWIMMING POOL ELECTRIC
will do the work,and the someone is not intended or offered for sale(Sec.7044,Business []OTHER
W�ce and Professions Cede:The Contractors License Law does not apply m m owner of OUTLETS—SWITCHIS—PIXY
6'3^ 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 NEN ESIDENTIAL BL SQ FT.
sale.If,however,the building.,impmvatunt is sold wimmuneyCarof completion.the SQ.FT.FLOOR AREA ® LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- P A
pose of sal.,). SAL' •�J
1,m owner of the property,em esdusively convading wiN licensed nmwcmrs to f/
consumer rhe project(Sec.]044,Business and Professions Code:)The Contractors Li- a0i 9 l
ase Law does not apply to m owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERM T FEE AL 8
who contract for such projects with a connoctor(s)licensed pursuant to the Co mucaors .
License Law. PERMIT ISSUANCE CITY OF w,ijHT IND
I am esempt arida Sec. .B&P C for Nis reason
ALTER—DRAIN&VF. AT A) VALUATION
Owner Dam
WORKERS most,
UE CL raped ON BACK ROW PROTECT.DEVICE cue
1 hereby vtfrm under penalty of perjury one of the following Jednmtinns:
I M1ave and will maintaineC<rdficste.fCOnsent to self-insure for Worker's Compcn- DRAINS—FLOOR,BOOK ARRA,COND. STORIES TYPE CONSTRUCTION
sanon,vs pmvidcd for by Section 390 of the Unfair Code,for the performance of the
work for ich this ia.it is issued. FIXTURES—PER TRAP
wha
1 have and will maintain Workers Compensation Insurance,vs required by S¢rinn
390 'he Lamar Cade,for the Performance ofthe work far, chis pcmrit is issued. GAS—EVSYSTEM-IINC4OUTLETS OCC.GROU APN
Orker's Compensation Insurance tamer and Policy number ane:
Curiae Policy No.: GAS—PA.SYSTEM-OVER 1(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASFlINI3USTRl.WASTE INTERCEPTOR
COMPENSATION INSURANCE L N DIVISION FEES _
.r less.)(This stollen need not he completed if the panni,is for one hundred dollaas(S 10) GR17ASETRAP
PLANCHF F aha
work for which
(certify thein Ne any
sal thebecome subject to the W isissued.
ampeshall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner sal as to become subject m the Workers ComPen. ENERGY
sation Laws of California.Date WATER HEATER WNENT/ELECTR GRADINGFEE
7O O 'Applicant )
^. h NOTICE TO APPLICANT:If,Etter making this Cenifcnm of Exemption,you should WATER SYSTEMOREATING
f' become subject to Ne Workers Compensation provisions of the LaMm Code,you must SOILS FEE
Wforthwith comply with such promit visions or this pershall hedcemcd revoked. WATER SERVICE
d Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Dam Receipt
V 0 l hereby affirm that them is a construction lending agency for the performance of
k the work for which this permit is issued(Sec.3097,Co.C.)
O U TOTAL:
Lendcrs Name a
Da Lenders Address TOTAL:
BUILDING Po
I comfy that I have mad thisapplicalme and state that the above information is
1.. 10 correct,I agree to comply with all city mrd county ominances end stem laws uleing to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
LJ z building construction.and hereby muhroom reprcumarives of this city m enter upon the
shove-mentioned property for inspection Purynsel. PERM IT ISSUANCE a✓ ELECTRIC FE
(We)agree to save,indemnify and keep harmless the City of Capmin.against
liabilities,judgments,costs and expenses which may in my way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEI
it i nnsetpiome of the gaming of this pr oto
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT LTO I(LOIM)CFM) M17CIIANICALI C
SOURCE REGULATIONS.
AIR HANDLWG UNIT(OVER 10.00(1 CFM) F.. CONSTHDCTIO TAX '
Signature mApplonmContrucmr Date EXHAUST HOOD(WMUCO a HOUSING MITIG.TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appficant or future building occupant store or handle harridans personalHEATING UNIT TO IM."BTU) s
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety I IEATINO UNIT(OVER 10,(KKI PTU)
Calc,Scene.25532(.)'!
❑Yes ON. VENTILATION FAN SINGLE RIiSIII) y Dam ce of M
7builWill the applicant or furore building cecap..(use equipment or devices which
dingdook
haumnus air contamimmts as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,01 BTU) TOTAL: is
not? BOILER—COMP(OVER 1(10.00 BTU)
❑Yes ❑No
I have real the hauidaus materials mancmcnt trader Chapter 6.95 of the Cali- AIR CONDITIONER ISSU NCE DATE
n Health&Safety Code,Sections 25505,M533 and 25534.1 mcarstmd Nut if the NEW RESIDENTIAL MECH. SQ.num curenrly have a tenant,Nat it is my responsibility to ladfy rhe occupmr
e summations which must he and prior to issuance of a Certificate Of Occupancy.
Owner or authoneed agent Dam TOTAL: ISSUED BY
OFFICE