S 0302 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD :-ELFCrRICA P ITNO.
BUILDING C DIVISION APPLICATION/PERMIT P n G. M 0 3 0 2
BUIL J, 1 - ON
. BUILDING ADDRESS: SANITARY NO. APPLICATION SGBMI'I-I'AL DAT'.
DOD /Ve 1 C SUl
OWNS 'S NA E: PHONW • ONTRA. 'S AM LIC NO'. NIC UNTROI.4
ARCH IT NGINEE �s ADD / Poo /1 ❑ �.
CONT Ci. �O a L BUILDING PERMIT INFO
✓2•fr�� ❑ Consultant Fees Paid by Applicant(Initial) BLI ELECT PLUMB fcf1
uCENSED CONT ACTOR' DECLARATION TY ELECTRIC PERMIT FEE JOB D SCRI TION
1 hereby affmm that I am licensed under provisions of Chapter 9(commencing TIAL'
W0Z with Section 7")of Division 3 of the Business and Professions Code.and my license is PERMITT ISSUANCE RFSID N�_
FBF i n full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�UU License Clans Lie.4 APPLIANCF_S—RESIDI--NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Z UW Dae Cwntmcror
VI ARCHO ECPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
OOvJ NPANELS Z. I understood my plan,shall be used as public records MODIFICATION
Z
OZ=fQ UY TO 200AMPR 0INTF.RIOR ❑CHIMNEY REPAIR
1.icenseJ Professional - 201-1000AMPg IMPROVEMENT 0SWIMM1IING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS IJ BATH REMODEUREPAIR El DEMOLITION
I hereby afford that 1 um exempt from the Contractors License Law for the goo U fnollowing reason.(Sectom 7031.5.Business and Professions CWc:Any city or county SIGNS ELECTRIC ❑OTHER
ii W I- which requires a permit to construct,alter-improve,demolish,or repair any sauctute
L prior tolls issuance,also requires the applicant for such permit to rile aligned statement SplzCI C C.
f y that he is licensed pursuant o the provisions of the Commemrs License Low(Chapter 9 COMMERCIALCSO (commencing wird Sectitn'll4g0 of Divixinn3 of the Business anJ Profcsxinns Cudel nr T P. -R NST.
C.q m 2' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tial
Section 7031.5 byanyapplicant tura Nianitmbjetts deapplicmuou civil penaltyof FEW - TENANT ❑FOOD SERVICE
on
t more than five hundred dollars(5500). IMPROVEMENT
�?C
01,as owner ofthe property,or my employess with wages as their sole compensator. SWIMMI GPOOL ELECT RIC OTNER
Sat willdmthework,anJ the smucmre is ootimendW nr offereJ for sale(Sce.]1144.Business
aand Profession,Cale:The Commend's License Law does not apply 10 an owner of OUTLET. —SWI'I CHCS—TIM ORES
property who builds or improves themon,and who does such work himself or through NEW RESIDENTIAL ELECfR SQ Ff.
his own employees, mi that such improvements arc not intended a offered for SQ.IL FLOOR AREA $SQ.FT.
sale.I[hnweveq the building or improvement is adJ within one year of eompletim.the
owner-builder will have the burden of proving that he did not build or improve for pur-
e pose ,ral
of e.). TOTAL: / r�
❑I,wf owner of the properly,am exclusively contracting with licensed contractors m xJ�
construct pross
project(Sec.7044,Business and Professions Code)The Contractors Li- /FEE
Genu Law does not apply to on owner of property who builds or improves demon,and QTY: PLUMBING PERMIT
who contracts for such projects with a can racmAs)licensed pursuant n the contractor,
License taw. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C forthis reason
ALTER—DRAIN&VIiNT—WATER(EAI VALUATI
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / a
I hereby affirm under penalty of perjury one N the following declarations:
❑ Ihaveandwill maintvinaCenificatcn(COnunOoulf-insurefor Workers Compcn- DRAINS—FLUOR.ROOF AREA,CONE. STORIS TYPE CONSTRUCT(
scion,as provided for by Section ffip of the Labor Code,for the pertnrmance of the
work for which this permit is issued FI%TUk1iS—PER TRAP
1 have and
will maintain Workcr'a Compression Insurance,as required by Section GAS—IiA.SYSTEM-I INC. OUT LETS APN
11.1 of the IaMr Code,far be performance of the work for which this lxnnit is issued. OCC.GROUP
My Workers Compensation Insurance comer and Policy number are: GAS—EA.SYSTEMOVER 4(EA)
Cartier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE PULL LNG DTVI:ON 'EES
(This section need not Weampleted ifthe permit is forme hundred dollar,,IS 100) GREASE TRAP PLANCHECK FF.E
unless)
I certify that in the performance ofthe work for which this Perrins issued,I shall SEWER—SANITARY—STORM EA.200 FT. ENERGY FEE
not employ any person in any manner m alio become subject as Ne Workers'Cordpen-
O� smimLawsofCullfnmin.11ute WATER HEATERWNENT/F.LECIA GRADING FEE
Z O Applicant
r+ (A NOTICE TO APPLICANT If,after making this Cenificse of Exemption.you should WATER SYSTEM/TREATING SOILS FEE
become subject to the Worker's Compensation provisions of IIIc Labor Code,you must
forthwith comply-with such provisions or this Nonashall he dommel revoked. WATER SERVICE
[� PAID
d
CONSTRUCTION LENDING AGENCY NI?W RESIDENTIAL.PLMB. SQ.I'T' .1e Receipt 4
I hereby offirm that hem is aconsuuction lending agency for the Performance of
U
U the work for which this permit is issued(Sec.3mG.Civ.C.) TOTAL:
O U Lemlers Nome TOTAL:
[� Lomices Address BUILDING -E
G 1 certify that I have reed this application end sat¢Wisdom have inf rn alimn Is E
Iti
VI correct.l agree to comply with all city and county ordinances andslme laws relating 10 QTY, ' MECHANICAL PERMIT SEISMICI .E
U z building constructaxi hereby authorize repmsenmtives ofthis city menerupon the -
r above-memional property for inspection purposes. PERM IT ISS DANCE ELECRI:FM
(We)agree to save,indemnify send Dec,harmless the City of Cupertino against
liabilities.judgments,costs arm expense,which may in my way action against said City ALTER OR ADDT0 MECIL PLUMBI GME
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IE,000CF10) MECHA ICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 111,000 CPM) CONST ICf10N TAX
Signature of Applicant/Conamum to EXHAUST HOOD(W/DUCT) HOUSING NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will thenpplitant orfuturebuddingnctepantpoccorhandle hazamaus material HEATING UNIT(*to EstonianBTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health ani Safety HEATING UNIT(OVER IIg1J100 BTU))
Code.Section 2551200?
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID Date Bee ' Y
Will the applicant or future Wilding uccupanl use equipment or devices which BOILER—COMP LOW OR 1W,0g RTU)
mit humorous air common.,ex defined by the Ray Area Air Quality Management IOTA
District? BOILER—COMP(OVER 100,0(00 BTU) _
❑Yes ON.
I have read Uc h ode.S s materials acquirements under Chapter understand
of the Csi-
AIR CONUI'TIONIiR SSUANCF-
fmmia Health ra Safely Code,Sections 25505,25533 and 25SJ4.I understand Ihm if Ne NEW RESIDENT IAL SUCH. SQ.FT.
of tlhe mqui s non iscurrentlywhich have a Want,p that o is my responsibility m notify the occupant
of the nquiremems which sun he met poor to ofaCrnifcvm of Occupancy.
Owner or authorized agent
Da¢ ISSUED BY:
OFFICE