S 0863 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPE BUILDING.ELECT RICAL- YERMI T NO.
BUILDING DIVISION APPLICATION/PERMIT PLUAIBINC.-MECIIANICAI. S 0863 Q 6 3
BUILDING PROJECT IDF.NTIFICA'1'[ON
VV
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT'.
9 4
=CHIG
' , ` P U C NfR, O N LI N NIC CO OLN
W (l: R'S CA ❑
Fax
PHONE: BUILDING PERMIT INFO
w,DbI4V s M �L ��1Q-l�'` ❑ Consultant Fees Paid by Applicant(Initial) BLDG C1'VMB MECH
U 1 C��L� ❑ �
CENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT ' FEE LOB DESCRIPTION
11yym thm I run licensed under provisions of Chap,9(commencing
0040 Division 3oflhe Business and Professions Code,and my license is PERMIT ISSUANCE J `S l� [ISSFDWL TIAL ❑KIT CHEN REMODEL
MUkF�]] Lick APPLIANCES-HF.SIDEN'I'IAI. ❑ADDITION ❑PLUMBING L PIPE
GOn DECL [dMULTI-UNIT ❑STRUCTURALZO � ARCHITECTS DECLARATION PANELS MODIFlCATION
my plans shall be used as public records
oz- UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
L•�F
in
Licensed Professional 201-10110AMPS IMPROVEMENT C]SWIMMING POOLS
S Sg1y OWNER-BUILDER DECLARATION OVER]"AMPS ❑RATH RC DEL/RIiPAIR ❑DEMOLITION
g OOCC a 1 hereby aDirm that 1 am exempt four.the Cometchn's License Law for the Al OTHER hln! )rnG SSC?
O y V following reason.(Section 7031.5,Business and Professions Code:Any city or courtly SIGNS ELECTRICAL. ,5
3 LL F" which requires a permit m construct.alter,improve,demolish,or repair any structure
aevUL
�1O prionoits issuance.also requires the applicant for such permit to file a signedatammem ' SPECIAL,CIRCUIT'/MISC. �.,5� 10 -
Ny that he is licensed pursuant the provisions of the Contractors Lianae Law(Chapter 9 ,
m�C�O (eommendng with Section 70110)nf Divisionlof the Busineo'und Prol'caslons Csde7 nr TIPARMLTI?R OR POLE INST.
d y M OL that he is exempt therefrom and the had,for the alleged exemption.Any violation of [I NEW BLDGIADUITION E]DEMOLITION
uXl tI. Section]031.5 by any applicant for a permit suhjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
}
or mom than live hundred d.11...($500). IMPROVEMENT
fC ❑has owner of the propmy,ornry employees with wage as theirsole compensation, SWIMMING POOLELECTRIC ❑OTHER
will do the work,and the mrocwrc is not in¢ndcJ nroRertd for sale(Sec RW4,Business
6 and Professions Code:The Contractors License does not apply m un nwncr of OIIThEfS-SWRCHPS-FIXTURPS
property who builds or improves thereon,and who does such work himndf or through NEW RESIDENTIAL ELECTR
his own employees,provided that such improvements am not intended or offered for SQ.]T.FLOOR AREA 5/SQ.FT.
wit.If.however.the building or improvement is said within oneyearofcarra"c m.the
oasnenbuilder will have the burden of proving that he did nut builder improve for por-
pram.fsaleJ. pL:
❑1,as owner of the property,am exclusively contracting with licensed cnntmaors to
construct the project(Sec.90,t4,Business and ,fiessamsGde:)The Contractors Li.
maw Law does not apply to care.ner of property who Int it's
or improves thereon, a L E 1 FEE
who contracts for such pmjecm with u contmmous)licensed pursuan,oche C)utruc1r'
License law. R N
I am exempt under Sec. ,H&P C for this ream
ER- -WATER IEA) VALUATION
Owner Dole _ •2!)�-
• WORKER'S COMPENSATION DECLARATION t W PROTECT.DEVICE j
I hereby inform under penalty of perjury one of We following dectmaila ms.
