99100014 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CU PERTINO BUILDING-ELECTRICAL ER 1 NO.
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: j� 3 1 SANITARY IN AP/PLICATION SUBMIITTT�AL.DATE
NEk'S, � I 4705sq pall
Q l NAM ` LIC
NO
lei1\ 4 1 NIC CONTROL#
IIII'F.C_'TI}iN INEEk: MLIC NO: ADDRESS: GYJZr ` ✓ �� ❑ ` �O
ONTACI': X013ELECTRIC PERMIT FEE hiE� /3 BUILDING PERMIT INFO
O r ❑ Consultant Fees Paid by Applicant(Initial) BLD El PLfUXl9Y ME�}i�
LICENSED CONTRACTOR'S UECLAkATION f QTY, u •�
1 hereby affirm that I am licensed Under PrvlsimaS of Chapter 9(commencing JOB DESCRIPTION
WCACIM wimsectionvtxlo)ofDivision3oftheBusincsaanI Prafe,simre Code,and toy bren&e i& RESIDENTIAL,
O O PERMIT'ISSUANCE
Fy'ly F in cull forces '' ❑SFDWL El KITCHEN REMODEL
6UZV
License Class Lic.# 553a APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
yQd Dme Contractor _
ARCHITECc:S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOt°Z Iundersmnd my plans shallbeusedispublience Is PANELS MODIFICATION
OZ.S'-0 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fro ul Licensed Pn+fcairral 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
C W Q•.1 OWNF.R-BUILDER DECLARATION OVER IWO AMPS ❑BATH REMODEUREPAIR -1 DEMOLITION
1 hereby affirm that am exempt From the Contractor's License Law for the
{1500.U following reason(Section 7031.5,Business and Professions Cade',Any city or county SIGNS ELECTRICAL ❑ ER
t++�0.y which requires a permit In mnswcl,alter,improve,demolish,or repair any swcturo
Fr�Oa Error o its issuance,alai requires the applicant fnr auch Enron no fleaeigned statement SPECIAL CIRCUIT/MISC.
y`4 that he is licensed pursuant o the provisions of the Contractor License Law(Chapter 9
GO (commencing with Section 7000)of Division of the Business and Professions Code)or TEMP.METER OR POLE IN 'I'. COMMERCIAL:
that he is exempt Iherefrnm and the basis for the alleged exemption.Any violation of ❑ F.W BLDG/ADDITION ❑DEMOLITION
�..y
Section 7031,5 by any applicant for u permit subjects lire applicam 1.a civil pensltymf POWER DEVICES TENANT ❑FOOD SERVICE
I more than fve hundred dollars(&5(1@.
MPROVEMENT
�d �1.a,owner ofthe propery,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC.
F'FO will do the work,and theatructure is not intended mothered for sale(See 9044.11usiness ❑OTHER
cail`� and Professions Code The Commgm's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
0.a^ pmpeny who wilds or improves thereon,and who does such work himself or throng
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS Q E,sale.If,however,the building or improvement is sold winhowe year ofcompinow.the SQ.FT.FLOOR AREA $ISQ.Fr
owner-builder will have the burden of proving that he did not build or improve for pur-
pose mf sada). TOTAL.
❑1,as owner of the partially,am exclusively contracting with licensed eoatmemrsto
construct the protect(Ser.IDM,Business and Professions Code)The Contractor's Li- `L
cense Law docs not apply to an owner mfpropeny who builds,improves atcrenn,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commemr(s)licensed pursuant o the Consort
License Law. PERMIT ISSUANCE
❑ Iwo exempt order Seo. ,B A,P C for this ore snn
Owner Data AUTER-DRAIN&VENT-WATER(EA) }yj� VALUATION
WORKER'S COMPENSA'HON DECLARATION C ALO OT's DEVICE ani I}''r 1 VA
I hereby affirm under penalty ofperjury one of the following declarations: oz
❑ Ihaveand will maimem aCenificate of Cunwill Wself-insure for WotUwsCoope RA STORIES TYPECONSTRUCfION
sation,as provided for by Section 3700 of the Labor Code,for performance Uf I
work for which this permit is issued. % E T 2 y��
❑ 1 have and will maintain Workers Compensation lumbance.as required by Section
3100 ofthe Labor Code,for the perfomtanee ofthe work�fyodr�w,thic/h/��this permit is is9rred G P F OCC.GROUP ^ AIN
MY Wntkcrviy npepeooMline lns artio Polia,xmand Y\Y 6�7IU �" GAS A.SY `Ir
Catena: 1 `` J (dv'
CERTIFICATE OF EXNhPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTR,WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need ten Rtmmpletetl it he is for one hundred dollars($ W1 nr less.) fd= A A PLANCHECK FEE
I certify that in the performance of the work for whichthis permit is issued,l: I
not employ any perorn in any manner...an to become mbjem,m the Workers'Com R R 00 ENERGY FEE
o z .him Law,of California Data WATER HEATER WNENT/ELECTR GRADING FEE
O Applicant `
.Z.t ^ NOTICE TO APPLICANT:If.site,making this Cunilleme of Exemption,you should WATER SYSTENIGREAI'INO
.ti becomesubjeal to the Worker's Compensation provisions of the Labor Code,you must SOILS HE
Lakl ti frodus ah comply with,such no,i mso,di,petmit,hall be deemed revoked. WATER SERVICE
a Q
�
z
CONSTRUCTION LLNUING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Dela Rece I#
U O I for mi ffithd thatconal i is s constructiond(Scalending agency for the performance of
i--i he stock for whicM1 this pemtit i,issued(See.31097,Ci,CJ
Lenders Nume 'TOTL
A :
� OWU. Lender's Address TOTAL: BUILDING FEE
1 cenify that 1 have rend this application and smte mm the above international
tNi IA correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
C.) Z building commutation,and hereby withmrize representatives ofthls city Incrustation the SEISMIC FEE
above-memioned property fnr inspection putpo+e,' PERMIT ISSUANCE(We)agree m save,indemnify and keep harmless+the City of Cupertino against ELECTRIC IEE
llobilloes,judgments,costs and expenses which may in any way wart again&,said City ALTER OR ADD TO MECH. PLUMBING FEE
a aorw,awo,mf the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT \ AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FE
SOURC.REGULATIONS.
2^ —QT AIR HANDLING UNIT(OVER UL000CFM) CONSTRUC ION TAX
SignaturFu aIpplica 'mn,racho Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle buzablous material HEATING UNIT(TO 100,10)BTU)
as defined by the Cupertino Municipal Code.Chapter 912,and the Health and Safety
Code,Section 25532(a)p HEATING UNIT(OVER IOLOW BTU)
El yes ON. VENTILATION FAN(SINGLE RESID) PAID Date COMP(3HP OR IOO, Reath,
Will the applicant or future building nceupanl use equipmen,or devices which
tet hazardous at,contaminants as defined by the Bay Area Air Quality Management BOILER 100,010 BTU)
T A
Dimrict? BOILER-COMP(OVER 100,11(10 BTU)
❑Yes' E]No
1 have read the Incitation;merlals requirementsAIR CONDITIONER under Chapter 6.95 of the Cali- ISSUANCE DATE
home
Health&Safety Cole,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant,that it is my responsibility to newly the occupant
o(me regmr cola whltM1 must be_m�t priono issuuna mf a Cardfiewe of Oecu �.y.
O�mau,honzed ngem Dale TOTAL ISSUED BY.
OFFICE