99100156 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY qa I ooI`J(U
J
F CUPERTINO BUILD NG-ELECTRICAL - PERM
DING DIVISION APPLICATION/PERMIT PLUMBING-MFcxnNICAL SOOOI.
BUILDING PROJECT IDEMTIfl kTION
G ADDRESS: SANITARY NO. APPLICATION SUBMI'I-1'AL DATE
ME: NE: CONTRACTOR'S NAME: LIC NO:
_ NIC CONT OLp
I CT/ GINGER; LIC NO: ADDRESS:LI_T: PHONE: BUILDING PERMIT INFO
❑ Consultant Fe"Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CON'TRACTOR'S DECLARATION QTy ELECTRIC PF,RMIT FFE JO)I ESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing OCZ ith Section 7000)nfDivision 3 of the Business and Professions Code,and my license is RESIDENTIAL:
IBU1 in force en c PERMIT ISSUANCE
F•�� ❑ADWL ❑KITCHFN<U�j License Cl Lic.q APPhIANCL'S-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
F st LL Umc Cnmmctor_
oste,'Doe [I MULTI-UNIT []STRUCTURAL
F',n ARCHITECTsS DECLAR TION PANELS
tri IundcrstaW my pians shall he anal as public records CHIMNEY
CATION
OZ�� PAIR
UPTO 20AMPS El INTERIOR ❑SWIMMING POOL
F�F',W Licensed Professional 201-1000AMPS IMPRBATH R zMFNTMODE [I DEMOLITION POOLS
OWNER-BUILDER DECLARATION OVER PRO AMPS ❑tlATll REh10DEUR13PA1R ❑DEMDLETIGN
6 1 hereby M.Thai I am exempt from the Contractors License Law for the
xIS 6 Ufallowing reason.(Section 9031.5,Business and Professions Cove.Any city or county SIGNS ELECTRICAL ❑OTHER
whieb requires a permit to consumer,alter,improve,demolish,or repair any structure
prior,.its bamnce.alm requires the applicant far each Percrum file a signed summer, SPECIAL CIRCUIT/MISC.
pC' ,bar he is licensed Pa...,to theprovisinnsofdom Convato's License Liw(Chaptal9
W�00 'commencirg with Section of Division 3 olum Business and Professions Co&I or TF,MP.METER OR POLF.INST.
IL q^c ,he,he is exempt therefrom and the basis for Ne alleged esempuiun.Any wisterias of ❑NEW BLDG/ADDITION ❑DEMOLITION
LXX] an Section 9031.5 by any applicant for a permit subjects the applicant m a civil penabyof POWER DEVICES ❑TENANT OFOOD SERVICE
m not more than rive hundred dollars($500).C�Q ❑1,asownermfthepropeny,ormyempinyeeswi,b wages as@entasia compensa,inn, SWIMMING POOLELECTRIC IMPROVIiMENT
will do the work,and the swcme is not intended or offered for min(Sm.704,4,Business OTHER —
ac unit Professions Code:The Conumct.es License Law does not apply m an owner of OUTLITb S ITCIIIS-PIXTURLS
IS 66 propeny who builds or improves thermn,and who does such work himself or Through
his own employees,provided that such improvements um not intended or offered for ES IAL ELIC R SQ fT.
sale.If,however,the building or improvement is sold within one year ofcorepledon,the SQ.FT.Iq-00ft ARE. g/SQFT.
.
neebuilder will have the burden of proving that he did not build or improve for per-
pase of sale.). TOTAL:
❑1,ev owner of the propea,,am exclusively convicting with licenmd c.ntmcmrs or
crnsomf the project(Sec.70.94,Business and Professions Cnde:)The Cnnlractor's Lt.
came Law does and apply toanowner of property who builds or improves Hereon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a eomvacr.r(s)licensed Pursuant n the Committees
License Law. MIT ISSUANCE
❑I an exempt under Sec. ,B&PClan
- TOR VALUATION
•
Owns,
nate
WORKER'S COMPENSATION DECLARATION 'R
1 hereby affirm muter penalty
af perjury one of the fnamefor doclWinamti
�.I have and will maimaine Cenifcam of Consenuo self-insure for Wmker'e open- I R ',A ,GOND. 'STORIES TYPE CONSI'RUCT10'.
