S 0459 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.F1LECII RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PI.IIMIIINC.'MECHANICAL S 0459
BUILDING PROJECT IDENTIFICATION
SANITARY NO, APPLICATION SIIBMITfAL DATE
BUILDING ADDRESS:
OWNERS Nnf1C\\ 6S ZJ�4I CO TRACIX)N'S NAME: S LICNO: D/ -NIC CONTROL.
16
S2 0�3D ARCHITECT/`ENGINEER: LIC NO. AI]DRCSS: ^ ❑
/V Rsi
CONTACT PHONE: BUILDING PERMIT INFO
❑ Crnsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA'T'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I um licensed under provisions of Chapter 9(commencing
DMZ whh Section II00),d`Divi,ian3oRhe Business and Professions Ccaie.and my license is RESIDENTIAL
WOO PERMIT ISSUANCE.
I" in full force and c t. ❑SFDWI. ❑KITCHEN REMODEL.
�U License a, Lilt.a f 1h 3hb
Q U _ Prfh s'( APPLIANCES-RCSIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F y,till Date Coal 1+1
yay MULTI-UNIT []STRUCTURAL
ARCHITECT'S DECLARATION
Z04r4 I understand my pus
lans shall be ed es Public records PANELS _ MODIFICATIONOZI UP TO 210 AMPS ❑IN'fl?RIOR ❑CHIMNEY REPAIR
F. Licensed Professional 201-10IIAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION ❑BATH REMODF.UREPAIR ❑DEMOLITION
9590 OVER IIXW AMPS
OOCC�6 1 hereby,Ilion that 11. exempt from the C scions Co e:Any c Law for the ❑MITER
igyx5�6V followinguiresa Permit
7nJLABusiness nimp improve.
dcofi i.orminycity orcountyarturn SIGNS F:LECfRICAI.
u+31i Fy which in issuance,
n permit to construe,applicant
improve,Demolish,Ci repair any sunaurc
F UJ�a that hoslicenance,olsorequires the
rovisi nsofthe well Conarctoit Licenste a sLaw(m¢ment SPECIAL CIRCUIT/MISC.
Eby that he is licemeJ pursmmmthe provisions of the Comrvcmh License Law(Chapter9 COMMERCIAL
0p (commencing with Section AXW)of Division J ofthe Business and Professions Cole)or TEMP.MCI ER OR POLE INST.
dq c that he is exempt thereWm and the hauls far the alleged exemption,Any viol.tion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 703 l5 by any applicant for a perardsuhjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
W m t more Nun five hundred dollars(SSWE.
C=6 1.in owner ofthe ro norm employees with wages as their sole cam tion. SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
Q ❑ t a Y my in Y s .ensu ❑OTHER
F- and dathe wons and the he Coreisnots Licded ense
awdoess not (Sec 7B 4.L Business
1
and Professions Cade:The Contractors License law docs not apply to en caner of OUTLF.'f5-SWITCIfES-PIX'TURF.S
pmpeny 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 NEW RESIDENTIAL ELECTR SQ Ff.
sale.Il:however,the building or improvement is sold within one yearoRomptetion,the FLOOR ANEA
ownenbuilder wilt have the burden of proving that he did not build or improve for pur-
pose of sale.). TOT
1,as owner of the property,um exclusively contracting with licensed conual to
construct the project(Sec.7(W4,Business and Professions Carl The Conerac urs Li- ,
cense law does but apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FE
whocoraowtsfor such protects with aenmmmnr(s)Ii,towd,tiol 1.1he Conu,emrs
License Law. PERMIT ISSUANCE
❑I am exempt under Sce. :B&P C for This recon
AUTER-DRAIN&VENT-WATER(EA) .UATION
Owner Date
t WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
• Ihereby affirm under penalty of perjury one of the following dmlaratimu:.
7 annual will maintain aCmiricatcof Consent raself.insure fm Workers Compm- DRAINS-FLOOR,ROOF.AREA,COND. TORI TY PE CONSTRUCTION
cation,as provided for by Section JAW M the Labor Code,for the Performance of the
work for which this permit is issued FIXTURES-i'ER TRAP CITY Ur UUrctifi (
❑I have and will nournma Worker,Compensation I...to..,as required by Section
3700of the Labor Code,for he performmon of he work four mwIh.i�ch�Rth�i�s.croon is issued. GAS-EA.SYSTI7M-I INC.4 OUTLIi TS OCC.GROUP AI'N
My Work(r.•i�g�qry�p{ryry@@yy��yy��Ins,ryn��c�����99'er and l'nlicy nAl%PI�O��q if GAS-EA.SYSTF.MEVER 4(G)
Lanier: l WI[.T(/YI"T FlLMP7�h1(ld 11ofic IS/ Pl rl
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION EFTS
(This sectuareedrot he completed ifthepermit is boom hundred dollar,SIW) GREASETRAP
1'LANCI IF.CK ILL
ar leis.)
I ceNfy thin in
performance fthe work for which this permit isIssued.Ism) SEWER-SANITARY-STORM EA.200 Fr. ENERGY FEE
not employ any person in any manner so m to become subject m the Workers Compen.
,7.' satlo oLaws of California.Dote WATER HEATER WNENTMLECTR GRADING FEE
z 0 Applicant
NOTICE TO APPLICANT:If,atter making this Cenifcate of Exemption,you should WATER SYS WG`REAT INC, SOILS PER
heroic subject to the Worker's Compensation provisions of 0 o
e Lur Code,you must
forthwith comply with such Provision,.,,his permit shall be deemed revoked. WATER SERVICE
ly a
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FN PAID
r7 z lending Pe Date Receipts
Ihorwhichshithenhereixmed(Sen.30endin for Performance of
�� the work for which this permit in isnuW(Sec..)097,Civ.CJ TOT
p Lemere Name TOTAL:
{UTa Lenders Address BUILDING FEE
1 1 certify that 1 have read this application midstale thin Ne move information is
tn Co."lagreem comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V building construction,and hereby authorim representatives Nthis city to enter upon the
aove-operomaJ property far inspection Pentoses. PERMIT ISSUANCE ELECTRI FEE
(We)as..wsave,indemnify and keep harmless the City of Cupertino against
liabilities,judgmetns,costs and expenses which may in any way accrue against said City ALTER OR ADD TO ME CH. PLUMBIN FEE
in consequence of the gmnting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,(XW CFM) MECHANIC HE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.0010 CFM) CONSTRUCfI NTAX
Signature of ApplicanVContmctin Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingnmcupntsmre or handle havnrdous material HEATING UNIT(TO 100,000 BTU)
a,defined by the Cupertino Municipal Code,Chapter 9,11,and Ne Health and Safety HEATING UNIT(OVER IM."BTU)
Code,Section 25532WC
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID Date Neceipt p
Will the applicant nr future building acap.,use equipment or devices which BOILER-COMP(3HP OR 1011,0(X1 BTU)
mit hazardont
hazardous air caminants as defined by the Bay Area Air Quality Management TOTAL:
District,
❑Yes ❑Nn BOILLR-COMP(OVER IM."IM."BTU)
I have radthe limandous materials Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE.
re,25533 an under
fomiu Health&Safety Code.Sections 25505,is ar,and 21534.1 uoersmnd that if Ute NEW RESIDENTIAL MECH.
building rices a currently have a met p Nat n is Lia ce of a Ce"lll us notify cc pancy. ��rr/►I
of Its tegavencnts which must Mmet prior to issuance ofa Cenifcate of Occupancy.
Owner or autborixed ager Date TOTAL: ISSUED By. , V
OFFICE