B 0286 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO Q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI O �+
�BU)I/L/DDIINNG PROJECT IDENTIFICATION
PU1/ ,9 6 L 110 A 1115,10-061 (�(J(� /�0 C SANITARY NO. APPLICATION SUBMITTAL OAT!
CO RACfOR'S NAME: LIC NO:
IgiN/C CONTROLM
'
ARCHI I hutIENOUNIAUL LI- l: ) ❑
CONTACT: PHONE.: BUILDING PERMIT INFO
�,8 ❑ CoB$ullant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M[CH
�WWN GGGGIIII ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECons of CO QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am fthe ed under provisions of Chapter 9 my license is JOB DESCRIPTION
�W= with SecreandlfOocDivisinn 3Ofthe Bgsinas end Professions Code,and my license is RESIDENTIAL
F,�O in full force and effect. PERMIT ISSUANCE
qUI" License Class Lt. ❑SFDWL
a U ❑PLUMBING
RE-PIP I.
LI....ZW Date Contrnetor. APPLIANCES—RESIDIiNT1A1.
❑ADDITION ❑PLUMBING RE-PIPE
F.D y ARCHITECTS DECLARATION
Z O--Ca [understand my plans shall M1e used as public records PANELS ❑MULTbUNIr ❑ URA
O Z O UP'f0 200 AMPS MODIFICATION N
Lnenscd Professional E)INTERIOR ❑S IMMING POOL
9 OWNER-BUILDER DECLARATION 201-IOW AMPS IMP0.0VIiMENT SWIMMING POOLS
W< 1 hereby o irm that 1 am exempt front the Contractor's License Law for the OVER 1000AMPS CV ❑BATH REMODEUREPAIR ❑DEMOLITION
O L U following mason.(Section 7031.5,Business and Professions Code:Any city or countyELECTRICAL ❑OTHER
3 LL Lk.. SIGNS
LL O N which requires a permit to c ic,uIw,alcor,improve,demolish,or repair troy sweum
yee priortnsliecuedi,also re qui res Provisions
fins.11, License ow(Chaptr9
J SPECIAL CIRCUIT/MISC.
the,he is license)pursoannnthe provision.of the Cantroctots License law(Chapmr9
C (commencing with Section of Division 3 ofthe Business and Professions Caste)or COMMERCIAL:
D O TEMP.METER OR POLE INSr.
6`0.i5e e' that is is 31.5 b therefrom and or M1axis for the allege)exempting.Any violation of ❑N17W BLDG/ADDITION ❑DEMOLITION
W'm"NWy Section]031.5 by any npplicaI'fora permit xobjects the epplicum ma civil penapy of POWER DEVICES
FZF} n mom than five hundmlJollars($5W). L1 TENANT ❑FOOD SERVICE
❑� I,as owner of the progeny.or my employees wob wages as Neirsoleeompensatian. SWIMMING POOL ELECTRIC IMPROVEMENT
wi do the work,and thentrudureis nen intended or.--.for a aIc(Seo.9W4,Bus iness ❑OTHER
63 and Prnfeasiom Code:The Comments License Law does not apply to on owner of OUTLETS—SWITCHES—FlXTUNFS
progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided Ihm such inoprnvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ FL
sale.If.however the building or improvement is sold withmmin yeer Ofcomplennatha SQ.FT.FLOOR AREA $/SQ.Fr
owner Wilder will have the burden of proving that he did not Wild or impmve for put.
Pa.
El 1,as Owner of the Pmpeny,am exclusively convecting with licensed contractors m TOTAL:
construct the project(Sec.744,Business and Pmfeasions Cod,)The Cmurawmes Li. � N D
cense law does not apply m an owner of progeny who builds or th
ineproveaeteon.and QTY N PLUMBING PERMIT FF,E
who contracts for such projects with a con ouela(s)licensed puts.ant to the Contimstuas
License law PERMITISSUANCE JUL g 116meD
0 1 am exam der ec. ..,B P C for - reason VI l� /11#{7
Owner ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CITY Ur kaUrCntkNQ
1 hereby affirm under penalty of perjury one of the following declarations:
l have and will main lain a CenificutConsent e of Conseno wif-insure forWmker's Compen- DRAINS—FLOOR.ROOF,AREA.COND.
cation,as provided for by Section 3'/W of the Labor Code,far the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37D the LsWr Coda for the perfmananccofaoe work fmxhichthis permit is issued. GAS—EA.SYSTEM-]INC.4 OUTLET OCC GROUP APN
My WmIses Compensation Insurer.carrier and Policy number Ire:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
('this section need not hecompleted it the permit is foram hundred dollars($LIN)) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Loy say thmintan-111--act Infuriation sues
the wmk for which this Perthe it Wisismeonva.l SEWER—SANITARY—STORM EA.2W FT.
not employ any person i a any manner no as m become subject w the Worken.'Cnmpen- ENERGY FEE
.ration Laws of CaGfomia Dam
0 WATER HEATER W/VENT/ELECfR GRADING FEE
NOTICE
F ti NOTICE TO DELT-hCANT,e Work IL after making This previsions
n s of of Exemption,you should WATER SYSTEMRREATING
a ' become subject to the Worker's Compensation provisions of the need solos you must SOILS FEE
fnMwitheomply with such pmvisinns o..his permit slull Wdeemed rcvokN. WATER SERVICE
0.
Uz CONhem is a [ONconst LENDING AGENCY NEW RESIDENTIALPIMB. SQ.FT. PAID
VJ 0 lfor by which
thatouni issued((See
constructionlendingagency fmthe performance of Date Receiplp
(L F the work for which Nis permit is issued(Sec.709),Civ.CJ
Lender's Name
0 Lender's Address ,TOTAL: TOTAL,;
I certify that l have read this application and state that the aWve information is BUILDING HE
fA c rrectlugreemcomply with all airy and county oNinances and Blore lows rel.tingm QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives oftlincitym enterupon the SEISMIC FEE
above-,mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Culture.,.in,, PERMIT ISSUANCE ELECTRIC HE
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADDTO MECH. '
I.comet eroce of the grunting of Nis pemdt. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(T'O 10,(NIOCFM)
SOURCE REGULATIONS, MECHANICAL.FEE
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Signature of ApplicanUContmcmr Date EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the,applicant or future building Occupant store or handle hiardous,material HEATING UNIT(TO I DO."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532D)? V HEATING UNI'P(OVER II WAS)BTU)
[I yes ONO
•` VENTILATION FAN(SINGLE RESID) PAID pate Receipt#
Will the of cournnl or future building occupant use equipment or devices which
emit Wardoux air contaminants as deOnM by the Bay Area Air Quality Management BOILER—COMP(3HP OR IW.WOBN)
Dimrict? TOTAL:
' ❑ ``Yes �J Na - BOILL'R—COMP(OVER IW,[NN)RTU)
Lha thehazodous.teriills AIR CONDITIONER ISSUANCE DATE
requirements under oftheCOIi-
buil,ll I .friary Gdc,Sections 2that,is and 25534.I understand that f(he NEW RE$IDEiNT1AL MECH. SQ.EL
buildin not not heveamnan6 that it is my me dbil tRnotifyth me wt
1y, m h et pro 0
Ownerminamriredegent s D.0 TOTAL:
ISSUED BY.
OFFICE