S 0400 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFJ�IIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J. 0400
BUILDING PROJECT IDENTIFICATION •T
BUILDING�DDEFSS: SANITARY NO. APPLICATION SUBMITTAL DATI
753 L E D 1. dE
(\ WNER'S NAME: /�� r n ONTR pM '�/� N ,
ru /V•• � N/C CONTROL# -
IARCHITECT/ENGINEER: - IC NO: A gbGbf.S'FivL ❑
CONTACT: PHONE:
' BUILDING PERMIT INFO
❑Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
I hereby affirm thatOUZO with SforceaOW)nfpivision3oRhe Business and Professions Code,a anylicense is
WWP mfull force and eBettC..'10 9O {{ 7 PERMIT ISSUANCE RESIDENTIAL '
FUpp License Chi, A Lin# �7 / ❑SFDWL ❑KITCHEN REMODEL
Zttl Date Contracror APPLfANCES-RESIDENTIAL
wQ0. ❑ADDITION ❑PLUMBING RE-PIPE.
F�ppb>> ARCHITECTS DECLARATI N
02 yG l understand my plansshall he isedns public records PANELS ❑MULTI-UNIT ❑STRUCTURAL
UP TO 2X0 AMPS MODIFICATION
Fs4 Glc] Llcenned Profesmonal ❑INTERIOR ❑CHIMNEYREPAIR
a0.' ❑ OWNER-exempt RDECe C-admON OVER 0AMPS
IMPROVEMENT El SWIMMING POOLS
',�j O t Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER IOfID AMPS D BATH REMODELIREPAIR El DEMOLITION
{�aF following reason,(Section]031.5,Business and Professions Code:An cit ❑OTHER
LL which requires a Y Y or county SIGNS ELECTRICAL
Oy¢ q permit to ennslmeL alter,improve,demallsh,or repair any swmure - /
,hothe s"caus dloorsarequires theappinaf the Cmanamniuoicense aw(Chtemetn SPECIAL CIRCUIT/MISC. J1r UJI /
that he is licensed pursuant to the Provisions rf the Comsines s License Law(Chapter 9
� QF
(commencingathisempt therefrom and adDivision oftheeged essanJon.Any
Code)A OTEMP.METER OR POLF.INST.
0.y o an
thathe7 exempt therefrom and or basis for the alleged exemption.Any violation of BLDG/ADDITION ❑DEMOLITION
'^ Sectionname" "5byany'an applicant fora permit subjects the applicant loacivil penalty of POWER DEVICES
p„y2q y not more than five hundred dollars(550(8. ❑TEN L1 FOOD SERVICE
F+� ❑Lothe work,
theproperty,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC /IbIPRO T
will do the work,and the stmmure is not intended or offered for sale(Sec.]044,Business r6 THER
3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or br peavey thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ Pp. -
sale.If,however.the building or improvement is sold within one year ofcompletam,the SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of,ale).
IL 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: �a j1
onswct the project(Sec.]044,Business and Professions Cade:)The Contractor's Li- CE1 �.:/D
cense Law dcesnotapply to an owner ofpmNny who builds or improves thereon.and QTY, PLUMBING PERMIT HE
is coronet, such projects with a commands)licensed pursuant to the Contractors DEC 121997
License Law.
L-]I am exempt under Sec, ,B&P C for this reason PERMIT ISSUANCE
weer DateALTER-DRAIN&VENT-WATER EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE •.�—��
I hereby aff rte ruder penalty of perjury one of the adlewing declarations:
❑I have and will maintain a CeniOcate of Consent o WIf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND.
sation,as provided for by Section 37W of the Labor Code,for the perfmmance of the _ STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
0 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Coda for the Performance of the work for which this permit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS
MyWorkelx Cnmoensati pa lnststntriernndYolic inter OCC CROUP APN
Carrier tic No GAS-EA.SYSTEMOVF.R4(EA)
ICATE OF hX M ION FROM OR ERS'
COMPENSATION INSURANCE GRFASGINDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars IS W) BUILDING DIVISION FEES
or less) GREASETRAP
1 certify that in the performance of the work for which this Permit is issuW,l shall PLANCHECK FEE
not employ any person in any manner sr as m become subject to the Werkerd Compen- SEWER-SANITARY-STORM EA.200 FE ENERGY FEE
Q ,Z sation Laws of Cnlifnmia.Date WATER HEATER WNENT/ELECTR
7 Applicant t - GRADING FEE
t7
NOT TO APPLICANT.IL afrer ma king this Cenifcate of Exemption,you should WATER SYSTEMaREATING
F" harms auhjem to the Worker's Compensation provisions of the Imbor Cnde,you must SOILS FEF,
forthwith comply with such provisions onhis permit shall be deemed revoked. WATER SERVICE
Q
,Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V 21 hereby affirm that there is a construction lending agency for the performance of t Data Receipt#
L>•s F the work for which this Permit is issued(Seo.3197.Civ.C.)
Lenders Nome
{U Lenders AddressTOTAL: - TOTAL:
1 canify that I have read this application and own that the above information is - BUILDING FEE
rs CA correct 1 agree to comply with all city and county industries and state laws relating to QTY, MECHANICAL PERMIT FEE
U71 building contraction.and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. f PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City,of Cupertino against ` - BLECfRIC FEE
liabilities.judgerents,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,IIW CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
Signature ot'Apphcana/Contmetor Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE - HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle Hazardous material ' HEATING UNIT(M Within BTU) Q
as defined by the Cupertino Mun"Pal Code,Chapter 9.12,and the Health and Sarety
Cnde,Section 25532(a)4 �// HEATING UNIT(OVER 100,000 BTU)
❑Yes LJNo
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit hazardeus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR 100,000 BTU)
District? TOTAL:
❑Yes BOILER-COMP(OVER 100,000 BTU) _
I have read the hazardous materials requirement,under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the ISSYANCE DATE
building does not<urremly have a tenant,that it is my responsibility to notify the acupant NEW RESIDENTIAL MECH. SQ.FT 1 �� '2
of Nepgnirn�¢nts which mu tmat prior to fit fit Campea�of itcupnnysv.� -`-+1E�(/,y� //1�•L
Owner n�r euthonutl agent A Data `I OTAL: ISSUED BY: U "I
OFFICE