S 1036 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P IT NO.
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IT
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL1036
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL.DATE
V 5-!r �-dc L,l t2 '0A% (:1u 19y,-r,0 c 3 vI L( !
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OWNER'S NAME: PHONE: CONTRACTOR'S NAME: - LIC NO:
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"#r7(maaA�4j el;beta -3916207
NIC CONTROL#
CHIT CT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: - BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLLDD�U' ElHUT/ PLUM MECH .
TZTIy` !]!st•OQ E I ❑
LICENSED CONTRACT'OR'S DECLARATION' QTy, ELELTRIC PERMIT FEE
I hereby amrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section of Division 3 of the Business and Professions Code,andm license is RESIDENTIAL'
'm00 �! G y PERMIT ISSUANCE
Fly.. in icca force and eRect. JO ' DSFDWL [I KITCHEN REMODEL
I"Uz Li cense Clens) l.ia# OgtQ APPLIANCES-RESIDENTIAL []ADDITION, [I PLUMBING RE-PIPE
y6 UateJ�Contractor
ARCHITECT'S DECLAR TIONPANELS ❑MULTI-UNIT []STRUCTURAL
zbr K ImuliamnJ my plineshall he used a,publicreemcs MODIFICATION
CZ40 UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F,4 W Licensed Profetomarl 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
Lq� a•.l OWNER-BUILDER DECLARATION OVER 1003 AMPS ElBATHREMODEVREPAIR El DEMOLITION
I hereby affirm that I am exempt from the Contractor's License Low for the
tq�.V rollowing reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
YJ+�rrLR _
No,F- which requires a permit to construct,alter,improve,dermloh,or repair any structure
�y
p
nor to its issuance,also requires the applicant for such permit to file a signed statement SPECIALCIRCUCUMISC. ,
y that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
m dOC (commencing with Section]000)of Division 3 of the Bminessand Prefessions Code)ur TEMP.M TORP tINST. COMMERCIAL
GGpx, oG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION D DEMOLITION
lL�,lr• Section]031.SbyanyapplicantforapermitsobjectstheapplicanttoaciAlp enall,of POWER V ❑TENANT ❑FOODSERVICE
not more than five hundred dollars($500).
F - IMPROVEMENT
6 ❑ I,as owner of the Property,or my employees with wages as their sole compensation. � SWIMMING OL IC
C willdothe work,andthearecture is notintendedoroffered forsele(Sec.J.,Business DOT HER
and Professions Code:The Contractor's License Law does not apply to an owner mT OUTLF.'1'S-SWIT S- TURES
property who builds or improves thereon,and who does such work himselr or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIU NTIAL ELECUR SQ FT,
sale.If,however the building or improvement is sold within one yearofcompletiva:the SQ.FT.FLOOR AREA $ISQ.n
mer-builder will have the burden of proving that he did not build or improve for pur1-7
-
pmemsale,).
D 1,as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of propeny who builds or improves thereon;and QTY, PLUMBI ERMIT FEE ,
who contracts for such projects with a contractor(s)licensed pursuant o the Contractors
License Low. PERMIT ISSUANCE Ju
0 1 am exempt under Seo. .B&P C far this reason
ALTER-DRAT & -W TER( '- VALUATION
Owner Date ♦ �,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT tV R-I{-)U
1 hereby affirm under penalty of e ofCon one of the folloinsure log declaratWorkees Co
Ihave andpro will maintain Section 37M of the Laor Code.
for Workers Comp the #RAINS-FLOOR.RODEAREA, b. STO ES TYPE CONSTRUCTION
worn,as provided for nd Section 3]00 of the Labor Cnde.for the performance(if the
' work far which this permit is issued. FISTORES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the perfnumber,of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My Worker's F iio InWyr Gamer and Policy
Carrier. +TAY'BnFNHa Policy No.:ry� 7�6 GAS-EA.Sys TEM-OVF.R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE
INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissemion need not m emoplered ifaiepemtit is forone hundred dollar,($100) GREASETRAP
or IessJ PLANCHECK FEE
I cmnifylhmin the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sr,as to become subject to the Workeri Compen- ENERGY FEE
0 Z intim,Laws of California.Date WATER HEATER WNENTIELECUt
0 Applicant I GRADING FEE
4 y NOTICE TO APPLICANT:If,after making this Cradle.,of Exemption,you should WATER SYSTEMII'REATING
h become suh'ect to the Workers Compensation provisions of the Labor Cade,you most _ SOILS FEE
forthwith comply with such provisions or this permit shall by deemed revoked. WATER SERVICE
UU0 CONSTRUCTION LENDING AGENCY NEW RFSIDENTIALPLMR. SQ,FT. PAID Date Serials is
0 I herebywhich ren then there is sued(See,
Co, gency for Ne performance of
the Work for which this permit is issued(Sec.309],Civ.CJ
� Lender's Name - TOTAL:
V Lender's Address - TOTAL -
I certify that 1 have matl this application and state that the above information is - BUILDING HE
iU((Z) correct.l agree to comply with allcityond county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
L) z building construction.and hereby authorimnepresenmtivesofthis ch,toenrerupun,he - SEISMIC FEF,
shove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE' ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE
m consequence of the granting mild,permit. .
APPLICANT yyDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,0[10CFM)
MECHANICAL FEE
SOUR 6LAT10.NS. /I
AIR HANDLING UNIT(OVER IO.fN10 CFM) CONSTRUCTION TAX
Sig(((n ,, TIApplicandContrector TLfW/�/ Date EXHAUST HOOD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building osentsntsmre or handle hazordous material' HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)] HEATING UNIT(OVER 101,000 BTU)
❑Yes0 No
- - VENTILATION FAN(SINGLE RESID) PAID Dam R i t#
Will the applicant or future building occupant use equipment moistures which BOILER-COMP(3HPOR 1 W frust BTU)
mit hazardous air contaminants as defined by the Bay Area Air Quality Management OT Q
Doulct" - BOILER-COMP(OVER 100,000 BTU) 1 41
❑Yes - GNn -
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER O ^ IC IIA E�TE
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the _ NEW RESIDENTIAL MECH. SQ.CE 'J
building it mol curtendy have amnant,that it is my responsibility to notify the occuyyparn -
ofthe moa�entswhich0mstbeny no issuance ofa Cenifca,g of Occupane. '� T
Owner n h�zed agent Dme TOTAL' ISSUED BY',y� -• `
OFFICE