S 0072 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, n
BUILDING PROJECT IDENTIFICATION 2,
BUILDING A13DRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
OWNER IS1/sA&eLLYNTO1✓E C7',- C.0 OCRNTEniO cam} 950/ ¢
1 I u R !e 2S S—D6Sf� NIC CONTROLS
/ Rt`HTECf/ENGINEER: LIC NO: ADDRESS: ❑ -
CONTACT: PHONE: - - - BUILDING PERMIT INFO
J� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION El ❑ � El ELECTRICPERMIT '1 FEE
1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
/OaZ with Section 7")of Division 3 of the Business and Professions Code,and my licensers PERMIT ISSUANCE RESIDENTIAL:
FOO
WZ in full force and effect. ❑SFDWL El KITCHEN REMODEL
s_zU License Class Lie. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
N6 LL Date Contractor ,
F=i ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O Pv�1 3 I understand my plans shall be used as public tecaids MODIFICATION
OZaO UPT02MAMPS ElINTERIOR [I CHIMNEY REPAIR
[..4b-W Licensed Professional 201-1"AMPS IMPROVEMENT L]SWIMMING POOLS
C4 214 OWNER-BUILDER DECLARATION OVER IOOOAMPS ❑BATH REMODEL(REPAIR []DEMOLITION
�'Q I hereby affirm that 1 am exempt from the Contractor's License Law for the
LU following reason.(Section 70315,Business and Professions Cade:Any city or county SIGNS ELECTRICAL. CI OTHER _
W O vi which requires a Permit to construct,alter,Improve,demolish,or repair any structure
d� prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIVMISC.
Tthat be is licensed pursuant to the Provisions of the Contractor s License Law(Chapter 9
LV�pO (commencing with Section"IOW)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of , ElNEW BLDG/ADDITION El DEMOLITION
W y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty(if POWER DEVICES ❑TENANT ❑FOOD SERVICE
FqZ
net moa than five hundred dollars($5(10). -
6 D IMPROVEMENT
1,as ownerofthe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
2=O ❑OTHER
will do thework,md the surcture is not intended or offered for sale(See.7W,Business
CL 3 m 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 ate not intended or offered for NEW RESIDENTIAL ELECTR' S
sale.IL however,the building or improvement is sold within one year of completion,On SQ.ET.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of Proving that he did oat build or improve for per,
psof snI I
. e of thepmpard,an,exclusively contracting with licensed commetors to TOTAL: p�
onstrum the project(Sec.7044,Business and Professions Cm1ca The Costmamr's Li- P
cense Law does not apply to an owner orproperty who builds or improves thereon,and QTY.- PLUMBING PERMIT FEE
who contracts for such projects with a couoaetor(s)licensed pursuant to the Comsae[oh
License Law, PERMIT ISSUANCE
I am exem a Sec .B&P C for this reason
wine, ALTER-DRAIN&VENT-WATER(EA) ; J-
` Dam V '
ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
bereby at rm under penalty of perjury ane of the following declumtians:
h ve and will maintain a Cenificale of Consent to self-in sure for Workers Champion- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sonar,os provided for by Section 37M of the Labor Code,far the perfnmunce of We
work for which this permit is issued FIXTURES-PER TRAP
❑1 have and will mainmin Workers Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.40ITfLETs OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy N..: GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FGFS
(This section need not be completed if permit is for one hundred dollars($(W) GREASETRAP
or less.) PLANCHECK FE6
I certify that in Ne perfarmanceofthe work for which this permit is issued,lshall SEWER-SANITARY-STORM EA.200 FT. 0
not employ any potion in any manner so as to became subject to the WorkersCampeau- ENERGY FEE
O Z satins Laws of California.Dam WATER HEATER WATNT/ELECfR GRADING FEE
7 O Applicum
A NOTICE TO APPLICANT.If,after making this Cenifreate of Exemption,you should WATER SYSTEMffREATING SOILS FEE
abecome subject to the Workers Compensation provisions of the"her Cade,you must
w f.thwtth comply with such provisions or this permit shall IN deemed revoked WATER SERVICE
WJ
V O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt If
I hereby ME.that there is a construction lending agency for the performance of
the work for which this permit is issued(Sea 3099,Co.C.)
0 U Leaders Name TOTAL:
W Lenders Address
04 I certify that 1 have mad this application and slate that the above information is BUILDING FEE
y correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z buildomemstmcti.a,and hereby auNcrira cv,nowaratives idmiscity to emerupoa Ne SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEB
liabilities,judgments,costs and expenses which may in any way mean,against said City ALTER ORADDTO MECH.
PLUMBING FEE
in asequence of the granting of this permit.
APPLICAN UNDERST NDS AND WILL COMPLY WITH ALL N N-POINT' AIR HANDLING UNIT(TO I(LOW CPM)
SOURCE R'GI A ION. MECHANICAL FBB
AIR HANDLING UNIT(OVER IO,IX)OCFM) CONSTRUCTION TAX
S ramreo icanVQmtmcmr ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore ar handle haeardnas material HEATING UNIT(TO IIXkIX)O BTU)
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)P HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPDR 100,W0 BTU)
,.;mous air contaminants as defned by the Bay Area Air Quality Management TOTAL
Diarict4 BOILER-COMP(OVER Iphoto BTU)
,
Yes ❑No
I have read the htonadaus materials requirements under,Chapter 6.95 of the Cali- AIR CONDITIONER s ISSUANCE DATE
fomla Heu1N&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 m notify the occupant -'
of the requirements which mu be an
prion.k,moeeof a Cerfificte. Occupancy.
/r Owner or aulhunaed ages ate " TDTALt ISSUED BY: LA
✓ - �,,. OFFICE