S 0463 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TV
OF CUPERTINO - BUILIIING-ELECTRICAL PERMTTNO.
NUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. S .0463
BUILDING PROJECT IDENTIFICATION
0BUIL,DTNG7ARdE S SANITARYNO. APPLICATION SUHMD9AI.UATI
5rfl L NAM@ - Pr 00 CONTRACroR'S NAME: LIC NO:/�� Un t r•`� /' /J a NIC CONI'Ruff.p
•ARCHITECTMIS (NEER: LIC NO: ll�+ ADrC$ ,a G(f
,, �'G.J/' J i C� �F+�-7 ❑
CO PHONE: •j /i-M BUILDING PERMIT INFO
S3—�iea ❑ Consultant Fees Paid by Applicant(Initial) BI. F:LF PLUMH MGCH
ct�u6Ler Ext n ❑ ❑
LICENSED CON TRACFOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing J09likSCRIPTION
O afZ with Section 700f)of Division Sof the Bimmusand Professions Gdyand my license is RESIDENTIAL,
O PERMIT ISSUANCE
O ❑$
in full force and effect. FDWI. ❑KITCHEN REMODEL
,UU License Class Lic.g APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RIi-PIPE
F Ie Dnm Contractor
w �' ARCHITECT'S DECLARATION ❑MULTI-UNH' El STRUCTURAL
1..,7m PANE" MODIFICATION
Z O „Z, 1 understand my plans shall be used as public rccnrds
OZ�p UP T02W AMPS ❑IMERIOR ❑CHIMNEY REPAIR
r4t2 Licensed Professional 201-I(gIf1AMPS IMPROVEMENT []SWIMMING POOLS
�^•,i OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR O DEMOLITION
C i�6 I hereby affirm that I am exempt from the Contractors License Low for the
following reason.(Section 703 1.5,Business and Professions Code:Any city in countySIGNS ELECTRICAL. [IOTHER
1.a W F which reyuires v permit m ennnru<t,alcor,impmva JemolixM1,or repair any nanurc
� s pdono its issuance,.soreyuims theapplicaut far such permit to file o signed smmment SPECIAL CIRCUIT/MISC. /
E y that he is licensed pernuan ro
to the provisions of the Connector's License Law(Chapter l COMMERCIAL,
W C (commencing with Section 900)of Division 3 of the Business and Professions Codu)or TEMP.METER OR POLO INST.
fl that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
D• Section 1031.5 by any applica,fora Permit sildectsthcupplicant to n civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
nm more than five hundred dollars($500). IMPROVEMENT
�Q ❑1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
wdl tlo He work,nnJ rhe stmcwm is not intended nr oRemd fm.ale(See.7044,Business
W and Professions Code:The Count License law does not apply m an owner of OUTLETS—$WITCHES—PIX'fURES
papery who builds or improves Hereon,and who dce.mch work himself or through
his own employees,provided that such improvements arc not intended or offered far NEW RISIDENTIAL ELECTR SQ FT.
sale.If,however.the building orimprovemem is sold withinnne yammf completion,the SQ. ) A S/SQ IT.
owner-builder will have The burden of proving that he did not build or improve for pur-
,twa
El1,a owner
❑ wn, W SEP 30. ECI
I,if r of the property,am exclusively contracting with licensed naed coors
construct the project(Sec.71144.Business and Professions Com,:)T1W Contactors Lt.
censeLow does not apply to an owner of progeny who builds or improves thercon.and QTY. PLUMBING PERMIT FEE
whoconvacts mrsuchpnjects with acomractons)licensed pumuanuaThe Conuacmrs CITY Ur uurchI INU
Licence Law. PERMIT ISSUANCE
❑I am vacant under Sec. ,B&PC for at
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. O NI//
. I hereby affirm under penalty of perjury one of the following decluratinns:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Cmnpen- DRAINS—FLOOR.ROOF,AREA,GOND, STORIES T PE CONSTRUCFIO
stairs,as provided for by Section 310 mf the Labor Code,for the performance of the
..,it for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Werelle Compensation Insurance,as required by Section
370ofthe Labor Code,far he perfmmlmocif the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Issuance,artier and Policy number am:
Cartier: Policy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEBNDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This sworn mad am he completed tribe permit is forma,hundred dollars(S 100) GREASETRAP
or less) PIANCHIiCK FEC 4101
I certify that in the Performance of the work for which this permit is issuwl.I shall SEWER—SANITARY—STORM EA. FF.
nm employ any Num,many runner so as to became subject to the Workeri Coapen- ENERGY FEE
ZZ smion laws of Call farm.Date WATEN HEATER WNEWT.Llt GRADING FEE
Applicant
rq NOTICE TO APPLICANT:If,after making this Cenifeare of Exemption.you should WATER SYSTEMiTRFATING
I-+ become subject to the Worker's Compensation provisions of The Labor Code,you must SOILS Flip
Cot forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
V]
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB, SQ.pp PAID
z I hemthyaffrm dmuherc iso construction lembril gency fnnhe performance of Urate Receipap
UC He work for which this Permit is issued(Sec.301 Civ.C.)
I" L^ IsWef's Name TOTAL:
{UTJ TOTAL_
Landers Addresa
Iy� yt I certify that I have read this application and state that the above information is BUILDING FEE
i.rrA cored l name to comply with all city and county oNimarues and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building construction,and hereby authorize representatives of this city it,enter upon the
above mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PGC
(We)isgree to save,indemnify sad keep harmless the City of Cannot.against
liabilities'udgmems,c round expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING HE
in co at m en,of th' Pertnia.
A . AN' U F STA �7 DWIL -Y WITHALLNON-POINT AIR HANDLING UNIT(TO IT3.(gIfICFM) MECHANICAL FEE
SO 7
9 -Y/ AIR HANDLING UNIT(OVCRIO,NBCFM) CONSTRUCTION TAX
SlgnmucofAidainant/Crounmm a Dam t EXHAUST HOOD(W/DUCf) HOUSING MITIGATION Mr.MATERIALS DISCLOSURE
Will the applicant or future building occupant store cr M1untlle hoardous material HEATING UNIT LTO 10,00 BT U)
as defined by the Cupertino Municipal Coda,Chapter 9.12,unit the Health and Sul'emy
Code,Swtion 25532(x)? m HEATING UNIT(OVER 100.000 BTU)
❑Yes, ❑No VENTILATION PAN(SINGLE RESID) PAID -
Dac Hweipp
Will the applicant oru m building necupana use equipment en devices which
ehaza
mit rdus oair commitment as cictined by the Buy Area Air Quality Manugcmcm BUTLER (31IP OR IO,fgg1 BTU) TOTAL:
District? BOILER—COMP(OVER 10,00 WITH
C]yes No
I have readthehamrdcus [arid,rtquiremems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE.
fomi ileal sety .Swtinnn 25505, 5577 and 25530.1 understand that if the NEW RESIDENTIAL MECH. $Q.FT.
bu buv Lthxt mx11 responsibiiiryto notify HcoccupanT -
oft uc w c [poor n`suance ofaC �a die+ OtffgpSmm%.
weer or emhorizcd aBem �, ISL- Date/ TOTAL: ISSUED BY:
OFFICE