S0020 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL �s�,,�,-2-24 PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAI' Sao
Lp
BUILDING PROjF3CP IDENTIFICATION rfi'�+`/
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
05 �j
OWNER'S E: PHONE: CONT CI'OR'S NAME: LIC NO:
�/ 10-46.360 NIC CONTROL if
ARCHITE )ENGINHER: LIC NO: ADDRESS rI� ❑
AJIA
7FCOWACT. PHONE: 5 3 BUILDING PERM I•f INFO
N/g ..�� ❑ Consultant Fees Paid by Applicant(Initial) WFE[: ---,—
I
SLOG F. f PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT affirm that I am licensed under previsions of Chapter 9(ex m inee, JDESCRIPTION
OC'Z10)of DvxonoensCod,and my liciascis SIDENTIAL;WOp PERMIT ISSUANCE.R FDWL ❑KITCHEN REMODEL.Li<.p gppl.lANCFS—RESIDENTIALDDITION ❑PLUMBING RE-PIPE
F Z WCo."
mF6pam ARCHITECPS ad
.UIC1ARAT )N ❑MUI.TbUNIT ❑STRUCTURA.
PANELS MODIFICATION
Z O rn Z 1 understand my plans shall be used as public recaNs
❑
OZ—p UPTO200AMPS INTERIOR El CHIMNEY REPAIR
,onlF ly Licensed Professional '201-I000AMPg IMPROVEMENT SWIMMING yPO`OLS
S OWNER-BUILDER DECLARATION OVER Il91OAMPS El BATH REN D :PAI M
LL L'6 1 hereby vtlimt that 1 aexempt from the Comracmis Licem a Law for she
K3 a U m following reason.(Section?031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
u1 ti which requires a permit to construct,alter,impose.demolish,or repair any structure
prior to its issuance.also require.the applicant for such pemnii to ileasignedsmmntunt SPECIALCIRCUIT/MISC. _
"MC that lm lslirenmJ Section
003)provisions 3she eBusimessand Professions
rof Law is Code)r9
�C�Q (commencing with Section?tl(10)of Division3of the Business and lhofessionsCde)or TEMP.METER OR POLI31NS2 COMMERCIAL:
W p`, C shat he is exempt therefrom and she hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL%7 u•
Section 7031.5 by any applicant fora samod,ti jec,the applicant an civil prnd,yof FEWER DEVICES EITENANT ❑FOODSERVICE
F y nci more than five hundred dollars(5500). IMPROVEMENT
I� Q �Lnsnwda,mbrpmpeny,or anyemploye<s with wv,eras their sole compensation. SWIMMING POOL ELECTRIC
01 p., willdnthewnrk,and theswcwte is not in¢ndWomReted mrsele(Sea.]MG.Business ❑OTHER
W. ad� and Rofeoa sslCodd.The Contmcton's License law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES
properly who hadds it,improve,thcrenn,and who does such work himself m through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECI'R -an.
SQ.FT.�
aide If, the building or improvement is sold within one year m compledon,the O BFA SISQ.fT.
wneotwilder will have the burden of proving that he did not build or Improve for put- D
pnscofsaled.
