S 0789 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY - t
,CITY OF CUPERTINO - - BUILDING-F.LELTRICAL - '" PERMI'ENO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION S 0789
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
z. LI Jfn WE- Cil cls I l'1r2
OWNER'SN ME: PHONE: CONTRACTOR'S NAMF,: LIC NO:
_ _
NIC CONTROL#
WiLUAM
4RCHITEMMNGINEER: LIC NO: ADDRESS: ❑
i Y-
CO ACT: ?HON - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH -
❑ ❑ ❑
LICENSED CONTRACTOR'S DEConsof CON QTY. - ELECTRIC PERMIT FEE
I hereby aft n that I amfhelicensed i under and
of chapter 9 my license
J L. DESCRIPTION .
aZ with Section]1KN1)ofDivision3ofrhe Business and Profes.anns Cade,and my license is
FWO In full force and effect. - PERMIT ISSUANCE
�ul SFDWI, El KITCHEN REMODEL
UUU� License Class Cme APPLIANCES-RESIDENTIAL. ADDITION ❑PLUMBING R&PIPE
rF A. Dam Contmuor
Fly ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCIVRAL
I Z pp2 VZ l understand my plans shall he used as public records MODIFICATION
OZ=1Q UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR ,
Q4t.M4 Licensed Prnlessinnal 201-10WAMPS IMPROVEMENT E]SWIMMINGPOOLS
-
o�d OWNER-BUILDER DECLARATION OVER IWOAMPS El BATH REMODEL/REPAIR El DEMOLITION
I hereby affirm that 1 am exempt from the Contractor's Liceri Low for the
W 3 6 U following reason.(Section 7031.5,Business and Professions Cade:Any city,or countySIGNS ELECTRICAL ❑OTHER
Gc y which requires a permit to construct,alter,improve,demolish,or repair any xmanare 0046
prior to its issuance,also requires the applicant for.cuch permit to file a signed statement SPECIAL CIRCUIT/MISC.
{}'a that he is licensed pursuant to the provisions of the Counselors License Law(Chapter 9
''m F500 (commencing with Section 9000)of Division 3 of the Business and Professinns Code)or TIME METER OR POLE INST. COMMERCIAL,
ti IS c K that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'^I°• Section]031.5 by any 4pplimal fora permit suhjeus the applicant to a civil penalty of POWER DEVICES
-'y []TENANT ❑FOOD SERVICE
� 6 not more rano rise hundred dollars(SSW).
❑ ldo the work,the the structure
r myemployeeswimwages asclei((See
70,m,11tai ass SWIMMING POOL ELECTRIC 0THER IMPROVEMENT
C will dothewons and m The Contractors
Liceedoroffe ed does of apply toren Business , ❑OTHER
and Professions Cade:The Commereof.and who
doer not apply toll owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,howeventhe building or Improvement issnld within one year ofcompletion.the SQ.IT,FLOOR AREA SISQ.FT.
ner-builder will have the burden of proving that he did not build or improve for pur- '+9 p II ..
pose of sale.). - V
E] 1,an owner of the property,am exclusively contracting with licensed counamors to TOTAL:
construct the project(Sec 7044,Business and Profession C-1 Tho Contactor's LI- 9y � �..#� 1
ase law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING.PERMIT FEE W #Wa3�A CD
who contracts for such projects with a contractor(s)licensed pursuant m alto Contractor's Y
License Law, PERMIT ISSUANCE -
❑IamexemptunderSec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) - VALUATIONOwner Date ��
ER' COMPENSATION DECLARATION BACK FLOW PkOIF,CT.DEVICE `/f.^�
crelays trm under Penalty of perjury one of the following declarations: J
I]Ihave and will maintain aComment af Consent o xlf-insure for Worker's Compen- DRAINS-FLOOR.ROLE AREA,COND. STORIES TYPE CONSTRUCTION
sauna,as provided for by Section 3700 of the Labor Code,far the performance of the
work for which mis permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Cade,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4 LA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISI NFEES
(This section need not be completed lithe permit is forone hundred dollars($100) -
orless.I CREASE TRAP PLANCHECK FEE
I verify that in the performance of the work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subject to the Workers.'Compen- ENERGY FEE
,Z main Lawn of California.Date WATER I[LATER WNENTEL/ ECTk
O Applicant t GRADING FEE
G7 V1 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
a ? become subject m the Workers Compensation provisions of the Labor Code.you must SOILS FEE
{7a forhwith comply with such pro visions or this permit shall be deemed revoked WATER SERVICE
Q
QQQ]... CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL MADE SQ.ET. PAID
UQ I far
rwhichnm that emit i issued(Sitei30 lending agency for performance of me Receipt It
Ir the work for which this permit is issued(Sec.309],Civ.CJ -
QLender's Name - TOTAL:
L4L Lenders Address TOTAL: J
I certify that 1 have and this application andstate that the above Infomm0oq Is BUILDING FF.P..
L.Iii correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U �.. building concoction,and hereby authorim mprvenm0ves of this city to enter upon the SEISMIC FEE
`t above-mentioned property for inspection purposes. -
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accuse against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Right CFM) MECHANICAL FEE
SOURCE REGULATIONS.
- J1 Z3 9 AIR HANDLING UNIT(OVER IO,OW CFM) CANSTRUCfION TAX
mucHintrae r Date EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle hucardons material HEATING UNIT(TO 100,000 BTU)
or defned by the Culmina Municipal Code,Chapter 9.12,and the Health and Safaty
Cade.Section 25532(x)? HEATING UNIT(OVER 100.000 HDU)
E]Yes ❑No PAID T
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP DAP OR 1 W,00D BTU) -
mot hazardoos air contaminants ax defined by the Bay Area Air Quality Menagm
eenl TOTAL'
s District? BOILER-COME(OVER 100,000 BTU)
EJ Yes Fl Na
I have read the hazardm
limitations ramenalsoccareents under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE,DATE
fousia Health&Safety Cede,Sceti.n,25505,2.5533 end 25534.I underswnd that if the NEW RESIDEM'IAL MECH. SQ.UP
building does not currently have a mount,that it is my responsibility m notify the occupant
of the requirements which must he mot prior to issuance of a Certificate of Occupanty.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE