S0086 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-BE �PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL. `�Z yllyl�lyV�•{lh
BUILDING PROJECT IDENTIFICATION
PNE
ING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ou HEl�D LN G �cq
'S NAM - PHONE: C RACTOR'S NAME: LIC
d D �O_r �s 6 NIC CONTROL p
RCHI'TECTIENGINEER: W - LIC NO: •J A DRE. Flo' zISifGNm
ev
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PIAMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION EAAN
LECTRIC PERMIT FEE
1 hereby affam that I mm fcenaed under pn+viaiona rf Chapter 9 kommencing JOB DESCRIPTION
yD4]1�Z with Section 7000)of Divis 3ofhe Businessand Prof Sion CWe.mdmylicenais RESIDENTIAL,
FOS fllfarce and eBat. 3Li ser Ll ANCE ❑SFDWL ❑KITCHEN REMODEL
TUU License Lic.p _!!
6 V -RESIDENTIAL ❑ADDITION �ryUMBING RE-PIPE
F W Dm CIC "I ///--")—
m�G ❑MULTI-UNIT STRUCTURAL.
ARCHITECTS D[CLARATION 2 1 umdersmndmy planashall he usedas public recorder MODIFICATION
PS ❑INTERIOR ❑CHIMNEYREPAIR-
„, {y LicensM fYofessionel S IMPROVEMENT SWIMMING POOLS
SYyWa'�{ OWNER-BUILDER DECLARATION MPS ❑BATH REMODEUREPAIR El DEMOLITION
rg 0.' a I herehy M.that 1 am exempt from the Cunuamots License Law for the
0K O6 V following reason.(Section 7031.5.Business and Professions fide:Any city Or county SIGNS ELECTRICAL [I OTHER
:4, which requires u permit to consvuct,altm improve,demolish,or repair any structure
h.ay O-1 poonoiu iasuunee,also requires the applicam for such pemtiuO fleusigned samment SPECIAL CIRCUIT/MISC,
that he is beenseol pursuennothe provisions of me Ctimmewr's License Law(Chapter 9
�ap0 (commencing with Section 7"rof Division 3 of the Business and Pmfessians Code)or TEMP.METER OR POLE INST. COMMERCIAL,
Is y M y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
S4G7 4•
Section 71131.5 by any applicant for a pemut subjau theopplwant m u civil penalty of POWER DEVICES LI TENANT ❑FOOD SERVICE
- F-Z nounow thou lava hundred dollars($500). 1 IMPROVEMENT
Q01. oaneroflhe property,army employees with wages as theirsolecompenvadon, SWIMMING POOL ELECTRIC
will Bothe work,and the suucmm is na
ot inndedoraffered for sole(Se:.]044,Bminesa
and Pinfounins Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
L 3.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.IL however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA ;,r1Q
FE
Ownerbuilder will have the burden of pmving that he did not build or improve for pur-
pose of sele.). p� T1
❑ I,as owner of the property,am exclusively comarmang with licensed conaacm s a - TOTAL"' tT G's
cons0ua the projmt(Sec.](134.Business and Professions CsaR)The Contractors Li-
censeLaw does not apply toanowner ofproperty who buildsorimproves theaon,and QTY, PLUMBINGPERMIT FEE fl
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors `�6��Tqy� L
License Farm PERMIT ISSUANCE Yle I eon exempt under Sec. ,B&P C far this reason
ALTER-DRAIN&VENT-WATER(EA)
C1�FSfy75
Owner Unto 1 1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROfLCf.DEVICE
1 hereby illfirn under PenaltyCmiflc to perjury one of the following decimations;Co
❑Ihave pndwillrrainaisetion11a of ComsattoCode,hours,
Worker's Compete DRAINS-FLOOR,ROOF,AREA.CONE). STORIES TYPE CONSTRUCTIOI
smirk,es provided for au Section 3]00 of the Labor Cede,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP ,
I]I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Carlo,for
tthe gpeerrfyocpmmannce of the work for which this permit is issued. GAS-FA.SYSTENI-I INC.4 OUTLETS OCC.GROUPMy APN
Carrieor'er. mol .? Ins�H'aM�poldy No mut : GAS-EA.SYSTEM-OVER4(EA)
C- affrr/IFICATEOFEXEMPTION FROM WORK RS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING UIV ISION FEES
(Oussaeion need not be completed Baha permit is forome hundred not ars(SI00) GREASE TRAP
7a,less.) PLANCHECK FEE
I certify that in the performanceofthe work for which this permit is issuM.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'COmpen, ENERGY FEE
Z
action Laws of California.Dom WATER HEATER WNEN]ELECTR
z 0 t GRADING FEE
Applicant
H NOTICE TO APPLICANT:If,after making this Cer ifcme of Exemption,you should WATER SYSTEM?BEATING SOILS FEE
F' become subject to the Worker's Compensation provisions of the Labor Code,you most
IYi forthwith comply with such provisions m his permitshdl be decmed mvokal. It WATER SERVICE
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.pm PAID Dam Receipt
V O I toabya0irm that there isoconswmion leadingagency fonhe perfarmence at
the work for which this permit is issued(Sec.3097,Civ.C.)
Q U TOTAL:
Lender's Name A
W Under's Address
I wr ify that I have read this application and state that the above information is BUILDING FEE
F III correct.I agree to comply with all city and county ordinances and seta laws reining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building conswctirn,and hereby miuma,represenmtives oftiis city to enter upon the
rr abovome..iased property for inspection purposes, PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep lurnless the City of Cupertino against
liabilities,judgmems,casaan nses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEL
imconscquenceof the n this permit.
APPLICANT NST S AND WILL C LY WITH ALL NON-PO NT AIR HANDLING UNIT(TO 1(1,000 CFM) MECHANICAL FEE
SOURC tiULAT1 is
GA/ `� AIR HANDLING UNIT(OVER IQfIgI CFM) CONSTRUCTION TAX
Signature of Applic ter Dme EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
H RDOUS MATE ALS DISCLOSURE
Will the applicant or future building necupatn slow or handle hazardous maadul HEATING UNIT LTO IOOJIIXI BTU)
as defined!by the Cupertino Municipal Cade,Chapter 9,12,and the Health and Safety
Cade.Sermon 2 53260 r HEATING UNIT(OVER IBLOW BTU)
❑Yes 7 N VENTILATION PAN(SINGLE RESID) PAID
Dao RccciptN
Will the applicant or future Funding oecupam use equipment or devices which BOILER-COMP OHPOR IW,000 B'N)
mit havoMous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Dlmrtcl?
❑Yw ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the hawdoka maaoale uniiaments under Chapter 6.95 rfthe Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Scomm 25505,25533 and 25534.1 understood Nm if the NEW RESIDENTIAL MECH. SQ.PT.
building does not enormity have a worst,that it is my responsibility in notify the occupant
of the requirements which must be mer poor to issumme of a Certificate Of Occupancy. _`Aa�
Owner Or amhodaw!agem Data TOTAL: ISSUED BY: /
OFFICE