99120103 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
BUILDINOADDRF_SS'. SANITARY APPLICATION SUBM LDATE
a442. DA
OWNJSNAME: ss�� ,F PN/NTE: CONTRACT'OR'S NAME: LIC NO:
,Q I "o CAM pG/ /r• I N/C CONTROL M
ARCH]'1'ECI'IENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: 8 BUILDING PERMIT INFO
a
6,l C a r.i r:U6,a q1_1.$_
2 f%� ❑ Consul ant Fees Paid by Applicant(Initial) BLDG ETEC PLUMB MECH
d ❑ ❑ ❑
LICENSE])that I CONTRACTOR p DECons of ION QTY ELECTRIC PERMIT FEE
1 hereby aft m That 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
BOZO with Section elefec Division3of the Business and professions Cade,and mylicenx is PERMIT ISSUANCE RESIDENTIAL:
F in full(urea vnd effect.
�UU License Class Lica ❑SFDWL ❑ L.
KITCHEN REMODEL
h6W Dam ve []ADDITION APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING REPIPE
(_D. ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
z,p H Z 1 understand my plans shall be used as public records MODIFICATION
OZ—q UPT0200AMPS C1 INTERIOR 11 CHIMNEY REPAIR
a4tawz Licensed lkoficoicnal 201-INX)AMPS IMPROVEMENT SWIMMING POOLS
C OWNER-BUILDFE DECLARATION It
Q I hereby option abut I em exempt from the Convenor's License Law Tonne OVER 1000AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
2 6 U following mason.(Section 7031.5.Business and Rofesaions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL I- which acquires a permit us lumberer,alter,improve,demolish,or repair any strucwrc try
bop prior to its issuance,vl.mraeirea they applicant fim mah
.F.�an I PP permino fleusigned.aaaemem SPECIAL CIRCUILM C.
HE Y that he s licensed pursuant m the provisions of the Contractor's License Law(Chapter 9
ct C) (commencing,ifla Section 7000)of Division 3ofthe Busat,ssand Prufeesiona Ccde)m TEMP.METER OR LE INST.
t1 a o�' thm he is exempt therefrom and the basis for the alleged exemption.Any violation of EW BLDG/ADDITION ❑DEMOLITION
-,y she
Section 7031.5 by any applicant for a Penni[subjects the applicant to a civil penalty ofPOWEk DEVIC TENANT ❑FOOD SERVICE
.ranch m five hundred dollars 1$5(X)1, PROVEMENT
=O no I.yr nwrx,of[he property,crony employees with wages axtheirsnlecnmpensmion, SWIMMING OI.HLECIRIG
C will do the work,and the structure is nor intended oroffered lir sale(See7c..Business ❑OTHER
3 and Professions Code:The Contractor's License Law does no[apply m oa owner of OUTLETS SWITCHES-FIXTURES
Property who builds or improves thenen,unit who does such work himxlf or through
his own employees,provided that such improvements arc not intended or offered for NEW R 'IDENTIAL ELECTR SQ FT.
side,If,however the buildingarin,mvemem is sold xillomen ,_of comple[la 1.fhe SQ.FT.FLOORAREA $ISQ.PT
owner-loader will have the burden of proving that he did not build or Improve far pur-
pose ol'sale.).
❑1.as owner of the proper,am exclusively contracting with licensed contranon to TOTAL:
consumer the prefect(Sm.7044,Business and Professions Code:)The Connacnrs Li-
cerise Law does not apply to an owner ofpropeny who miles or improves thereon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a cantraclons)licensed pursuant union Conm en rs
License Law. PERMIT ISSUANCE
❑1 am exempt u�,der See. B A P C for this reason
O 7 - ALTEk-DRAIN&VfiNT-WATER(LA7 LUATION
WORKER'S COMPENSATI N Df LARATION BACK FLOW PROTECT.DEVICE
I hereby all roe under penalty of perjury one of the following dec larutions: D O
❑I have and will maintain u Cenificvre of Consent m sell-insvrc for Worker's Compete, DRAINS-F100R,ROOK AREA, ND.
