S 1560 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PEWy\yIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NIECHANICAL V 1560
BUILDING PROJECT IDEM'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTALDATE
Avar eg sso,Iy �'L-1 T5
NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
V&"* Alf p Y eVgfN T^x a "'11WAv N/C CONTROL N
ARCHITECtENGINEER: rF LIC NO: /` ADDRFSS: ❑
CONTACT: PHONE
BUILDING PENMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGIA.Ii PLUME MECH
❑ 11 ❑
LICENSED CONTRACTOR'S DECLARATION
with SeQTY ELECTRIC PERMIT FEE
O C Z 1 hereby.111"m hot isi
1 am licensed under provon.om
f Chapter 9lcumcmcing J DESCRIPTION
{0O Section 70o(Division 3 ofthe Business and Professions Code,and my license i+ NESIDENTIAL:
in full fomcandeflcat. PEltMITISSUANCE
�UU License Class Lick ❑SFDWL C KITCHEN REMODEL
yG4 Date, Contractor APPLIANCES-RESIDE.N'I'I Al. []ADDITION El PLUMBING RE-PIPIT
ARCHITECT'S DECLARATION PANES CMULTI-UNIT CSTRUCTURAL
Z 0 y Z I understand my pl...hall be used ns Public records MODIFICATION
OZ�O UP T021x1AMPS ❑INTERIOR El CHIMNEY REPAIR
F 11 f W Licensed Prom samid 301-1000AMPS IMPROVEMENT
p,� ❑5 W IMMING POOLS
,,.4.I OWNER-BUILDER DECLARATION OVER 1000AMPS C BATH RHMOU'IIREPAIR IJEMO 111 ION
6 1 hereby settlor that 1 um exempt from the Contmeoo License c Law co tire,
O d U following arena.Sardroof t 9onstru t,atter, and Prel demols h.or Any citys county SIGNS ELECTRICAL 11 OTHER
which requires u permit m construct,atter,improve,demolish or repair any structure
yg prior to its issuance.also requires the applicantfor such Permit o rile a signed statement SPECIAL CIRCUIT/M ISC.
� } tP
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
W p0 (commencing with Section 7(100)of Division J ofthe Business and Professions Garda TEMP.METER OR POLE IN.ST. COMMERCIAL:
d p,o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tzXl LLy
Section 7031.5 by any applicant for a permit subjects hc applicant to o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($50))'
FQ CI,as owner of the property.or my employees with wagesas their sole compensation. SWIMMINGPOOLELECTRIC IMPROVEMENT'
will do the work,and the structure,is not intended or offered for sale(Sec.]DLI,Business C OTHER
L 3 m and Professions Cat The Contmcmea 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 am not intended or offered fur NEW RESIDENTIAL ELECTR SQ FI'.
sale.IL however,the building or improvement is sold within one year ofcompletion,the Z SQ.FT.FLOOR AREA $/SQ.FT.
noo-budder will have the burden of proving that he did nm hnlld or improve lin pur-
p enfsuleJ.wtt , P A
[-] Lpr
as owner of the operty, exclusively contracting with licensed contractors 11, /'s'' !1 -
nsthe project ISec.]1416,,B ontr
Business and Professions Cwle:7'Ihe Convacurr's Li-
cense law does not apply to an owner of property who builds or improves thereof,and QTY. PLUMBING PERM FEE ��J� �� /'J
who contracts for such projects with a commemgs)licensed pursuant to the Contractors M
License law. PERMIT ISSUANCE .�
(rain ex aPI undermB S . , &P C far this ma.am Y
Il:na AIT HTR-DRAIN&VENT'-WNI'17R(EA) j- AL1UAIION
WORKER'S COMPENSATION CLARATION BACK FLOW PROTECT.DEVICE V
IherebyuRrm under penalty of perjury nm the lMlowing declarations:
O (have and%in maintain a Carriacou,of Consenrto self-inose for Worker's Comiam- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPIiCONSTRUCTION
smion.as provided for by Section J]ql of the tabor Calc,fur the performance of the
work far which this,road is issued. IIXTU RIiS-PER TRAP
❑1 have and will nmimme Workers Compensation]it mrancc,us required by Seaton
3700 ofthe ad Code,for theperform:mce ofthe work for which this permit is issued. GAS-HA.SYSTEM-1 INC.4 OUTLETS OCC.GROAT' APN
My Worker's Cumpsnuation Insurance carrier and Policy number ort:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4IEA)
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTR,WASTE INTERCEPTOR BUILDING DIVISION FENS
(Uieseaion need oathscoriplctedifthevarrat is fromash.ndreddiduars($100) GREASE TRAP
ser less) PIANCHECK ME
I caddy lhal in the performance of lire work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.2W FT
not employ any person in any manner sous to Name subject to the Workers'Cmapcn- ENERGY FEE
Q ,Z smion Lawsof Culikerou.Date WATER HEATER WNENT/IiLECfR
z� ApplicantGRADING FEE
salsa NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM?REATING F SOILS FEE, become subject to the Workers CnmPemahnn provisions of the labor Code,you must
forthwith comply with such provisions or this Permit hall be deaned revoked. WATER SERVICE
Q PAID
CONSTRUCT
ereisr'ION LENDING AGENCY NEW ItIilIlJliNT1ALPLMIL $Q.I'll Date Rceci tp
UO k for
rwhich thithntouti is reconstruction 30lending agency for the perfnmannm of P
FL U the work fort which this permit is issued(Sec.Jag],Civ.C.)
O Lenders Name TOTAL:
V Lenders ATOTAL:
I certifyctifythat I have mail This application and stem That the eMwe information is BUILDING FEE
i.. ((A correct I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL.PERMIT FEE
U 4 brolUingennswction,and hereby wnhorire rcprnentativca of liras city menturupon the SHISMIC FEE
ahovamentinncd properly for inspechou purposes. PERMITISSUANCE ELECTRIC FEE(We)agree to save,indemnify mW keep harmless the City of Cupem ar,agaimt
liabilities,judgments,costs and expenses which may in any way deems against said City ALTER OR ADD TO MECH.
in nscquenro of the granting of this pemait PLUMBING FEE
APPLICANTUNIIERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10,00(1 CFM) MECHANICAL.FEESOURCEJ`�iy;`GULNf10NS. �/
kke;l1w � /'_/� AIR HANDLING UNIT(OVER III,IxXCFM) CONSTRUCIONTAX
Signature ol'AApplicant/Contrsclor /F(D/ta EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MAT ERIAfS SCLOSURE
Will the applicant or future building occupant store or handle haurdons material HEATING UNIT(TO 100,000 BT U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(ap HEATING UNIT(OVER IfNhgp BTU)
❑Yea C]No VENTILATION FANS I NGLE RESID) PAID
Will the a r licaut or future building terse t use e t or devices which Date Receipt p
IP 6 Paso Area
ROILEE-COMP(3HPOR gLooll
nmitiety ux'oir contaminants as JclineJ by the Bay Arca Air Quality Management TOTAL:
ismet9
g ❑Yes ❑No BOILER-COMP(OVER 100.000BTU) IQ
I have mad the havardous materials regmmucenv under Chapterfi95 aflhe Coli- AIR CONDITIONER ISSUANCE DATI3
humin Hcehh&Safety Code.Sections 25505,8533 and 25534.1 understand that if the NEW RESIDENTIAL MUCK, SQ.EL
building does not cormarly have o marm.(fail it i+my re pomaihllry m notify the occupant
of the regaircnmma which must he mel prier I,,issuance of it Gcrlftmle of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE