S0001 B 0170 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 50001 5-10170
BUILDING PROJE6T IDENTIFICATION .[.�
BUILDINGADDRESS: SANITARY NO. APPLICCATIO MIMALDDATE
^
NL'N' NAME: PHONE COIA- OW'S,NAMF.: LIC NO:
(S N/C CONTROLp
t ARCHITECT/ENGINEER: LIC NO: AI37RE1S: ❑
CONTACT: PHONE: BUILDING PERMIT INFO_
❑ Consultant Fees Paid by Applicant(Initial) BLDG [LEC p1.UM MEC
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby aRrm that 1 am license under provisions.(Chapter 9(commencing JOB DESCRIPTION
CCz with Smion]quddDivision 3ofthe Business and Professions Code,and my license is RESIDENTIAL;
I-IfBIO PERMIT ISSUANCE
04""0 in force`std eR� - ❑SFDWL ❑PLUM KITCHEN REMODEL
<UU License ss Co.M ppPLIANCL•S-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
t-. yI Date Contractor
Fly ARCHITECTS UPCL AT N PANELS []MULTI-UNIT [I STRUCTURAL
ZO't2„Z, Inndenawd my plans shall be well ns public records OP T0200 AMPS MODIFICATION
OZ- ❑INTERIOR ❑CHIMNEY REPAIR
[r.4 Licensed Pmfe>simel 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
C
NJ OWNER-BUILDER DECLARATION OVER 1000 AMPS C1 BATH NEMODEIIREPAIR ❑DEMOLITION
jj I hereby affirm that I am exempt tram the Contractor's License Law for the
Following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL [I OTHER
t 1i '3 w y
a which requires a permit to construct. wnm
et.alter,improve,demolish,or repair any su \ O 9-t J
tzp
Oprior toits issuance,also requires the applicant for such Permit o file a signed statement / SPECIAL CIRCUIT/MISC.
ythat he is licensed lormaatto the pmvisionsofthe Contractors License law Chapter
p'p0 (cammeming with Sexion]000)of Division 3ofthe Business end Pmfcuion,Cod.)or TEMP.MEI'GR OR POLE INSt -COMMERCIAL'
a d p that he is exempt therefrom and the basis fm the allrge exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
W Section]031.5 by any applicant for a permit mbjan the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
I- not mom that five hundred dollars(45IXB. IMPROVEMENT
f G �I,as owner of the property,or my employees with wages as their sole man oration, SWIMMING POOL ELECTRIC
p( willdap,work,and the structure is nm(marded or offered for sale(Ser.7044,Business []OTHER
a and Professions Code:The Contractor's Liman law does not apply to an owner of OUTLETS-SWITCHES-F TU ES
properly who builds or improves thereon,and who diva such work himself or through
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELEC9' SQ FT.
sale.IL however,the building or improvement is sold within one year of completion,pe SQ.FT.FLOOR ANDA SISQ.FT.
owncrbudder will have the burden of proving that he did not build or improve for pur-
Lu ss of sale.). / -
❑ I,as owner of the Property,am exclusively contracting with licensed comraxno to T k[! ��
construct the projat(Ser.TIG,Business and Professions Code:)The Contractors Li.
cense Use does not apply to an owner of property who builds or improves mere.nand QTY PLUMBING PERMIT FEE
who contracts for such projects with a co mucamo)license pursuant o the Conwcmrs ((��
Limme law. PERMIT ISSUANCE 5D
❑1 am exempt under Sec. .B&P C for this neuron
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent usself-insure for Worker's Common. DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
satlon,us provided for by Section 3]0(1 of the Labor Code,for the performance of the
work for which this permit is issue. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Sexton
3 I ofthe Labor Cmfe,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40U OCC.GROUP APN
My WarclL�s oat gji ffiycecarrier and Polis 111165(1. GAS-EA.SYSTEM )
Cartier.7 i—T\1 Polis Nn.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GRLASF/I RL WA. NTLiRCEPTO
COMPENSATION INSURANCE BUILDING DIVISION FEES
(lbissection dad not hecompleted d the permit is broom hundte dollars(s 100) GREASETRAPo VJ_
or Ices) PLANCHGCK FEE
I certify that in the performance ofthe work for which this pemtit is issued,I shall SEWER-SANT ' -S'S A.200 IT.
not employ tory proud in any manner so as ,,haceme subject m the Workers'Cumpen- ENERGY FEE
satian Laws of California.Data WATER HEATER ENT/ELECTR
f GRADING Fl3E
Applicant
N NOTICE TO APPLICANT.If,after making this Certifirnte of Exemption,you should WATER SYSTEM? iATING SOILS FEE
C" become subject to the Workers Compensation provisions of the tabor Cade.you must
Ikl r�� forthwith comply with such Provisions ambit permit shall be deemed revoked. WAGER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT PAID
L)0 l hereby affirm that there is a conswdion lending agency for the performance of Dole aeig.8
f" the work Permitsu
ha which this Permit is issued(Sae 3(19],Civ.C.)
LI, Lenders Name TOTAL: o TOTAL:
Lenders Address .O
I certify that I have read this application sad state that the above information is BUILDING FEE
LrA enrrem.l ugreemenmply with ell city and county ordinances and nate laws relmingm QTY, MECHANICAL PERMIT FEF.
building construction,and hereby ampoule,rcpimum,tim,of this enyo,emerworthe gEISMIC FEE
stru
above-meminned property far impeepon pnupnsos. PERMIT ISSUANCE
(We)ngrce to save,indemnify and keep harmleas the City of Cupertino againG TiLECIDUC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE
in consequence of the smiting of this permit.
ApPL CANT UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Luton CFM) MECHANICAL FEE
S H kGULAilONS.
AIR HANDLING UNIT(OVER 10,000COM) CONSTRUCTION TAX
,ig u ApplicwVCGnMct" ate EXHAUST HOOD IW/DUCIT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slam or handle flounders ar
lers mebil HEATING UNIT GO 100.000 BTIB
os pert
defined by the Cupertino Municipal Craft.Chapter 9.12,and Ne Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER IOl BTU)
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Dam RImptp
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR HI(I,(50 RTU) ''']
emit huurdous air contaminants as define by the Bay Area Air Quality Management a. f 1.
Distrix] BOILER-COMP(OVER 1ul l BTU)
❑Yes Fl No
I have read asa
the hrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER s ISSUANCE DATE
forma Hwlda&Safety Code,Sections 25505,25533 and 25534.1 understand that Base NEW RESIDENTIAL MECH. SQ.FT,
builbrifd.norpromdybaveatenarn,Petit ismyinaloreibilitymmdfytkottupant
Of the requirements which must he,ton Friar to Laurence of a Ceninw¢of Caere
Owner or whomagent Dam
ee TOTAL: ISSUED BY: J D
OFFICE