'nation,as provided for by Section 37M of the Labor Code,for the performs of the
work for which this penia is issued P
❑T have and will maintain Workers Compensation Insurance,as required h .
3700,41m,Labor Codc,forthe peafarareve of MT wad Ott which tIT GAS-RA. S :M- OCC.GROUP 2 Nr-.
My Worker's Compensation Insurance carrier and Policy number me:
Turner. Policy No.: .S
CERTIFICATE OF EXEMPTION FROM WORK17
COMPENSATION INSURANCE T HUILDING DIVISION ETES
(This section need no he completed Yuba permit is for one formed dollars(5100) GRPASETRAP
in laws)(This FEF.
Teenify that in The performanceofthe work forwhich This pe moi,is issued,Ishan SEWER-SANITARY-STORM EA,200 FT.
not employ any pars, n any manner m as to become subject 1.the Wodwi Cnmpen- ENERGY EEE
Z same Laws of Calif aria.Date WATER HEATER WIVENT/ELEM GRADING FEE
Z 0 Applicant 1 _
NOTICE.TO APPLICANT:If,site,making This Cenifcsm of Exemption,you should WATER SYSTEMITRPATING SOILS FEE
a 7 become subject to,he Worker's Compensation provisions of the Letter Cove,you 111.11
[t7 " forthwith comply with such provisions or this permit shall he deemed CE
revoked. WA] SERV I
Q PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.Irl, Dam Receipt a
V0 I hereby aRnn lbmthere is.construction leadingagency,for The permormnceof
H. 2 the work for which this permit is issued(See.3097,Civ.C.) TOTAL:
0 L) Lenders Name
TOTAL
Lciac rs Address
P. 1 entry that 1 have rend This application and state that the above nomination is BUILDING FREE
it fA cn,recT.l agreemromply with all city and county urdinnncesand nate lawsrela,ingm QTY, MECHANICAL PERMIT FEE SEISMIC FEE
V building c.nstmerion,and hereby nuthotiu reprcmemolas nfthisciuy To Toler upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep humorless the City of Cupertino against
liabilities,judgments.coats and expenses which may in any way amemogorisl said Cry ALTER OR ADD TO MECP. PLUMBING FEE.
otueyuen'a ng of ''permit.
tS
I'UNDHRS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,gXICFM) MECHANICAL ITiE
RCHREGULA S.
AIR HANDLING UNIT(OVER 10,000071) CONSTRUCTION TAX
pplicunt/Cnntmcm, Dam EXHAUST HOOD(W/DUCT} HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or Ince le hazardous material HEATING ON IT(TO I th,don 13'TU)
enied by the Cupertino Municipal Code,Chapter 9.12,and The Health sod SafetyHGA'fING UNIT LOVER 1 W,(NN)BTU)
e,Section 25532(e)^
❑Ycs ❑No VENTILATION FAN'SINCLB REMD) PAID
Uma Recrip,k
�. Will The applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR Indiana BTU)
ou
Tmi,hazards air marai manta as defined by me Buy Area AT,Quality Management 'f
District? BOILER-COMP fOVER[00.000 BTU)
❑Yea FIN.
I have read the hazatdnus materials requirements Tom,Clapu,6.95 of the Cali- AIR CON DI LONER ISSUANCF Dr,AATTs/E'`4'/�\/
fomis liwllh AT Safety Cove,Sermon 25505,25533 and 25534.I undcrsund That if the NEW RESIDENTIAL MF,CH. SQ.FT. F✓
batch note ,at.That it is my rexp.nsibilhy ns.notify the occupant
of require hid sbe met p��rmissuance n(a Cenifmu of Qcupancy.
Osv ant ❑am to TOTAL: ISSUED T
OFFICE