S 1024 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL IFNO. 1024 OZ4
DUILmNC DIVISION APPLICATION/PERMIT DING PRo4:-MECHANICAL. `V
. BUILDING PRUdEC'f IDEMI'It'ICATIUN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/O,S u riNO of 0.
O NAh]E:/ �WZ'V'g�� HO CO NACIDR'S NAM L': _ LIC NO: NIC CONTROLM
ot
�ANCHITECTN GINEEIU CND, ADDRESS: U! ❑
CONTACT, PHONE: ///7 BUILDING PERMIT'INF0
ED1VF255 L EIZ a/. Consultant Fees Paid by ppIi enf(Initlal) BLDG [CET PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONTY ELECTRIC PERMIT FEE
I herehy.Worm thin I am licensed under provisions of m
Cloquer 9(comenciQ
ng JOB DESCRIPTION
wnh Sermon nXm)onawisinn 3rnne Baunmr and l+nkaemnxcmle.and my ucenreis
R O p PERMIT ISSUANCE
D RESIDENTIAL
in full force and effect. ❑SI7DWL ❑KITCHEN REMODEL
AF.: License Class Lich ApPLIANCE9-RESIDENTIAL El ADDITION ❑PLUMBING RFPIPE
N<L Date Contractor [I MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
z0 rat PANELS - MODIFICATION
z I understand my plans shall he axed as public records
Oz—O UP TO 2lq AMPS ❑INTERIOR [I CHIMNEY REPAIR
Fs4I•Y�2
Licensed Professional 201-11100 AMPS IMPROVEMENT (]SWIMMING POOLS
G� , OWNER-BUILDER DECLARATION OVER I AMPS S ❑BATH REMODEDREPAIR ❑DEMOLITION
aW a I herehy off nn that I um exempt from the Cnnvadnr's License Law for the _
5y O S U following reason.(Section?031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL _1 OTHER .
LLl'�IL FV which which".I.is permit tr consul eltem improve,demolish,or repair any s..am
..l prior to its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
s License Law(Chapter9
p. that heir licensed pursuant to the previsions of the Cnmmcmd
0
CO (commencing wit Section 7008 of Division 3 of the Business and Professions Code)Or I IM P.METER OR POUF.INST.
a 6 c OE that he is exempt temfrom and to basis for to alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D17MOLITION
^,h Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER D.VECES TENANT ❑FOOD SERVICE
not me than five hundred dollars(S500). IMPROVEMENT
Q ,es owner of the property,or toy employees with wages us their sole annflensation, SWEMMIN ODI.ELECI'NIC
oche work,and the structure is not intended proffered for sole(Sec.7Q4V,Business ❑O'fHER
and Professions Cade:The Commctors License Inw does not apply o on owner of OUTLET ITCHES FIXTURF_S
pmperty 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 R IDE L EL SQ FT.
sale.If,however.the building or improvement soils within one yearofeompletionJhe SQ.t1't� R RF.A 8/SQ.FT.
owner-builder will have the burden of flowing that he did not build or improve for pur.
posof oared. TOTAL:
I,as Owner of to property,am exclusively contracting with licensed common.m �a
+mtmet the project(Sec.]044,Business and Professions Crde)The Contrucora Li. -
uLaw does not apply manrwnefofpropertywhebtildaorimproves Inomma it QTY. PLUMBING FEE
who contracts for such projects with a contrectons)licensed pursuovt o the Contractors
Licenx Us.. PERMIT ISSUANCE
❑Ino exe pt der5 c. .R&PC.for this reason
ALTER-DRAIN&VENT-WATER IEA) - VALUATION
Owner Date G
R . 'S C N DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ufOnn under penalty of perjury one of the following tleclarntions: cc
❑I have and will maintain o Certificate ofConscnin self-ireuo for Workers Camper- DRAINS-FLOOR,BOOP,AREA COND. STORIES I'YPECONSTRUCTIC
sedan,as provided for by Section 3700 of to Labor Code,for the peffomtunce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Citamo mtinn Insurance,as required by Section
3700of the Labor Cale,for the perfommdce ofthe work for which this permit is issued GAS-EA.SYSTEM-IINC.40UTL OCC.GROUP APN
My Workerx Compensation Insurance carrier and Policy number are: 'Q
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIVINDUSTRL WASTE EWERC
COMPENSATION INSURANCE BUILDING DEVISE P' S
(Thoseemannecd notbecompinediftepermit is for one hundred dollars(SI00) GREASETRAP
or less.) LANCHECK FEE
I certify that in the perfonrasceofthe work for which this permit is issued,lshall SEWER-SANITARY-STORM EA,200 FT. �(�,,
not employ any persnn in any manner so as o heanne suhjeu to the Worker.'Compcn. I'W.{w.rY FEE
Z ,arms La ,ifCalifornia.DOW WATER BUY BRW/VENT/ELECTR Ur V
Il GRADING THE
ry y NOOCE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IRFATING SOILS FEE
F! become subject to the Workers Compemmlom provisions of the Labor Cole,you must
ai forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
J Q
11
CONSTRUCTION LENDING AGENCY NEW RESIDL'NTIAL PCMB, SQ.FC PAID
� 'z' E hereby affirm that there is a comesction lending agency for the performance of Dam Receipt
U the work l or which this permit N issued(Sec.31X97,Co.CJ
OI"a lenders Nome TOTAL:
U Lenders Address TOTAL..
I
aI certify tat 1 have read tis application and state that the above information isBUILDING FEEst.I agree to comply wit all city and county ordinances and state laws relating a QTY, MECHANICAL PERMIT FEE SEISMIC FEE
ding consuuclimatim numbyamhorimrepresentalwo,of this city n,emerupn the
ve-mentioned property for inspation purposes. PI3RMIT ISSUANCE [LECfRIC FF.F.(We)agree o save,indemnify and keep harmless the City of Cupertino agaistlities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH{ PLUMBING F'EE
onsequence of to granting of this permit.
LICANTU DERSTANDSA WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO IO,000CFM) MECHANICAL FEE
RCE E '1 NS. IF
AER HANDLING UNITIOVER 10,0(D CFM) CONSTRUCTION TAX
Signa rc hwnVCootmetor a(' Date HXHAUS'1'HUOD(W/DUCT) HOUSING MITIGATION FtBFi
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or main building Occupant store or handle hazardous material HEATING UNIT(TO[NEW BTU)
no defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety A '(QIiB 1110.(100 BTU)Code,Satins 25532(a)'! BETING ON['1V
_
0Y. ❑No - VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment nr devices which BOILER-COMP(3HP OR 100.00X)BTU)
emit baccodaus air contaminants as defined by the Bay Arca Air Quality Management TOTAL.
District? BOILER-COMP(OVER 100.W0 BTU)
❑Yes ❑No
I have read the hozmdoux materials requirements under Coupler 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 8505.255]3 and 255:{4.I understand tat if the NEW RESIDENTIAL MECH. SQ.FT.
building does nm comedy have a tenant,that it is my responsibility,to notify the occupant
of the mgairemenu which most rte met prior to issuance of a Certificate of Occupancy.
Owner or autonted agent Date TOTAL' ISSUED BY:
OFFICE