S 0865 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO' "ME:
RICA6 Pr MIT NO.
BUILDING DIVISION APPLICATION/PERMIT NICAL 0865
TIFICATION
BUIL'NGADDRESS: Y SANITARY NO. APPLICATIONIs NSSUUBMITTAL DATE
99
OW E ' MWLA ZION : ONTRACLIC NO: NIC CON'I'ROLg
CHITECTi%N EER: LIC NO: s ❑
CONTACT PHONE' BUILDING PERMIT INFO
( rI� ❑ Consultant Feel;Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
11 g�h `u� I`1 / ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm Nat I am IiceneW under pmvisions of Chapter 9(commencing JOB DESCRIPTION
OaZ with Section of Division J of the Business and Professions Cale,and mylicemers
won PERMIT ISSUANCE
FSB in full force and FOWL ❑KITCHEN REMODEL
CA U U License Lic.p
6 U APPLIANCIiS-RESIDENTIAL ❑ADDRION ❑PLUMNING REPII'li
I-�Z W Dam Comracsnr -
rAed ARCHITECTSDECLAR ION 0MULT14SIT ❑STRUCFURAL
PANELS MODIFICATION
I undertmnJ my plonn shall bo usN ns public scrods
OZr a UPT0200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
rOi'M Licensed Pmfessored 301-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER.BUILDER DECLARATION OVER IIXIIIAMPS El BATH REbDE /REPAIR ❑UGMOLITION
LyyY7 K ad Q 1 hereby affirm has I am exempt from the Contractors License Law for the {-'
X 6 U following reason.(Section 71171.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. 'HER
Y 3 W which requires a permit to construct.alter,improve,demolish,in repair any soucmre
try prior it)its issuance,also requires the applicant for such permit to file a signed smmmnfeSPECIAL CIRCUTUMISC.
p. that he is licensed pursuant to the provisions of the Contractor's Licema Law(CUPmrY COMMERCIAL,
(commencing wish Section]000)nf Division 3 ofthe Business and Pmfessions Code)or I'EMP.METER OR POLE INST.
6y Gym that he is exempt therefrom and the basis for the alleged exemption.Any violation of PO ❑NEW BLDGIADDH ION ❑DEMOLITION
a :20 Seaion]f17L5 M1y any upplicam fora pemdt nubjcets the applicnnno ucivil penahy of POWER DEVICES ❑TENANT ❑FOODSERVICE
Z6
W not mom than five hundred dollars(SSW). -
� [,as owner ofths,property. 1 cos with woes as their sole cam nsation, SWIMMING POOLELECTRIC OTHER IMPROVE
C ❑ trope Y Yetnpo)' a , ❑OTHER
_ Il do the work,end the stmcwreisnm intended oroffertdfor sale(Sec.]1400,Business
F OUTLETS-SWITCHES-FIXTURES
6 a and Professions ilds The Cvea d lam License Law dies nm apply to un ownor,.f
property who employees.
pr vided t s therehm and whoerste m not ante tied or onhrough
his own employees,provided that such improvements are not intended or.Bare.)for NEW RFSIDEN'FIAL❑LECIR SQ PT. _
sale.IL however.the bNidingor impmvemem is sold within one yearofcnmpleticn,the / SQ.FT.FI. A ESQ.FT
Owner builder will have the burden of proving that he did not build or impmsrc for par-
posewsale.), TOTAL: t/ A
1,as owner of the pmpeny,am exclusively contracting with licensed contractors to pl
construct the proec
project(S .7000.Business and Profusions Calc:)The Contractor's Li- r
cense law does not apply to an Owner of Proteny who holds or improves thereon,and QTY. PLUMBING PERMIT F �ry 0h cut_
who cumructs for such projects with a commetons)licensed pursuanuo the Cofnmemre /
License law, PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(FLA) VALUATION
Owner Duce ^
WORKER'SCOMPENSATION
saw
DECLARATION BACK FLOW PROTECT.DEVICE 9 -
4❑ I and alarm under penaltyle perjuryone tof othefollowingdorker'i Co
I have and will maimeina CcrtificmeofConscnuosd4insure far Workers Compcn- DRAINS-FLOOR,RODE AREA.GOND. xTGRlls TYPE CONSTRUCTION
an ..,as provided for by Sulion 37M of the Labor Cale,far the performance of the
work for which this permit is issued FIXTURES-PE.R TRAP
JJJ have and will maintain Worker's Compensation Insurance,us required by Section
37W of the labor Code,for the performance of the work for which this perch is issued. GAS-EA.SYSTEM-I INC.00UTLETS OCC.GROUP ANN
My Wqy�ara��C�um{pr�c eras 1 ace camorond P, iIuI ym����jjyjyyg[g
Carder.a—W'+ policy Nu.:Na+-lal GAS-EA.SYSTEM-OVER
CERTIFICATE OF EW:MPTION FROM WORKERS' GRI:ASS/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Diss section neW not becompleted lithe permit is Unions,hundreddollars($100) GREASETRAP
PLANCHECK PC
or less.) L'
I minty that loans lseffmmance.fibs work for whichthis permis is issued.I shall SEWER-SANITARY-STORM P.A.200 FT.
