B 0149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. 1 PERMITNO
BUILDING DIVISION APPLICATION/PF.RMIT PING FROG C`p IDEANICAL 50001 Z X8,014 9
BUILDING PROJECT III:NTIFIGTI(lN
BUILDING ADDRESS. / SANITARY NO. AI'PLICATION SUBMITTAL DATE
OWNERJ�AMP-:,OI` PI1 NF-: ow CTO NAME: CNO ]�
�W ` NIC CONTROL If
AR ECfIE '(NEE _ L NO: ` ADD / S: ❑ L�
NT,g/f; 4,�Q DC7 o PHONE: BUILDIN PERMIT INFO
[D Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�3
-92.4- n-� c:Y ES- 2'
LICENSED CONTRA OR'S DECLARATION QTY. ELECTRIC PERMIT FEF.
1 hemby affirm that I am liven.- under provisions of Chapter 9(commencing JOB DESCRIPTION
n�Z with Scction]B(I(B nfDivisionJofthe Business and Profeaaions Cude,mW mylicenseis RESIDENTIAL
�i100 PERMIT ISSUANCE
in full force and eRect. .L iZ ❑SFDWL ❑KITCHEN REMODEL
�UV License Class Lie.a APPLIANCES-RESIDENTIAL ��BTf]ON [I PLUMBING RE-PIPE
L.Z W Date Contractor a
N 6 at A1U1-TI-UNIT ❑$TRDCTDRAL
7y ARCHITECTS DECLARATION PANELS
Z65K lundersmndmyplonsshallheusediarsalourm'ds UP TO 200 AMT'S MODIFICATION
OZ-� ❑Im'ERIOR ❑CHIM NE REPAIR
f-s W Licensed Profesoored 201-10(10 AMPS IMPROVEMENT OSWIMMING POOLS
""$,$`s CC � OWNER-BUILDER DECLARATION OVER IIXNIAMP$ DEATH REMODEURF:PAIR 0 DEMOLITION
1 batch,affirm that I am exempt train the Contractor's License Law for the
kO L U following reason.(Section 7031.5,Business and Professions Code:Any city m county SIGNS IiLECfkICAL []OTHER
4�Q which myuires a permit m constmct,ultee improve,demolish,or rtpair any strvcwre
prinnnits issuance.esu reyuires the applicant for each pennino filcasigned xmtement SPECIALCIRCUITIMISC.
ytbut he is licensed pour,uonuo the provkhosiduac Contractors License Le.(Chapter s
aOC (commencing with Section 7")of Division 3 afthe Business and Professions Code)or TEMP,METER OR POLE INS? COMMERCIAL'
0,y n that he is exempt therefrom and the hosts for the alleged exemption Any violation of El BLDG/ADDITION ElDEMOLITION
^
I�il( 4• Section 7011,1 by any applicant far a proof subjects the applicant o a civil penalryof POWER DEVICES 0TENANT ❑FOOD SERVICE
I. N at more than rive hundred dallars(S50E. IMPROVEMENT
CZ^.QFl1,us owner of the property,or my amploy,am with wages as Neirsole compensation, SWIMMING POOL ELCCTRIC
will do the wark,and theshuctme,is nm intended counted foreale(Set.70,14.Business ❑OTHER '
W and Professions Code:The Contractors License Law deltanot apply to nn owner of OUTLETS-SWITCHES-FIXTURES U
0.3 property who builds ar impmves therein,and who does such work himself ar through
his own employees,provided that such Impmvemcros meant(mended.,offered far NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building arimpmverrom is sold within one year ofcompinian,the SQ.F`KFLOOR AREA 8(SQ,IT.
