S 0344 a —
APPLICANTTIS
OF GUPF.RILL I INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
BUILD INO-ELECTRICAL PE I'I'NO
BUILDING 111VISION APPLICATION/PERMIT PLUNiRING-htF.C11ANICAI' 0344
„BUILDING PROJECT IDENTIFICAfION
BUILDINGADDRESS SANI'I'AItYNO. APPLICATION SUBMITTAL DAPI
OWNER'S NAME: PHONE: - CONAC OR'.'NAMI?: LIC NO:
//� NIC CON'I'ROLX
/L to O
•�ARCIIHCcT/ENGINEF.R: LIC NO: ADD F'S: ❑
CONTACT. PHONE: 6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLUG E1 ' PLUMB MIiCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby vfErm mm I am licenaal under promalom of Chupmr 9(canvnmctng JOB DESCRIPTION
OetZ th Section]000)nf DivisianJofthe Business and Professions Cale.and my license is RESIDENTIAL
y�OO wo PERMIT ISSUANCP.
F W F to full farce and eReexln 7e< J— ❑SFDWh ❑KI'T'CHEN REMODEL
�zU License Class Link APPLIANCES—RESIDENTIAL ❑ADDIT'ION ❑PLUMBING RF.-PIPE
G 0. Date Gsencmf
ARCHITECT'S DECLARATION-
❑MODC1URN.
ZOr-Z I�mdersmndm,dorabshull Moused ospublasoenl+ PANELS MODIFICATIf1N
OZ�O IJP To 21q AMPS [I INTERIOR 0C HMNEY REPAIR
h•H�W Licensed l'mfessional 201-10MAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
' .�] OVER 1000AMP.Y ❑BATH 121!MGDI?IAREPAIR ❑UI:MOLITION
6 1 hereby,Scar that 1 am exempt from the Csomis C's License Low for the
xS O y U following babas.. arroutoo]m3L5,Business and Pmfdernel Cale:Any city nrbonmY SIGNS ELECfRIGAI. []OTHER
y13 tL F which re,,moo a permit m ca.the elfin impnrve,demolish nr rejoin any structure J
�O prion.hx issunnee.ulna reyuirep the applicant for such pcnninn floe signal xunemeot SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors Liccrec Law(chapter 9
1+l�aOC (commencing with SectimilfglolofDivision 3ofthe Businessand Professions Cove)nr TEMP.M13TER OR POLE INST. COMMERCIAL:
d p,m tG that he is exempt therefrom and the basis for the alleged exemption.Any violition of ❑NEW RLDG/ADDI HEN ❑DEMOLITION
iC t�
Section 7031.5 by any applicant for a permit subjects the applicant it)a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dollars(55110).
HZY wages sole OTHER IMPROVEMENT
pp Q ❑Laowner
k,the property.or my employees wilhebalos sale
le(Sec.cam,Business SWIMMING PIXll.1iLECl'R
y5�i0 will dothe work,and thestructureCo eisnots License
dos not apply to an Business OTHER
(yl m
and Pmfcssigns Cale:The Commcuds License Law docs rm1 apply to an owner of OUTLETS—SWITCHES—FIXS
a 3 property who builds or improves thereat,and who daes such work himself or through
his own employees,provided that such impmvmnenls arc not intended or offered far NEW RI?SIDEN1'IAi.ELISC'IR
sale.If.however,the mildingarimpmm
vcent is sold within one year ofcomplction,the SQ.FI'.FLOORPEA SISQ.FT.