Las owner of she properly,am exclusively contracting with licensed contractors m NAY
construct the project(SCC.904cl,Business and Professions Code:)'Me Commoners Li- 11
�'�qp
ceme Lawdoes non applymam ownerofpmpeny who builds crimprova thcrenn,and QTY. PLUMBING PERMIT FEE all
who contacts for such projects with a contractors)licensed pursuant to the Contractors
License
Licence Law. PERMIT ISSUANCE QIN OF UupEHTINO
1 um exempt under Sec. .B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DG CLARATION BACK FLOW PROTEGE DEVICE
1 hereby affirm under Penalty of perjury one of the following dmlamtions:
❑(have rend will maim mineCion 370at 0.1
unuoCode,lot Cher Wcontac Canopied-,ofthe DRAINS—FIAOR,ROOF,ARTA,CO STORIES TYP[CON51RI1LTIOD
amino.m pmvlJhi for by Section 191X1 mi rhe Labor Code,fort the pedivmunm of the
work for which this pertain is issued. FI%TURES—PBR TRAP
1 have and will maintain Workers Compensation Insurance,os terminal by Station
3900 of the Labor Cede,for the Performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INCA OUTLETS OCC GROUP APN
ma
My Wor e C h 1r@r ace Cartier and Pnli�y u hpJtt�{arPO,t1 pI GASB—
EA.SYSTEM-OVER 4(CA)
Carrier: .72lg�lf�iunlicy N r�!o O a'1
CELLFTFICATH OF EXEMPT ION FROM WORKERS' GREASF./INDUSTRL WASTE,INTERCEPTOR
COMPENSATION INSURANCE BUIIAING DIVISION FEES
;z
(This section red not bo completed ifthe permit is for one hundred dollars(SI00) GREASETRAP
or less.) PLANCHECK HRP.
I certify that in the perfurnme mus,work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FE.
not employ any person in any manner m as m become subject m the Workers'Compen- ENERGY FEE
O z nasion Laws of Cahfomid Date WATER HEATER WNENT/ELECTR GRADING FEE
z Applicant
NOTICE TO APPLICANT:IL wine,making this Cerlificnte of Eacmption,you should WATER SYSTCMHRfiATING
F become subject to the Workers Compensation provisions of the labor Cade,you must SOILS LEE
forthwith comply with such provisions or permit shall be deemed revoked. WAS ER SERVICE
CONST'RUCT'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O [hereby vRmuhat there isocoanmetien lending agency forthe perfamanceef Date Receipt#
— the work for which this Permit is issued(Sec.3097,Co,CJ TOTAL:
QU Lenders Name
ULcndcr's Address TOTAL:
1 arlify that I have read this application and state that above information is BUILDING FEE
G ti correct l agree to comply with an city and county ordinances and amen lows adding it, QTY. MECHANICAL PERMIT FEE
J building construction.and hereby monastic,representatives of this city m enter upon the SEISMIC FEE
above-mentioned pmpeny for inspection purposes, PERMIT ISSUANCE ELECTRIC IEE
(We)agree m save,indemnify and keep hamlets the City of Caperton against
liabilities,judgments,costs and expenses which may in any way rectae against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of the, shin permit.
FAN
APPLICANT UNDIES FANGS AND WILL COMPLY WI fit ALL NON-POINT AIR HANDLING UNIT LTO 10,1110 CFM) MECHANICAL FEF.
SOURCE.REGULATIONS.
AIR HANDLING UNIT(OVER 10,1110 CFM) CONSTRUCTION TAX
Signature of Applican/Cmilmcmr Dam EXHAUST HOOD(WMUCI} HOUSING MITIGATION FEE
HAZARDOUS MArER1Al.S DISCLOSURE
Will the applicant or future studding occapetr store or handle limitations material HEATING UNIT(TO 100,01X)B'1'U1
as defines)by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
Yes ON. VENTILATION BAN(SINGLE RESID) PAID Uma RcmipsN
I Will the apparent or Poutre building occupant use equipment or devices which BOILER—COMP CUPOR 100.000 BTU)
"Lilt haardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
WrieR Was ON. BOILER—COMP(OVER 1110,(110 BIL)
1 have mail the hazardous materials AIR CONDITIONER ISSUANCE DATE
requirements oder4.1 understand
rsta of of Cali-
Health ui Safety Cuda,Seders 85et it
33 and 25534.1 understand the if the NEW RESIDENTIAL MECH. SQ,IE
buildingdme nh have meant.dung isuamy ce of a Cirirytonotify the
pancy.
of th L c cis Nth nmat ha men prior m issuance of a Certificate of Occupancy.
Own&Br authors again Date TOTAh ISSU[D BY:
OFFICE