I have and will maintain a Certificate of Consenuo self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,GOND, STORIES TYPE CONSTRUCfIC
satien,as provided for by Section 17M of the Labor Code,for the perfomrance of the
work for which this;permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation hemance,as required by Section
3Ll0ofthelabnr Code:fm Neperfmandawafthewnrk fm whichthispemrit is issued. GAS-EA.SYSTEM-1 INC 40lD'LETS OCG GROUP Afy�
Myen's Co npensui I Wmnce annervnd Policy nym
Carie, t ' -__S Policy No.:�Y� GAS-
EA.SYSTEM OVER4(FA)
CERTIFICATE Op-P{ERE PPTION FROM WORKERS' GREASFIINUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(Thlssemion nadnot he completed if the pemsit is foronc hundred Jollan(SI W) GRF.ASETRAP
PLANCHECK n
or l n.)
I cetify that in the performance of the work for which this pemrit is issued,lshall SEWER-SANITARY-S9'ORM EA.200 FT.
not employ any pmo
e ....m er
a nnse as m become subject m the mars'Compete IiNCR( :EE
cation laws of California.DaniWATER HEATER WNENT/F.LECTR 'RAD] GFEE
O Applicant
t7 y NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should WATER SYSTEwrREATING ti S g
F became subject to the weeme,Compensation provisions of the"For Gde,you must
ai t„t farhwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
T Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLb1B. SQ,FT PAID
Date Receipt p
O I hereby affirm that here is a construction lending agency for the performance of
L)
Ur'+ the work for which this permit is issued(See3099.Civ.C.) TOTAL:
LL,O Ll Lenders Name 'TOTAL:
,0 W Lender's Address BUILDING FEE
0. I ceotil'y in.,1 have read this application and slate that the abowe information is
V) correct.I agree to comply with all city and county ordinances and slate lows relating m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building construction,and herebyamhodu repressamoloeaofthls city to enterupm the - L
oW,menth ned pmpen r inspection purposes. PERMIT ISSUANCE Sky ELECTRIC FEE 611.o o
(We)agree hs ve ndemnlfy and IF harmless the City of Cupertino against
las ilities,jedgcsendexpensc h' hmm
ayinany way create against said City AUTF.RORADDTOMECH. PLUMBING FEE
in comequ ofth mntingoftid - /p
APPL TO 'RSTAN LI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE V C s
SO CE REC . TION.
AIR HANDLING UNIT(OVER 10,000 CFM)) CONSTRUCfIUN'1'A%
Mrc en v Ca Date EXHAUST HOOD"YOU HOUSING MITIGATION FEF.
BOGUS MATH DISCLOSURE
Wil heappli at or future building occupant store or handle haamalousmmerial HEATING UNIT(TOIW,1Ml0BTUI �Zk 2Q
m delisted y the penin)Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT LOVER 1011,(gIB BTU)
Code.Serf .32(a)'?
C]Visa ❑No VENTILATION PAN(SINGLE RESID) PAID
Dare Receiptp
Will the applicant or thrum,building occupant use equipment or devices which BOILER-COMP CHP OR 100,000 BTU)
• emit hawJous air contaminants as defined by the Bay Area Air Quality Management TOTAL: Z I
District? BOILER-COMP(OVER EI0.000 BTU)
❑Yes ❑No
AIR CONDITIONER �'�` -h O ISSUANCE DATE
I have read the h orke.S s tiro,25505.25533
55 requirement under Chapter understand
of the Cali- Ik nVK�YJ
building
Hwhh ne Safety tlyha Sections t,that i is my and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT
I building Jtus not currently haveamnant,that it is my responsibilirymnotify the acupant
of the requirements which must be met prior m issuance of a Cerdmute of Occupancy.
Owner or amhunxN agent
Date TOTAL: I D ISSUED BY:TOE...9����'���a-
OFFICE