re r,,bati]def will have the burden of proving that he did not build or improve far pur-
pow of salt.). ' r �1
1,as owner of the progeny,am exclusively connecting with licensed crnaneols m C01A1. JUL ^n`R v cit
construct on,pmjmt(Sec.70v4,Business and Professions Code:?The Conlmclurs
cense Low does not apply to an owner of property who milds or improves thereon.and QTY. PLUMBING PERMIT FEE
,ximmnOa
ach,unseen projects with atm.ass,i)license,]pursuai ,),hennlmror
nt the Ce 'e CI11yy
Ur uurth IIgU
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C far this reason
Owner Date ALTER—DRAIN&VENT'—WATER(1iA) VALUAHON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby union under penalty of perjury ane of the folbwin6 de,aaetinn+:
❑ I haveond xillaimamin a Cenifcaleof Cancan toself-insure for Warkce,G,mpen- DRAINS—FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
motion,as provided for by Section 3700 of the Labor Cale,for the performance of the
work for which this penton is issued. FIXTURES—PCR TRAP
0 1 have and will maintain Worker's Compensation Insurame,as remind by Section "
1]fq of the LaMrCWe,fonhe performance of the work far which this permit is issued. CAS—I?A.SYS'fEM-IINC.400TI.I7.TS OCC.GROUT' APN ,
My Wmkerc Compensation Insured <anero
ial Policy manda,,
Comer: fin>P Pali,Ne':��v � vis' SSC CAS—1?A.SYS]IN-OVER 4(EA)
C17RI'IFICATE OF EXEMPTION FROM WORKERS' GRF:ASFJINDUSTRh W'ASTI?INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
('Dtisuetine account he complemt if Nciammil is foronehundred dollar($100) GREASETRAP
nr
less)Missive
FEE
leenifythat in theperformaramoftbe work fnrwhich thiaperri tisissued,]shall SEWER—SANITARY—STORM HA.200 FT.
nut employ any person in any manner so as to bm
ecae subject m the Workers Certain. ENERGY THE
Zaz salon Laws of Culifomia.Dote WATER HEATER W/VEN'I'd;LECTR
Applicant t GRAVING Flit?
lA NOTICE TO APPLICANT':IL after making this Certificate of Exemption,you should WATER SYSTEht/IREATING
a '^ become suhject to the Workers Compensation provisions of the Labor Cade,you must SOILS FET?
G forthwith comply wink such pmviamour this permit sholi he deemed revoked. WATER SERVICE
aQ
CONSTRUCTIONLENDINCAGENCY. NEW RESIDENTIAL PLMII. 50.14, PAID
UO True Reecipt#
]hereby which
lire thatpermit
i is a ed Ses.ion lending agency for the perlimmenee of
the work for which this paomil is issue]fSa.3(19],Civ.C.)
� Fa Traders Name TOTAL:
0'U Lenders Address TOTAL:
BUILDING FEE
I emify the I have read this application send store the the eMwe information is
ow
kA rortem.l egreco omply with all ed,tnd county ordinances and smv laws rclmingm QTY, MECHANICAL PERMIT 1 FEE
U a' building construction,and hereby authorizerepresentotives oflhleeity to enmrupon the SI?EdvUC Il3I?
ahnve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the Cityof Cupertino again. ELECTRIC Plif:
( liabilities,judgments.casts and expenses which may in any way accrue again.said City A CI'ER OR ADD TO MSCI I.
+ in PhI1MRINC FEEnsequence ofthe granting oflhis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W TH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
MECHANICAL.FEE
SOURCE REGULATIONS.
AIR HANDLING UNI'P(OVER 111,000 CPM) CONS'fRUC'1'[ON TAX
Signawre of ApplicaMCourgenr ia MIAUtip HOOD IW/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
josdideopplicant or future miWingoecnpant saunter handle Immediate,material BEATING UNITG 0l0 RTU)
a defmN by the Cartoon.Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Seeing 2553200! HEATING UNIT(OVER 100,000 BTU) ,
0 Yex [J No V 17NTIL61'ION PAN(SINGLE REST DI PAID
Use Remiptx
Will are applicant or furore building occupant use equipment or arta which
.mit hazordnus air asmaminunts as Jclined by @M
c Bay Area Air Quality Management BOILER-COMP pHP OR IfN1,(sD 13T'U)
TOTAL,:
U
l ❑Yes ❑No
MOILER—COMP(OVER 100,000 BTU)
I
I have read the humanities materials nquirmtmnts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomis Health&Safety Code,Sections 5505,25533 and 255]4.I understand that if 11 NEW RESIDENT1AL MECIL SQ.FT.
building does not currently have a tenant,that it is any responsibility to unity the occupant E.
it]the requirements which must he met prior to issuance of a Cmidam of Ormpancy.
11,
Osmermouthodzedage.t DamTOl'AL: ISSUED BY: a
OFFICE