S 0856 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
��. CITVOF CUPERTINO BUILDING-ELECTRICAL. PF84ITNO. 0w car.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING-MECHANICAL. V` y8 {6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNEN'S & CONTRA R'S A E 0
NIC CONTROL#
4RCHDEC NG EER: LIC O: U E.
ONTACT: �n�., --ZH7ONE: - - BUILDING PERMIT INFO
�/" #c// /�Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE IIrKIJ
1 hereby affirm that l am licensedunder provisions of Chapter 9(commencing JOB DESCRIPTION -
�0OC'z with Section Division3of the Businessvnd Pr fissions Code,anJ my licenuis
0 PERMIT ISSUANCE. - 71 RESIDENTIAL'
in full force and off !/
CWF - ❑SFDWI, ❑KITCHEN REMODEL
R U License Ivs Lic.# -- gppL1ANCE$-RESIDENTIAL
F+ LLI Date Conrnmtns ❑ADDITION El PLUMBING RF.-PIPE,
1„ lei ARCHITECT'S DECLA A I PANELS ❑MULTI-UNIT L1 STRUCTURAL
Z O h 7J 1 understand my plans shall be used as public records MODIFICATION
O,Z4C _ UPT0200AMP5 [I INTERIOR ❑CHIMNEY REPAIR
' W License]Prnfessionvl - AMPS ❑BATH REMODEUREPAIR [3 DEMOLITION
201-1000AMPS IMPROVEMENT E3 SWIMMING POOLS
OWNER-BUILDERDECLARATION 000
I hereby affirm that I em exempt fromm the Contractor's Licence Law for the OVER 1
3 W F following reason.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL EJOT
O which requires a permit to construct,antic improve,demolish,or repair any structure r
priormits issuance,also requires theapplieint Broach pennitto fileasignedsmtemeat SPECIAL CIRCUIT/MISC. I�
tbathe is licensed pursuant to the provisimnsofthe Commcmrs License Law(Chapter9
(commencing with Section 7")of Division 3 ofrhe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of [INEW BLDG/ADDITION ElDEMOLITION
W^m Section]031.5 byany applicant,fora permit subjects the applicant m e civil penalty of POWER DEVICES ❑TENANT E1 FOOD SERVICE
Onot more then five hundmd dollars(5500). P VEMENT
❑I,as owner of rhe properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do be work.and the structure is not intended proffered lattice(Seo.➢WT,Business T 'R
a3$ and Professions Code:The Contractors License Law does not apply to an 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 are not intended or offered for NEW RESIDENT IAL ELECTR SQ In
sale.If,however,the building or improvement is sold within one year of completion the SQ.FBFIFL 7R
AEW. $/SQ FT.
owner-builder will have the burden of proving that he did not build or improve for pot,-
poseof sale.).
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOT
causeLawdproject(Sec..im Business andry,wh i boo Code:)The Co therawn.Li-
cause
i- ED
seLaw fines nm apply to an ownerofproperly who builds or improves thereon,orJ QTY, PLUMBING PERMIT
� who mnlmcb for such projects with acommangs)licensed pursuant to the Contractors
License Law. PERMIT ISS DANCE
❑I am exempt under Sec. B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
Alm WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alarm under penalty of pe jury one of the followingdeclarations:
I haveand will arsomina Cedifcate of Consent in self-inure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
111111 tion,as prevlded for by Section 3700 of the Labor Cade,for the performance of the
w rk for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Werk is Compensation Insurance,as required by Section
. od wfth,Labor Cade,fort ejpparrjformal�eoftheworkfmr which rthhiis permit�iss ii,mad. GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Wad o satY-✓WicP at and Polley nmUZ7A/1 .
Cartier: aPolicy No.: OAS-Eh SYSTEM-OVER
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI.WASTE INTERCEPTOR
(This saction need not be comp Wed a,it the permit is formhundred dollars($1(p) BUILDING DIVISION FEES
or less.) CRGASC TRAP PLANCHECK FEE
I codify Nat in the perfmrmanceofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner w as to become subject to the Workers'Compen- ENERGY FEE
�-. inner Laws of California.Data. WATER HEATER W/VENT(ELECTR
Z Applicant ( - GRADING FEE. rV
-
n.t ti NOTICE TO APPLICANT IL after making this Certificate of Exemption,you should WATER SYSTEM/rREATING
a become subject to the Workers Compensation previsions of the Labor Code,you most SOILS NEE
rx
UJ G forthwith Omply with such provisions munapermitdoolbedeemaina,.ked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT.
{U Z I farwhich rte thatpermit i issue (Sri.i30 lending agency for the performance of y Date cipr#
the work for which this permit Is'Issued(Seo:.309],Civ.CJ I I
O (~ Lender's Name TOTAL:
LU Lender's Address '1"OPAL: n
I certify that I have read this application and stare that the above information is , BUILDING FE
!r f0.A cored 1 agree m comply with all city and cnumy ordinances and stoic lows rearing n. QTg MECHANICAL PERMIT FEE
V 4 building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
�' above-mentioned property for inspection purposes.
(We)agree m save,indemnify sad keep tharmlea the City of Cupertino against PERMIT ISSUANCE ELECTRIC
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH.
in consequence of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM]
SOURCE REGULATIONS. MECHANICAL kE
AIR HANDLING UNIT(OVER IR00b CFM) CONSTRUCTION AX
Signature dApplican✓Cnnweter Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I orr"BTU)
as definW by the Cupertino Municif3l Code,Chapter 9.12,and the Health and Safety
Code,Section 23532(o)Y / HEATING UNIT(OVER 100,(1!X1 BTU) -
E]Yes No PAID -
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building rocapant ue equipment or devices which
it hazardous air co laminanrc as rued by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1 W,(XI0 BTU) /
isuicl? /pCt' TOTAL:
El Y11 F/No BOILER-COST(OVER INAOOBTU)
I have road the hazardous materials requirements under Chapter of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&,aptly Code,Sections 25505,25533 and 25534.1 understand that drhe NEW RESIDENTIAL MECH. SQ.FT.
M1ulldingdces tly ha ¢ r,that it is my responsibllllyt sou yah otitic t
ofthem a is s lh prinnnissuence ofa Cern ale O
�� �r ,-
O nr au orizwl agent —�-1 Dam IOTA : V ISSUEDBY: r t
OFFICE