not employ any person in any manner so as to become subject the Warkeri Compen- ENERGY FEE
Z sution laws of Califomia.Date WATER HEATER WNENT/ELECTR
z C) Applicants GRADING FEE
F7 NOTICE TO APPLICANT.If,after making this Cmifictee of Exemption,you should WATER SYSTEM?REATING
h
become subject to the such to pmCompensation provisions of me labor Grde,you must SOILS Eft.:
a � forthwith comply with such visiom.obis permit shallboJeemed revoked. WATER SERVICE
Lk Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM9. SQ.PT. PAID
U QIherehysi irm has primmwcuon leadingagerty for the perfonnaneamf Date Receipts -
(~ the work for which this permit is issued(Sec.7(19],Civ,CJ
O
OTAL.
Lenders Name
TOTAL:
lender's Address
y Icertify that 1 have read this application and state that the above information is BUILDING FEE
N bone,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction.and hereby sathodre representatives ofthis city to enter uponthe
above-mamiomed property for inspection purposes. PERMIT ISSUANCE ELECTRIC PER.
(We)agree to save,indemnify and keep hamtles,Ne City of Cosponsors against
liabilities,judgments,costs andexpenses which may in any way mane against said City ALTERORADDTOMECH. PLUMBING FEE
in consequence ofthe granting of this permit.
APPLICANT UNDERSTANDS AND WIL COMPLY M LL NON-POINT AIR HANDLING UNITGO 10.00ICFM) MECHANICALFEE
REGULATIONS.
AIR HANDLING NI (OVER 10,WO CFM) CONSTRUCTIONT
Sig.atuaof ApplicaMCn mr Det EXHAUST HOOD(W/DUCT) HOUSING MITIG NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occepuntstore or handle ban intissinaeial HEATING UNIT(TO Ilk,"BTU)
Us Jefi red by she Cupertino Municipal Code,Chapter 9.12,and the Houlth and Safety -
Cafe,Section 255320)? HEATING UNIT(OVER ItN),"BTU)
❑Yes ❑No - VENTILATION FAN(SINGLE TRI
PAID Dam Rem tg
Will the applicant or future building petulant use equipment or devices which BOILER-COMP(3HP OR Usfts )BTU)
J emit hozardoes air...mminants as ds,fined by the Bay Are.Ail Quality Management TOTAL:
Disaict? BOILER-COMP(OVER 100,000 BTU)
❑Yes [I No
AIR CONDITIONER ISSUANCE TE
1 have read the hazardous mmsr255 5,2553 a under Chapter 6.95 milt Culi
bumie building
&Safety Cade,ea vases t.that,2557)end 25570.I to notify
that if chs, NEW RESIDENTIAL MECH, SQ.FT.
of the re dsxs not currently haves¢tont,that o is my responsibility a,notify the coadfaint
of the reyuiremems which must 4 me prior m issuarce or.Cenificme of Occulancy.
Owner or authorized agent DataTOTAL: ISSUED BY:
OFFICE