ration,as provided for by Section 37W of the Labor Cotte,for the performance of the STORIES TYPE CONSTRUCTION
work for which,his Not is issued. FIXTURES-PER TRAP
C 1 have and will maintain Workers Compensation Insurance,as required by Section
371X1 of the Labor Cade,for performance of the work for which this permit is issued GAS-EA.SYSTEM-IINC. OUTLETS OCC.GROUP �s b �APN�
My Worker's Comp ens aa t lmee uranIt ie,and Pm ey nand w are: L
Carrier Policy No.: GAS-HX SYSTEM OVA4GFO
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASFIINDUSTRL ASTE INTERCEPTOR /
COMPENSATION INSURANCE BUILDING DIVISION FV 6S
(fhissection need notbecomPleted ifthepeami,isfnronehundmddollars($]MI GREASETRAP
or less.) PLANCHECK FHP.
Loy any Persnthe Perforany
nance nerof slubehe kfor subjectch to permit trissued.'Conser. SEWER-SANT RY-STORM EA.211(1 FT.
not employ any person in any manner so as m became subject the Workers'Compen- ENERGY HE
,(2 ppLaws of California.Date
zO Applicant WATCH NF.A R W/VIiNT/ELECfR GRADING FEE
ti NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you should WATER SY EMTREATING
a ' becomesubject[o the Worker's Compemulion pare isions of[he Labor Code,you must ITS FEE
forthwith comply with such parvismns or this permit shall bedmined revoked WATERVRVICE
Uz CONSTRUCTION LENDINGAGENCY NEW R.SIDENTIALPLMB. SQ.FT. PAID _
UQ work
whicby h this
pe there isoconberc.30 lending agency for the performance of '(Dara /GRettipaM 1
the work for which this panni[is issued(Sec.309),Civ.C.1 / U-� I ^
0 U Lender's Name LJ TOTAI'
Lenders Address TOTAL:
Fy 1 certify Rist I have read this application and bete than[he above information is BUILD FEE
V) correct.I agree to comply with all city and county ordinances and sate taws relating to QTY. MECHANICAL PERMIT FEF. I /
(.J z building<nnbmaion.and hereby motorize reprcsenm[ives of chis cirymemer upon the SETS MaFFEE ✓�/
above-mentioned property far inspection purryscs' PERMI'P ISSUANCE(We)agree R,one,mentally oil keep harmper
less the City of Cupertino against I..LE it ICJFEE_
liabilities,judgments,casts and expensex x hick may in any way twereart,dns[said City ALTER OR ADD TO MIiCN.
in consequence of the meaning of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TU 10,0110 'M)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING ON]r(OVF: o,(M)CFM) CONSTRUCT ION TAX
Signature of Applicant/Commemr Date EXHAUSTHOOD(W/DU ) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will[heit,icome,future building rccupam umcor handle hazaadaes material HEA'1'INGUNIll .0XBTU)
as defined by the Cnpenino Munic}PuI Csnlc,Ch pier 9.12.and the Health sand Safety
Cade,Section 25532(a)! / HEp'1'ING UNIT(OV.R If if"BTU)
❑Yes FD$ti"'o PAID
VENTILA'1'IONF (SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which Date Receipt 0
crab hezerdous air comuminanm a defined by the Bay Area Air Quality Management BOILER-CO (3HP OR 10TODO BTU)
District'I TOT a J
❑Yes No BOILER-C P(OVER IW."BTU)
1 have read rhe hauNnux namrials AIR COND TONER
requirements under Chapter 6 to of the Cali- ISSUANCE.DATE
laden,He [h&Safety Cladf„ tions 25505,25533 i 2s my [,25534.1 understand the
that if the NEW RESIDENTIAL M11fiCH. SQ.FT / k r / �a
building m not emarentlyin a tenant.that it is my msrynaibility to nrnify the trcvpam L ( (/
,,fine svehicho me[prior bs issuance nl'a CeniBermol_Ope
Owner or pmhoriz got •�~I // /,Dam TOTAL: ISSUED BY:
OFFICE