• owneohuilder will have the burden ofpraving thathedid notbuild orimpmvefarpmr
pass of aamJ. U
❑1,as owner of the property,am exclusively contracting with licensed contractors to q'OTAL: 7
construct the es not (Sec.o an Business and Professions Cade:)The Contractors rid
censeonwdtsforschplymun owner ofprnpens who
sedpnimpmves Contra.ond QTY, PLUMBING PERMIT FEE
who contracts for such projects with uconvunor(s)Iicenud pursuant to Ne Contractor's
License law. I I PERMIT ISSUANCE
l am exempt under Sec. ,B&PCforthismavm
ALTER-ORA IN&VENT-WA I'ER IEA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.UEVICF. D O
1 hereby atfrm under penalty of perjury one of the fiallowinsure log declauWarker iaos:
❑Ihave and will maimnineCmificem of Cnnsenuo ulf insure for Workers Compen- DRAINS-FLO(IR,ROOF,AREA.CONU' STORIES/ 'TYPE CONSTI(UC'1'[ON
sation,as provided for by Section 3700 of the Labor Gyle,for the performance of the
work for which this permit is issued, FIXTURES-PL'R TRAP a
F1 have and will maintain Worker
Labs Compensation Insuranceas required by Section' Y
Al
3100ofthe or Coda,for the perf0-8 cc urine work farwhichthis permit is issued. GAS-FA.SYSTEM-I INCAOUF1-ETS .GRO APN
My Worker yC iia vmnw ter and Policy numheram: Dq5-EA.SVS'fE -0
MVBRA(1!A)
Caricr. F Policy No,: Gil Y Ur 5+U- d
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHANDUSTRL WASTE iNfERCf:PIUR
COMPENSATION INSURANCE RLDING DIVISION FEES
[This section need nm he completed if the permit is rat handledW
ol lms(S 1001 GREASE TRAP
or less) toPLANC E FEB ..S' 7,
I certify that in the performance of the work for which this permit is issued,l shall SF.WER-SANITARY-S'fORM IA.21M)Ff.
natemploy any person in any mammy sn astir become subject to the Wnrkern'Compen- IiNERG E 2
Z sationlowsof California.Date WATER HEAL HR WAIENTIELECTR GRAD( GFF.F.
Applicant )
y NOTICE TO APPLICANT If,after making this Cenificam of Exemption,you should WATER SYSTHM/TREATING
become subject to the Workers Cmnpensatiun previsions of the Labor Code,you must SOILS Eli
W forthwith comply with such provisionm
s or this permit shall be domed revoked. WATER SERVICE
�ZCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID -
U Iherehy affirm Inthere iseconstmctian lending agency ranbe perfommncc of Dmc Recciprp
P the work for which this permit is issued(Sec.3(19"1,Civ.C.)
QU Lender's NameT
r AC:
W Lauder.Address 'FfTTAL:
Iy 1 certify that 1 have trial application a d dote tum the above informilion is BUILDING FEE ✓
C CW) correct.I agree toeamply with all ciryand emmty onlirean
acesd sure laws relating to QTY. MECHANICAL PERMIT FEE
Z building emmstructiogand hereby aehodze representatives of this rill a call'upon the - SEISMIC FEE
aha o-onot aped property far inspection pmpowes. PERMIT ISSUANCE
(We)agree mauve,unsoundly and keep mless harthe City of Caperton against ELECTRIC FEE
liabilities,judgments,crisis and expenses which may in any way acmm against said City AIA'I214 OR AILD TO MECH.
in PLUMBING FEE
atmospheric of the grvming of this pemdt.
APPLICAM17 UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IR(100CFM) MECHANICAL FEE
SOURC 'GUTA NS. (��
AMA
AIR HANDLING UNIT(OVER 10,1100 CPM) CONSTRUCTION TAX
br O
Sig alum of Appllcun ARD0r Dom li%IIAUST HOOD(W/DUCT) HOUSING MITIGATION IEE
AZARDOUs MATI?RIAL. DI ""RE
Will the applicant or future building oecup tare or handle harmdnua material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
HEATING UNIT LOVER I00,IHN1 BTU))
Code.Section 25532(m?
El Yes FIN. VENTILATION FAN(SINGLE RESID) PAID (lee RecallsN
)' Will the applicant or future building occupant use equipment or devices Which us deBOILF-R-COMP(3HP OR 100,1100 BTU)
emit hisiork air autonomous as find A.eby the Bay AAir Quality Management TOTAL:
District? BOILF-R-COMP(OVER 100,000 BTU)
❑Yes Fl No
I have mad the hmardaus materials mquimounu under Chapter 6.95 of the Cali- AIR CONDITIONER a IS SUANCE DATE O
forom Health&Safety Code,Sectiona 25505,25533:md 25534.I undara I that if the NEW RESIDENTIAL.MECH. SQ.ET.
building does mmcurmn0y haveamwnt,the it is my responsibility to meify the occupant
of the requirements which must ue met prior to issuance of a Cenificee of Occupancy. `)/�
Owncrorauthodecdogent Data TOTAL: a:1 ISSUED BY; �/ v&
OFFICE