B 0427 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 1�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL pn(,2t O -295 FrF
BUILDING PROJECT IDENTIFICATION soQN L V.L
BUILDING ADDRESS: SANITARY NO. APPLICAION SUBMITTAL DATE
A� 20 6-�ow�12r� . -� S-2o
OWN13R'$NAMB: PIIONf3: CONTRACTOR'S NAME: LIC NO'.
/U N/C �j CONTROLk
CHITECT NGINEER: LIC NO. L ADDRESS: ❑ �� /�
W -2`2 v oV
'ONTA T. ^^MMPH--ONEq�6 O - BUILDING PERMIT INFO
(407 f Consultant Fees Paid by Applicant(Initial) BLDG Ly F.0 _1LUMB ECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commenning JOB DESCRIPTION
OCZ with Section 90"B of Division 3 ofthe Business and Professions Code,and my license is R P
WOO PERMIT ISSUANCE
F+W
in fall vhome Class
eRect. ppWl, ❑KITCHEN REMODF.1.
Ca'u License Class Coor APPLIANCES-RESIDENTIAL ❑A DITION ❑PLUMBING R1uPIPE
ti¢ Ume Co a"
'Dias, DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO z I underst ,, mrec
and my P1. h.11 beuda,Public ords MODIFICATION
OZ-O UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 11100 AMPS Ll BATH REMODEVRBPAIR ODEMOLITION
y,ffXX 6 I hereby afrinn that 1 nm exempt Earn the Commcmh License Low for the
O y U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W a W N which requires a permit to construct,alma-improve.demolish,armful,any Nm`mm
��yOy priorto its issuance,ulsorequircs theapplicant forsuch permit o file asigned smartut SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions ofthe Contractors License Law(Chapter 9
0 (comm
nocig with Section 9000)of Division 3 of the Business and Professions Code)or TEMP.MET BR OR POLE INST. COMMERCIAL:
that he is exempt dmaetiom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVIos, ❑'TENANT ❑FOOD SERVICE
not more than rive hundred dollar.($50th.
FZ>' IMPROVEMENT
S 6 ❑ Lasthe work,the property,re imy s act
aoyees withwagesox their sole compensation, SWIMMING L E IC
$a andwildo the and the he Conisnm,Licensemmided La doesred of apply Inat,Business El OTHER
LL]
and Professions Caie:The Gmauctnr's License Law does not apply m an owner of OUTLETS 4
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDGNTIAh SQ
vale.If,however the building or improvement is sold within Ona year of emin,mtinn,the SQ IT..FLOOR AREA $/SQ.ET
n ner-builder will Bascom burden of proving that he did not build or improve for par- 1.Wtij&I MtMA
V .). TOTAL:
nrof me property,am exclusively contracting witn heenaed umtraatnnm
construct the project(see.9044,Basincvx and Pmfesslons Co—,I n.Contruemrs Li-
ounces Low contact apply to a a owae,,,f property who builds or Improve,thersum and QTY PLUMBING PERMIT FEE
who commcts for such projects with a connacmr(s)licensed pursuant to the Contmi ��'-{{tom-�11��••'''�w/11�i
License Law. PERMIT ISSUANCE
0 lamexemptunder Seo. ,B&PCfor this mason
/ q� ALTER-DRAIN&VENT-WATER(HA) VALUATION
o
WORKF. COMPS 10 CLARAI'IONL�� BACK PLOW PROTECT DEVICE
1 hereby affirm under penalty of penury one or the following declarations: _
I have and will maintain a Corti neare of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,RO •A BA.CON4A,\ STOR 'S TYPE CON' TION
xenon,as provided for by Section 3700 of the Labor Cade,for the performance of the 3 -
work for which this permit is issued. FIXTURES-PER TRAP -
❑I have and will maintain Worker's Compensation insurance,as required by Section •t ___
3900 of the Labor Code,for the performance(if the work for which this permit is issued GAS-EA.SYSTEM-II .4O1TLETS 1 C innn OCC GROUP APE
My Worker',Compensation Insurance Gamer and Policy number me ��
Cmrm: Policy No.: GAS-EA.SYSTEM-O trt 4(EA)
CERTIFICAOI Op EXEMPTION FROM WORKERS' GREASE%INDUSTRL W'+STE INTERCP.PTOR
COMPENSATION INSURANCE yU1LU GUI VISION FEDI
(This section need not be completed Che permit,,focenohundrcd dollars($100) 3l
orlwa) GREASBTRAP PLANCHECK PEE
I penny dant In the Performance of the work tor which this permit is issues,l shall SEWER-SANITARY-STORM EA.200 PT.
not employ any pen in any manner so as to become suhjem m the Workers'Compen- ENERGY FEE
zi o,.tion Laws of California.Date WATER HEATER WNENT/ELECTR
Applicant ) GRADING FEE
z ti NONCE TO APPLICANT:If,afar,making this Cenificnte of Exemption,you should WATER SYSTENITREAI'ING SOILS FEE
othwith comply with uchS9s Cmnpeor shun provisions bthe Labor Code you mos
Q nvisions or tM1ls permit shall he deemed revoked. WATER SERVICE Q /���
az RUCTION LENDING AGENCY NEW RESIOEWIAL PLMB. SQ FI'. PAID Receipt#
1 thereby moron that them in n constmcAon lending agency for the perfonnanceof j plot
V the work for which this Iran,is issued(Sec,3097,Civ.C)
W Lender's NameM. TOTAL:
O V Lenders Address TOTAL:
a • 1 certify that 1 have read this application andsomethat the above information is BUILD OIL
ti h correct.I agree a comply with all city and county ordinances and state laws reining a QTY, MECHANICAL PERMIT FEE (�
U building construction,and hereby authon.,c representatives(if this city to enter upon the SEI7
above-mentionpose
ed p,.,rty for inspection purs. PERMIT ISSUANCE 0
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECT C pEE a
Iirdilines,judgments,costs and expenses which may in any way accrue against said City AF,TERORADDTOMECH.
in ennsequence of,he gaming of this permit. PLU BIEE
ND F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'TO 10,0!X)CFM) O
SOURCE -GURy. CATIONS �c CH FEE J
fdl`? AIR HANDLING UNIT(OVER IO.(NIO CFM) C STRUCTION TAX
$;gots oreure n��ApplieatW(Iwllmetor DnQa EXHAUST HOOD(W/DUC'q HOUSING MI'TIGA'TION FEE
HAZ RDOUSMA'1'ER SDISCLOSURE
Will theupplieamorfunimbrohimg oecupmnxtmvcr1Emdlahammrko,material HEATING UNIT Ufa 100,000 BTU)
as defined by the Carina.Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 B'rU)
E]Yea E]No VENTILATION FANS INGLE RESID) PAID
Date Receipt p
Will We applicant or future building occupant use equipment or devices which y01LER-COMP(3HP OR 100,000 BTU)
omit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes FIN.
I have most the humolus.s mamriak requiremen6 under Clarence 6.95 ofihe Cali- ISSUANCE CONDITIONER ISSUANCE DATE
train Health&Safety Cade,Sections 25505,25533 and 25534.I understand mot d the NEW RESIDENTIAL MECH. SQ.Er /� J
building doer not curtcn0yh L that it is my responsibility to amity the occupant C/ /
ercqui nswh'h En Inissuance of a CGnl�ic�at of Occupancy. �
l� I Y
Ow'T,a,authorized ag Date TOTAL. ISSUED BY:
OFFICE