S 0223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING'ELECTRICAL PBRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAI. Q O A�]�j
BUILDING PROJECT IDENTIFICATION O GLJ
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL UATE
D9 70 1l 10 _?7
OWNER' N/C CONTROL#
N Ii: 1'110 ' CONTRA O AMB: NO'.
(` ARCHI E .NGINHER: LIC D: AD R S: ❑
CONTACT: V/ yfpNP.i�/ - BUILDING PERMIT INFO
V /✓(7/� /Y/ ❑ Consultant Fces Paid by Applicant(Initial) BLDG E1IFp' PLUMB M(G11
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter (commencing JOB DESCRIPTION
Z with Section 7000W Division 3MEhe Btemoscsand Professions Cade. dmy license is RESIDENTIAL:
FOO 'nfullforceandeR PERMIT ISSUANCE a ❑SFDWL ❑KITCHEN REMODEL
CQUkJIF- t
Ucense Cl is Cam APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
un4 L Date Cunwctor
I..Dw A CHITECCS I3ECLARA ON PANELS ❑MULTI-UNIT []STRUCTURAL
Z O 4 I understand my plans that[he used as public mcords MODIFICATION
OZ- UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
rl4tJ Licensed Professimod 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Syd ; mt OWNER-BUILDER DECLARATION OVER I000AMP5 BATH REMODEUREPAIR ❑DEMOLITION
��aa OC 6 I hereby affithat L um exempt from the Contractor's License Law for the
a O y U following rcesnv.(Section 7031.5,Business and Pmlexsions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
which requires a permit to construct,alter,improve,diminish,or repair any structure A
0 priortoitsissuance,also requires the applimm for tach permitmfileanigneJ statement SPECIAL CIRCUIT/MISC. C
f } that he is licensed Pursuantto the provium,.fthe Contractors License Law(Chapter 9 a
Ly�pO (commencing with Section 700)of Divisinn 3 ofthe Business and Profemlons Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 byany applicant fare pemutsubjcas meopplicmnun n civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y not more than five hundred dollars Wild). IMPROVEMENT
Q ❑ 1,mmvnerorihepropeny,ormyemploymswidtwages us their ante cnmpenstion, SWIMMING POOL ELECTRIC
O will doshe work,md the immune is not intended or offered fursule(Sec.7044,Business DOTTER
LAl and Professions Code 'the Contractors License Law does not apply m an owner of OUTLETS-SWIT L'S-FIXTURES
a 3.. property who builds or Improves theram,unit who does such work himself or.through
ON Own cmpinyece,pmvided'that suchimprovements arc nm intended or offered for NEW RESIDE A ELECTR SQ FI'.
sule.l[howevee the mildingor improvement lxsnld within one yemofcnmpletion,the
oSQ.FT.FLOOR AREA $/SQ.FT,
owner-builder will have the burden of pmving that he did nm build or improve for pur-
posc of sole.).
t
C]1,as owner of the prelim,,u celmi,ely contracting with licensed Immacmrs to TOTAL::
construct the project(See.7W4,Business and Professions Code:)The Contractor's Li- f
u Law does not apply to an owner of property who builds or improves theon,and QTY. PfB G PER FEE
who commcn for such Projects with o contractor(s)licen.sed pursuununtM1e Comrectnr's !!!
License Law, PERMIT ISSUANCE
1 am exempt under Sec. ,B ffi P C fur this reason
ALTER-DRAIN&VENT-W A ALOATION
Owner Da¢ BACK FLOW PR(TI'ECT.DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of Perjury one of the following declanotionc
❑I have and will maintain aCerificamof Conant mself-insumfor Workers Compen- DRAINS-FLUOR,BOOR AREA,COND, STORIES TYPECONSTRUC[ON
sation,as provided for by Section 371X1 Of the Leon Code,for the perfommnce of the
its for which this Permit is lamed. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700cfthelaborCe]e.for the performance nflm woit rt,
for
wwhhii0imis permt/issiissued. GAS-EA.SYSTEM-1 INC.4 oTrLEfS OCC.GROUP APN
My Camerhe� a nsy3tlsJy j;Buryy01"no YI yNN:-/07[�_ZXV GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIMDUSTRL WASTE INTERCEPTOR
(This sectiam iced not be completed Winepermit is fn ran ehandreddo11ars($100) 1 LNG DIVISION FEES
or less.)
GREASETRAP PfANC - 'E s
I certify that in the performance of the work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 ff.
not employ any person in any manner so as m became subject u the Workers Compen- ENERGY FUE
zZ satin.laws of Cidde mn.Data WATER HEADER WNENT/ELECIR
Applicant 1 GRAD \\\a
try NOTICE TO APPLICANT:IL after making this Cenificem of Exemption,you should WATER SYSTEM/IREATING
a bceome subject to the Workers Compensation ptavidons of the Labor Code,you must SOILS FEE
forthwith comply with such ponsWomarthis permit shall be deemed revoked. WATER SERVICE (\
� O CONSTRUCTION LENDING AGENCY NEW RESIDENT[AL PLMB. SQ,IT. PAID G\Date Receipt
I hereby affirm that them is a consuuctinm Icndi......ey for the Perfnnnmtee of
the work for which this pemtit is issued(Sec.3097,Civ.C.)
o I-'t Lender's No. T L:
V Lender's Address '10'fAl.:
4 1 certify that I have mud this opplicumn and state that the an...information is BUILDING FEE
List correct.1 agree to comply with all city and county ordinances and stole laws relating ,, QTY. MECHANICAL PERMIT PER
U71 building ennsnuction,and hereby authorim representatives Ofthis city toenterupon the SEISMIC FEB
above-mentioned prnpeny for notwetima purposes: PERMIT ISSUANCE.,
(We)agree to an.,indemnify and keep harmless the City of Cupertino against s I?LL'CTRIC FEE
liabilities,judgments.costs and expenses which may in any way oveme against said CityALTER OR ADD TO MECH,
PLUMBING FEEin consequence of the grunting of this permil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,00)CPM)
MECHANICAL FEE
SOURCE REGULATIONS. -
AIR HANDLING UNIT(OVER 111,000 CFM) CONSTRUCTION TAX
Signature ofApplamosCmdractnr Data EXHAUST HOOD ORMUCT) HOUSING MITIGATION
HAZARDOUS MA'D?RIAL,S DISCLOSURE
Will the applicant or future building occupmm score or handle haardous material HEATING UNIT(TO 100,1101 BTU)
as defined by the Cupenino hhowifal Gavle,Chapter 9.12,and the Health and Safety
Code,Section 25532a1? HEATING UNIT(OVER 101,001 BTU)
❑Yes VENTILATION FAN(SINGLE RESID) PAID
Uam Receipt#
e Wild the applicant
to or furore building by the Bl use equipment of devices which BORER'COMP UHP OR 100,001)PTU)
ran hazanlnus air comaminon¢as defined by the Bay Area Air Quality Management - TOTAL:
District? / BOILER-COMP(OVER U10,000 BTU)
❑Yes /I'r'f4
I have read the Incurious numerous requirements under Chapter 6.95 of the CanAIR CONDITIONER ISSUANCE DATE
(omit Health&Saf y Cale,Sections 25505,25533 and 255M.I understand stmt if the NEW RESIDENTIAL MECH. SQ.14. r G�
�fwllft
dingdrcssly haven mount,that it is my resparoibilitym mify th occupante m mast (pet#normissuancenfa Teri ycr or or m TOTAL: ISSUED BY:
OFFICE