S 0350 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 0350
['
BUILDING uTiRur inilyrIF'ICATION
BUIL DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
o xc, f7--28-F7
WN 'S NAME: PHONE: CO FACTOR'S NAME: / LIC ei �
�,
OWN.
CONTROLM
RCHITE /ENGINEER: LIC NO: ADORE ^ / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ I?' ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEL?
1 hereby affirm de
OO with Sethat 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
D0Z Section 3 of the Business and Professions Code,and mPERMIT ISSUAN
y license is RESIDENTIAL;
in full Ponce and effect. El SFDWL El KITCHEN REMODEL
CE
ly
�U�j License Class Lic.p ApPL1ANCE5-RESIDENTIAL ❑ADDITION RVMBING RE-PIPE
W Date Connector
F❑y ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑SIRUCPURAL
Z O y Z 1 understand my plans shall be used as public moors MODIFICATION
OZ p UPTO 200AMPS C1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT EjSWIMMING POOLS
OWNER.BUILDER DECLARATION OVER]"AMPS C)BATH REMODEUREPAIR ❑DEMOLITION
I hereby atGrm that l am exempt form the Contractors License Law far the
3 4 U following reason.(Section 7113 1,5,Business and Professions Code:Any city of county SIGNS ELECTRICAL C1 OTHER
LL O which requires a permit to cotmwm,alter,improve,demolish,or repair any structure
prions its issuance,also requires the applicant for such permit n file v signed statement SPECIAL CIRCU IT/MISC.
} that he is licensed pursuanua the provisions of the Contractor's license Law(Chapter9
EMI'.
QO (commencing with Section 7")of Division 3 ofthe Business and Professions Ctde)or I' METER OR POW INST. COMMERCIAL
Na p,o eC that he is exempt therefrom and the basis for the alleged exemption.Any viNmine of LJ NEW BLDG/ADD1710N ❑DEMOLITION'
m Section 7031*5 by any applicant far.Permit suldecrs the applicant too civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mart Nan five hundred dollars(SSW). IMPROVEMENT
C < []I,as owner ofthe property,or my employees with wages astheir sole atmpenaution, SWIMMING POnI.ELECTRIC
0a22GGwill do the work,and the structure is not intended or offered formic(Sec.764,1.Business ❑OTHIiR
d 3 and Professions Cale:The Contractors License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTUREf
property who builds or improves Intend,and who docs such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RF'_SIDEN'HAL ELECTR SQ FT.
sale.IL however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AR[i $/SQ.I'K
owner-builder will have the burden of proving that he did not build or improve far pur-
pose of sa]e.).
❑I,as owner of the property,am exclusively contracting with licensed contrarian to T A g�
construes the project(Sec.71F,4,Business and Professions CodcU The Contractor's Li- P A 1 ,D
cense Low does not apply m an owner of pmpcmy who builds or improves thereon,and QTY. PLUMBING PER EE
who contracts for such pmjats with a contractods)licensed pursuant o the Co muchn's � Q
Ltcensc Law. PERMIT ISSUANCE l-YY L t�j 8
❑I am esempr under Sm. ,B&P C for this moon
ALTER-DRAIN&VENT-WATER IEA) AI'IOry
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE YC/h �Urfff��/yp
1 hereby ll mai under penalty of perjury oneofthe insure it decWarerCo
❑Ihave and will dlforbinetion 37am of tumour Code,for to Wformace of the
URAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
order,es pro h thi far mi Barron 3710 of the labor Code,for the performance of rhe
work lin which this permit is issued. FIXTUliliS-PGR TRAP
❑ 1 have and La will maintain Worker's Come ofthe w rk for%In h required by Section
Jig-
J]a0of the lsahsr Coda for performance of the workforJlwh-ic[h�,this permit tats issued. GAS-1?A.SYSTEM-1 INC.40MtETS OCG CROUP AI'N
MyWoCartierr 's Cum `on sue�ae curie Policy NO. n`�K719 LJ GAS-IiA.SYR9'F.M OVER 4(1iA)
CERTIFIC TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIAINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissectionneednot becompleed ifthcpermit isfornnchundreddollars(5100) GREASETRAI'
or leu.) I'LANCHECK FEE
I certify that in the performance olthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.21X1 FT.
not employ any person in any manner so as to become subjectto the Workers'Campen- ENERGY FEE
,$ station Laws of California.Date WATER GRATER W/VENDELI.CTR
�/02 Applicant 1 GRADING FEE
oo NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTE117REATING
becomeh emoct In the Workers Compensation pmvit bol of the Labor voce,you most SOILS ITS,
� forthwith comply with such pmvisienx or this permit shall he Deemed reveled. WATER SERVICE
Q PAID
CONSem is acombustion
ON LENDING AGENCY NEW RESIDLN]'IAL PLMO. SQ.FT,
V O Uam RacipsN
Ihereby ichaffirm mi Permit
issuersSea 30lending agency fnrnhe perfonnnntt of
he work for which this permit is issued(Sec.3097,Civ.CJ
LL.f,' Lender's Name TOTAL:
{Kit Landers Address TOTAL:
I certify that I have rad this application and state that the above information is BUILDING FEE
f0./] correct.l agree to comply with all city and county ordinances and state lows relating to QTY. MECHANICALPERMIT FEE
V Z building construction,and hereby mararre representatives of this city to enter upon the SEISMIC FEE
.hove-mentioned property far inspection purposes. PERMIT ISSUANCE.
(We).give m arm
rove.indemnify and keep hless the City of Cupemimo against IiI.EMR]C F171
liabilittes,judgments.cons andexpee which may many way;wanm.guinst said City AITERORADDTOMECH.
in mme....cantor gra gofn ' ermit. PLUMBING PUT
APPLICANT UNDE ' AND.' D W OMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CPM)
SOURCE REGU NS. MF.CHANICALITE
AIR HANDLING UNIT(OVER 10/0I0 CFM) CONSTRUCTION'FAX
Sly6rdrol'Apillic,HAZARDOUS
for d Date EXHAUST HOOD OVMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building accapam store or handle hazardous material I[BATING UNIT(TO I(X).(M BTU)
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)Y HIIATI NG UNIT(OVER 100,000 BTU)
E]Via, ❑No PAID
VCMILATION PAN(SINGLE RESID)
Data Receipt
Will rho applicant or future building occupant use equipment or devices which
emit hmardous air contaminants
theBs as defined by the Bey Arca Air Quality Management BOILER-COMP(7HPOR 100,00 BTU)
TOTAL:
Disvim4
❑Yes ❑No BO]LER-COMP(OVER 100,000 BTU)
I have readthe hazsrdous materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
Earn Health&Safety Csde,Sections 25505,25533 and 2.5574.1 understand that if the NEW RESIDEM'IAL MECH. SQ.ET.
building does na currently have a tenant,ohm it is my responsibility m notify the uccupant
of the mquimments which must he met prim m issuance of a Certificate of Occupancy. 4--f-0.
Owner or authorized agent Data TGTA1- ISSUED BY:
OFFICE