S 1205 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OECUPERTINO BUILDING-ELECTRICAL PE ITNIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1205
BUILDING PROJECT'IDENTIFICA'UON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l 4 d p 21 cs
0 ER'SN ME: _ ^' PHONE: Og CONTRACTORS NAM LIC NO:
fY Poor, ISMNIC CONTROLO
ARCHITECT/EN NEER: LIC NO ADDRESS i is ❑
600q 71 IL '7941 k-st,
CONTACT: PHO Ec BUILDING PERMIT INFO
La-v5 ❑ Consultant Fees Paid by Applicant(Initial) LD ELECT PLUMB Nkva�t (
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing J B DESCRIPTION
CaaZ with Section 7000)of Doislon 3 ofthe Business and Professions Code andntyliccnuels RESIDENTIAL
00 in full foaeand effect. PERMIT ISSUANCE
WWP^., I ❑SFDWL El KITCHEN REMODEL
i-ZU License Class Lie# APPLIANCES-RESIDIiNI'IAI, ❑AUUI'1'ION [I PLUMBING RE-PIPE
yaa Uma,-• Commcmr
[[--++Om ARCHITECTS DECLA 'ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOv5z4. land .toad my tans hall be used as pu r MODIFICATION
O'z-, !j UPT02WAMPS
'/,4„E',W Licensed Professions ❑INTERIOR [I CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDERD CLARA ION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Q 1 hereby affair that I ata exempt from the Contractors License Low for the
iqqiS5 O 0.0 fallowing reason.(Section 70315,Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
prorto its issuance,also requires the applicant for such permit to file asigned statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the,bea are,ofthe Compactors License Law(Chapter 9
W QD (commencing with Section 9IXNgof Division 3 ofthe Business and Professions Code)or P.METER OR POLE(NST COMMERCIAL'
0.y o C that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ 'W BLDG/ADDITION [I DEMOLITION
>C 4Section?031.5 by any applicant a perm2vubjects the applicant to a civil Penalty of POWER DEVICES
W^p, ANT ❑1700D SERVICE
not more than five hundred dollars($50%
F Z Y IMPROVEMENT
pCy 6 � I,aahe week,the thewhommyot intended or
forth (See. 044,Business
SWIMMING POOL ELECTRIC
F Q will N lit....as and the Claiwn,mant's
is not intended Laoffw
core,
for n,apply 1.4a Business OTHBR
3 w and Professions Cade:The Contractor's License Taw does l apply to an...a,Ili 2 (IUTLEI'S-SWITCHEfi-FI%TU
propeny who builds or improves thereon,and who does such work himself or through
his own employee,e provided that.such improvements slid
A arc not intended a offered for NEW RESIDF.N'TIAL F.LECTR
sales If.howaver.the building orimprovemenl is e,IJ wilbin one year of ntmpletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par-
pose of saley
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to Y,P?AL
construct the project(Sec.9040.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT F AID
.
who contracts for such projects with a comracter(q licensed pursuant to the Contractor's n
License Law. PERMIT ISSUANCE PER
E] I am exempt under Sac. ,B&P C for this reason �+ j O Is
ALTER-DRAIN&VENT-WA'I" N
Owner Dam �JrL'
/ WORKER'SCOMPENSATION DECLARATION BACK FWWPROrEC f.DEVICE
I
[have
Iffirm penahyof ofCouencefthcfellowingdedaretinny \ „
❑ Ibave aravide main by eCion 3700ficate,of the Lab rCode,for the Woders Compere DRAINS-FLOOR,ROOF,AREA.GOND.
smion,m provided tar by Section 3900 of the Labor Code,for the pcAnmtancc of the STORIES TYPE CONSTRUCTION
work for which this permit o issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as requited by Section
3700 ofthe Labor Code,fors a performanceofthe%ofklinal chthieprood Lsi suW. GAS-EA.SYSTP.M-IINC.4OUTLETS OCC.GROUP APN
My Wareu ad Policy nu h .
Cameo dict'No.: OAS-CA.SYSTEM-OVCR4(EA)
CE I IFICAhimTE OF EX EM PTIUN FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'1RL WASTE INTERCEPTOR
(This section need not be completed iflhe permit is from hundred dollars($100) U (VISION FBHS
_-
GRRAS
orloss.) SEWER TRAP PLANCHE F
Toy any Nrhat In in any
of the work for which this pcnn wkro,'Cmr,ued,I all SEWER-SAN]'1'ARV-STORM EA.21%1 FT
oat employ any person in coy manner w as m become suhjen nt lM1e Workurs'Compcn- ENERGY
ZZ Ballon Laws wCulifomia.Date WATER HEATER WNENT/ELL'CI'R
O Applicant GRAD G PEE
rt' , NOTICE TO APPLICANT:If,after making this Certifmte of Exemption,you should WATER SYSTEMOTIEATING
f" become subject the Worker's Compensation provisions of the Labor Code,you most SOI _PE
Wti forthwith comply with such provisions or this pemtit shall he deemed revoked WATERSERVICE
P
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.1°Il PAID Date Receipt#
I hereby affirm that thea is a wmnaamn lending agency for the performance of
the work for which this permit is issued(Sec 309'!.Civ.CJ
Of~ Lenders Name T L.
WLcndcr'I A rrify t TOTAL
1 certify That 1 have cad this application and state that the above information is BUILD FEE
hcorrect.l agree to comply with all city and county ordinances and shite laws mining to QTY, MECHANICAL PERMIT FEE
V Z building concoction,and hereby auNnrize representatives ofthis city to emarupen the SEISMIC FE
stave-mentioned property far inspection purposes PERMIT ISSUANCE
(We)agree to se,indemnify and keep bannlcas the City of Cupertino against ELECTRIC PEE
av
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO SUCH.
in rmequence,f" grantingofthispemtit. PLUMBING FEE
APDL ANT UN .RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO II1,IXq CIM)
501' 'E REGU 10'A' I nv,__
MECHANICAL FE
r Z•s AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
S amore afA plic:mUCompcWr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardom optical HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cafe,Chapter 91 12,and the Health and Safely
_ Code,Section 25532(x)9 HEATING UNIT(OVER 100,000 BTU)
YesNo PAID
VENTILATION PAN(SINGLE RESID)
WII thea applicant or tum building t use equipment or devices which
Dom ceipt#
pp goccupan quipmen BOILER-COMP(3HP OR IW,OW BTI))
mit hezeNous air nmhiminants as defined by the Buy Areu Air Qmlity Management
TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Ym II7_{N_,
I have read the hazardous manials requirements under chapter 6.95 of the Call- AIRCONDITIONER ISSUANCE DATE
fimin Hicatillle Safety Com.Sections 25505,25533 and 25534.I undcrsmnd that"'he NEW RrIl DEN'TIAL MECH. SQ.LT.
building nwcu ly M1u amnan0 diel it is my responeibtlitym notify lheoccupam
,f the torte tact prior 1,issuance o[a Ccrtilicm:ofAr-eo ray.
Ow r rnutho zed ag nt - 1,Uumg TOTALISSUED BY:
OFFICE Jr.1