S 0057 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL p PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
llolS `.�A V�TeAa—
OWNER$Ngy$� o" PHONE: CONTRALTOR'$N LIC NO:
OPia`��%;.- I1 N/C ��- CONNTTR///OLL#
ARCHITECT/ENGINEER: _ /G LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby approach.1 am licensed under pmvisiens of Chapter 9(ctiamena lag JOB DESCRIPTION
OCZ with Section 7000)of Division 3 of the Business and Professions Code,and my liters RESIDENTIAL:
Op in full force and affect. PERMIT ISSUANCE.
W" ❑SFDWL *CHEN REMODEL
HUV License Class Leo.# APPLIANCESRESIDENTIAL IT
LUMBING RE-PIPE
Ned Dale ContractorDECLARATION MULTI-UNIT Ll STRUCTURAL
z O m 7 1 understand my plans shall be used vs public records PANELS MODIFICATION
OZ-, UPTO 200 AMPS [I INTERIOR El CHIMNEY REPAIR
F4 W Licensed Professional 201-101 AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 101111AMP5 . El BATH REMODEUREPAIR [I DEMOLITION
Sic I hereby affirm that 1 am exempt from the Contractors License Law for the
e.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
sw aeaF1
which requires a remain to construct,alter,impmer,demolish,or repair any swcture
yO prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
y that he is licensed pursuantto the provisions of the Centravtors License Law(Chapter 9
AD (tommenaing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.MITER OR POLE INET. R 1 1'
q m y that he is exempt therefrom and the basis for the alleged exemption.Any violmion of NEW BLDG/ADDITION El DEMOLITION
LLX7 0. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
T NANI' El FOOD SERVICE
< not more than five hundred dollars($500)
. O1,as owner ofthe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will de the work,and the stmclure is not intended or offered for sale(Sec.704,1,Business ❑OTHER
W CCC ro and Prufesxiom Code:The Committers License Law does not apply to ea owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does such work himself in through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ Ff.
sale.IL however the building or improvement is sold within one year efcompletion,the SQ Fr.FLOOR AREA $/SQ.Pf.
owner-builder will have the burden of proving that he did not build of improve for pur-
poseofsvleJ. L V
1,as owner of the progeny,am exclusively comme ing with licensed contractors to Y gq
construct the project(Sea 9044,Business and Prefeedons Code.)The Contractors Ll-
cause
i- Y
c sec Law docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wlm eonlmma fm cch projects with a comaacmr(a)licensed pursmam m the C.mractor'S �e/`
License Law. - PERMIT ISSU NCE I� IStlY
1 am empt undo Sec. B&P C for this reason
O �. n,,. I _ ALTER-DRAIN ENT-WATER(BA) ,I� / �r ped ppl',�ff 11//�'�
RKER'S COMPENSA ION DECLARATION BACKFLOW T.DEVI / WI'��IyV
`
fit
1 relay off under penalty of perjury one of the following declarations: V �iJ
❑Ihave and will rrwintaineCertificata of C.nsenuo eelf-insure for Workers Compen- DRAINS-FLOOR,R ,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have end will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Cole,forthe performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40 ETS OCGGRO P APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASETNDUSTRL WASTE INTERCEPTOR
IL DIVISION FEES
(This section need not hcempletedif thepermlt is for ouehundreddollars($100) GREASE TRAP
PLANCH /
.r loss.)
Ioyanythat
reason in any mannercof on as
for Subjectch to per aitislss ed.IComihall SEWER-SANITARY-STORM EA.200 I7.
not employ any person in any manner so us le become suhjen to the Workers'Compen- ENERG E
,Z Safi..Laws of California.Date WATER HEATER WNENT/FLECTR
y� Applicant \ GRADI 'W
q Vj NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you Should WATER SYSTEMOREATING
a ^� become subject t.the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W G forthwith comply winumah promsronsor.his pemriishall be deemed revoked. WATER SF.RV ICE
Q
� zCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELSE. SQ. PAID Data Receipt
I hereby affirm that Here is a construction lending agency for the permanence.
G the work for which this permit is issued(Sec.3097,Civ.C.)
W (~ Lender's Name 'TOTAL:
L) Lenders Address TOTAL: -
CR.1 I mnify that 1 have rend this application and orate that the clause information Is BUI NG FEE
y correct.l agree to comply with all city and county ordinances and state laws relating to Q'ry, MECHANICAL PERMIT FEE
. )Z building construction,and hereby cathartic represenelives of this city t.water open he SEISMIC
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify end keep harmless the City of Cupenino against ELECTRIC FE
liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in cunsequence of t o granting of this permit. PLUMBING FEE
APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0 f000 CFM)
MECHANICAL PEE
."1 E REGUU TIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ig amA am Cmatwamr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION F E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.001 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,
/:as
25532bo? HEATING UNIT.(OVER 100,000 BTU)
❑.Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date. Rccei t#
Will Ne applicant or future building occupant use equipment or devices which
.Jail homandous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME CHIP OR I00,000 BTU) TOTAL.
District? BOILER-COMP(OVER 100,000 BTU)
1` ❑Yes ❑No
I have read the hazard.arraderialsrequirements under Chapter 6.95 of the Cali- AIR CONDITIONER _ ISSUANCE DATE
fomes Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a tenant,that it is my responsibility to notify the occupant '
mthe ragn menents which must be met prior m issuance of a Certificate of Occupancy.
Owner or madamzed ager Dale TOTAL: ISSUED BY:
OFFICE