S 0409 . APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING-ELEI'RICAI. PERMII'NO.
C
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 0409
BUILDING PROJECT IDENTIFICATION N
BUILDING ADDRESS: SANITARY NO. APPLICATION gUBMll9'Ah DATR
I� lcl `(n:1 1 o1L� D2 cvF�-n"NU CJ1 9so/L/
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: V
�oEtSQF l SE2 Y.S_ 996- 2633 4 vtl R. DA!_MAu cD raal.x
orRCHITECP/ENGINRER: LIC NO: ADDRESS:
829 7_'l�/41,16 R JLw� C. 9t6�
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BI. G ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELF.CTRICPERMIT FEE JOB'DESCRIPTION
1 hereby in.that 1 nm lieenied under provisions of Chapter 9(commencing
OZZ with Section Division 3 of the Business and ProfessioreCode.and my license is RR -SIDS
FOO ' full force and effect PERMIT ISSUANCE
ty� m ❑SFDWI, C3 KITCHEN REMOUEI.
%U�J License Class Lic.X APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y W Date_ Comructor ❑MULTI-UNIT El STRUCTURAL
ARCH TECTS DLCLARATION 0OZ l understand my plans shall be used as public records PANELS MODIFICATION
Z
0 - UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
dull Licensed Professional 201-ICMAMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER IWOAMI'S C3 PATH REMODELfREPAIR CDEMOLITION
1 hereby affirm that I am exempt from the Contractor's License Law for the
iq O�V following reason.(Section 7031.5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
r+'a 4.F' which requires a permit m conewct.alter,improve,demolish,or repair any nuvnum
Ib0 Priorm its iwuunce'likoreqaloe,theupplicam torsion permillu filcusigned stommem SPECTALCIRCUI'GMISC.
<X the he is licensed pursuant the p..vi.slnnsofmc Contractor's License Law(Chapter 9
W +p0 (commencing With William7000)of Division 3nfthe Busiroxximl Professions Culver or TEMP.METER OR POLE INST COMMERCIAL-
a p,^y that he is exempt therefmm and the basis for the alleged exemption,Any violation of ❑NF.W BLDG/ADDITION DEMOLITION
LXrI 4• Section]031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
>py„ not more than five hundred dollars($NM). IMPROVEMENT
?6 01asown,"d the Pro y,or my employees with wages as their.sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
O will do the work.and da.711uem.knot imenl,dor nRered forsale(Sut,7 W.Bialtless
.,,it Professions Cock:The Contractor's License Law does not.,ply to an owner of OUTLETS-SWI'I'CHE,S-FIXTURES
6'1^� progeny who builds or improves thereon,and who does such tinhimself or through
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R 5
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.I4.FLOOR AREA i/SQ.Fr.
owner-laildar will have the burden of proving that he did not build or improve for pur-
poseof sale).
❑1,as owner of the property,am exclusively contracting with licensed Contractors to TOTAL' PAI .
consumer the project(See.]044,Business and Professions Code:)The Contractors Li. t - P ry
cense law does net apply to an owner of property who builds or improves thereon,and QTY. PLUMBINCPERMIT FEE /
who contracts for such projects with a commeods)licensed pursuant to the Contractors AU
License Law. PERMIT ISSUANCE G
l am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) V
Owner Data ALTER
.e
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Qjp- T/A'
I hereby affirm under Penalty of perjury one of the following declarations: / 'I
❑ I have and will mountain aCeniOcare of Comcm to self-insure for Worker's Comoro. DRAINS-FLOOR.ROOF,AREA,COND. STORIES 'I'YI'ECONSTRUC'HON
anion,as provided for by Section 3700 of the Labor Cade,for the performance of the '
were for which rho,permit is issued FIXTURES-PER TRAP
r ❑1 have and will maintain Workers Compensation Insurance,as required by Section
37Ml of the laMrCone.for the performance of the work for which this permit is knord. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy Nu: GAS-EA.SYSTEM-OVER 4(EA)
f CERTIFICATE OF EXEM PTION FROM WORKERS' OREASFIINDUS'IRL WASTF.INTERCEP'rOR
✓ COMPENSATION INSURANCE _ BUILDING DIVISION 13EFS
(Thissetion need not be completed tithe permit is for one hundreddollars($100) GREASE TRAY
or less.) PLANCHECK FEE
I certify the in the performaweof tine woo for whicM1lthis permit is issued,ishall SEWER-SANITARY-STORM EA.2g11T.
notamploy any person in any manner so as D tbJ n n Workers'Compen- ENERGY FEE
z sation Laws of Condo .Dam WATER HEATER WNENT/ELECTR
Applicant ��✓'— GRADING IPE
X. y' NOTICE TO APPLICANT:If,after making this CenifiLle of Exemption,you should WATER Sys rFA/fREATING I SOILS FEL?
a hcome subjed In the Worker's Compensation pmvismo,of the LuMrr Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Da Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT, PAID
L) 0 ihercby aHirtn thauhcre isaconntmnion lending agency for the perfomunce of Date filis Rttci X
F the work for which thin permit is issue)ISec.309],Civ.CJ
Q Lenders Name TOTAL:
Lender'a Address - TOTAL'
I certify the 1 have read this applicutinn and state that the above infnrmatidn is BUILDING PL
LSO correct.l agree to comply with all city and county ordinances and statute laws relating to QTY. MECHANICAL PERMIT FEE
6,1 Z building construction.and hereby authorize repmwomives ofmis city to enter often the SEISMIC FINE
above-mentioned property for inspection purµrses. PERMIT ISSUANCE
(We)agree to save,indemnify mW keg owners-Ne City of Cupeniou against ELECTRIC W?F.
liabilities,judgments,costs and expcnsn which may in any way accrue against said City ALTERORADOTOMECH.
PLUMBING FEE
A consequence UNDERSTANDS
Sthisp Wln - - -
APPLICANT UNDERSTANDS AND WIL OMPLY WITH ALL NO -POINT AIR HANDLING UNIT(TO IQIXId CFM) MECHANICAL E
SOURCE REG ATIONS. -
'�� AIR HANDLING UNIT LOVER 10,000 CFM) CONSTRUC' ON TAX.
Y Si of Appiicaot/Contrador - D Date EXHAUST HOOD(WMUCD HOUSING ITIGATION FEE
HAZARDOUS MATERIALS DISCLOS RE
Will the applicant or future Wilding occupant store or handle honoous mmerial HEATING UNIT(TO 100,11110 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Codc,Secuum 2553200? HEATING UNIT(OVER 100,00)BTU) IF
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
- Dom - Receipt x
Will the m future building occupant use equipment or devices which BOILER-COMP Olin OR 100,OIXI HTU)
emit Wondrous airit contaminants
minants as defined by the Bay Ates Air Quality Management 'I OTAL:
Dlstne] BOILER-COMP(OVER Iffl,001 BTU)
❑Yes ❑Ne
I have readthe hamrdausmaterial,requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISS NCE DATE
famia Health&Safety Code,Sections 25501,25533 and 25534 1 understood that if the NEW RESIDENTIAL MECH. SQ.FT.
building doe,nm eurrendy have a tenon,that a is no,responsibility m notify the c..Paut
of the requirements which must M met Her to kor oa ce of a Cenilicate of Oce imu cy.
Owner or authorized agent Date TOTAL: ISSUED!11Y'.
OFFICE