S 0737 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMIT NO..
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0737
BUILDING PROJECT IDEM'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWN NAME: HON • CONTR AME: �` hIC O: -
I-�. III NY ✓/rr- N/C CON'I'ROLtt
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AW
/RC 1'PECT/ENGINEER: LIC NO: ADD 7
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AW\\ CONTACT: PHOIJE: -(/ BUILDING PERMIT INFO
�� [3Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
` ❑ ❑ ❑
LICENSED CONTRACFOR'B DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9 aommencing JOB DESCRIPTION
M=Z with Section 9Wn)of Division 3 ofthe Busineaaand Professions Crde,and na,Been,is RESIDENTIAL
F�� ubolt forceforce zn PERMIT ISSUANCE (]SFDWL ❑KITCHEN REMODf.I.
�UU Lletnsc Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
h.7yW Data ntmcmr
¢R• CoARCHITEC`ES DELLA ATION ❑MULTI-UNIT ❑STRUCTURAL
zC)z - I understand my plans shall be used as public records PANELS MODIFICATION
UP TO 200 AMPS
W Licensed Professional
El INTERIOR [_1 CHIMNEY REPAIR
9p"I OWNER-BUILDER DECLARATION 201-H%IpAMPS IMPROVEMENT 0SWIMMING POOLS
W< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I"AMPS ❑BATH REMODEUREPAIR El DEMOLITION
ini$$'O yU following reason.(Section 7031.5,Business and Profesion.Cade:Any city or county SIGNS ELECTRICAL ❑OTHER �vev�,Tj�!\_L IiL�
n'+'3 t E' which requires a permit toctmgmc6 alter,improve,demolish,or repair any wunnre \V/'�
.F.� printout,issuance,al.so requires the applicant forsuch Permit to file a signed statement SPECIAL CIRCUI3'IMISC.
6 that he is licensed ummarntm the provisions of the Commit.,'.License Law(Chapter 9 COMMERCIAL:
act himntencing with Section 7000)of Division 3 of the Business and Professions Code)m TE MP.METER OR POLE INST.
IL%M tY that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI DON
X�rn Section 7031.5 by any applicant for is permit subjects the tFilieumn.o civil penahy of POWERDEVICES [-]TENANT ❑FOOD SERVICE
� Gnot more than five hundred dollars IS500)' IMPROVEMENT
❑ I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended lir offered bristle(Sec 9044,Business ❑OTHER
and Professions Cade:The Conlpctors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' progeny who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ F . -
sale,If,however,the building or Improvement is sold within one year if auplactinn.the SQ,FT FLOOR AREA FTu-buildu will have the M1urden of proving that he did not build nr improve for par-
e of sale.).
0 I,as owner of the property,am exclusively contracting with licensed contractors m TOTAL: `
construct the pmjtct(Sec.9044,Business id Professions Code:)The Contractor's hi- -
centa Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FE
who contracts for such projects with a confusions)licensed pursuant to the Contractor's is
License law. PERMIT ISSUANCE
❑ I am exempt under Seo. ,B&PCforthisreason
Owner Date
ALTER-DRAIN&VENT-WATER(EG 1. NtFN
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WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
f I have and will maintain aCenilicamof Concenot self-insumfor .Worker's Compere DRAINS-FLOOR,ROOF.AREA,COND. S ECONSTRUCTION
_,satiun,as provided for by Section 3710 O the Labor Code,for the performance of(he
work for which this permit is issued. la FIXTURES-PER TRAP (r T
❑I have and will maintain Worker's Compensation Insurance,as required by Section V'1 Y �f
3300afthe Lobar Code,Por the pedurammoof the workf�Bnuur��w�'hihiccyhythis permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP
Ca
Workess mpensnq yyPope,No.Y7-^' rY/Zr/J GAS-BA.SYSTEM-OVER 4 EA)
GarW ffJai
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, GREASEINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(This section need not be completed ithe permit is for hundred Jollary(EI W) GREASETRAP
or leas) PLANCHECK FEE
I certify thour let performanceefthe work for whichthis permit..isated,lehall SEWER-SANITARY-STORM EA.2W FT.
ort employ any person in any manner so as m become subject m,the Worker:Compen- ENERGY FEE
O z
sodium Laws of California.Date WATER HEATER W/VENT/ELECTIR
Z O Applicant I - GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Ceniticate of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Worker'sCompensation provisions of the Labor Code,you must SOILS FEE
W fonhwith comply with such provisions lir this permit shall be deemed revoked WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ,FT. PAID
U O (hereby affirm that there is a constimetirn lending agency for the performance of Dam Receipt#
F4 ti the work for which this permit is issued(See,3(197,Civ.C.) -
O U Lenders Name TOTAL:
WLenders Adtlress TOTAL:
p, 1 certify that 1 have read this application and.tate that the above information is BUILDING FEE
o
Zi correct.l agree to comply with all city and county ordinances and state laws reforms'.reforms'. QTY. MECHANICAL PERMIT FEE
r
LI z buIl0ing conswetion,and hereby nuthorice representatives nfthis city to emmrupon the SEISMIC PP.B
vbme-mentioned rty Por Inspection purposes. PERMIT ISSUANCE
(W ee m ve,indemnify and keep harmless the Ciry of Cupertino against ELECTRIC FEE
liabilii ,judgme is and expensexw t y' any way accrue againu said City' ALTER OR ADDTO MECH.
PLUMBING FEE
' on. q nc ft min fthisp tis. m
APPLIC U 'RST '�5 W ,L vMPLY WITH ALL$Lytl'T�IIQT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC Gni gT10 � C__7a^, ' MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONST RUCTION TAX
Signa re of Applicanl/Cnnwmnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WAlthe applicant or far..building occupant Ofq store or handle haandoas material t HEATING UNIT 100, BTU) p
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Svfety
Code,Section 25532(a)4 HEATING UNIT(OVER 100,000 BTU)
DYcs ON. VENTILATION FAN(SINGLE RESID) PAID '
Date Receipt#
4111 the applicant or furore building byes,occupant use ce Air tut or device.which BOILER-COMP(3HP OR 14,000 BTU)
emitict I s air containments as defined by the Bay Area Air Quality Management 'TOTAL:
District
❑Yes - ❑Na BOILER-COME(OVER IINI,BBB BTU)
1 have read the Imzmdnus pastorals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health A,Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Cr
building docs not ctnrently have a tewnt,that n is my respansihilay to notify me occupant
0,
tithe requirements which mon he met our so issuance of v Certificate of Occupancy.
Owner or authorized agent Dam TOTAL ISSUED BY:
OFFICE