S 1150 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF fr N0
BUILDING DIVISION - APPLICATIONXERMIT PLUMBING.MECHANICAL 1150
- BUII.DINGI'ROJECTIDENTIFICATION
BUILDING
.wwAD11DDR�RESS; \ SANITARY NO. APPLICATION SUBMITTAL
DATE
CC l11
Ilu
9#-rMn ru� 1ma ONES=,2� 1 CONTRACfOk'S NAME, LIC NO: SEC CONTROL#
-� ARCHITECT/ENGINEER: - LIC NO: ADDRESS: - ❑
tiGNTACT ONE BUILDING PERMIT INFO
nny �i>.wa�l Prl O. oL 3
I � „ U San pasOl ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL LMB MECH
vt�r Pv.t„sho O O ❑ � .❑
LICENSED CONTRACTOR'S DECLARATIONQT'Y ELECTRIC PERMITY FEE
i hereby affirm that I am licensor under provisirns of Chapmr 9(cmmmencins " .n JOB DESCRIPTION
Da'L with Section 9000)of Divisinn3 of@n Business and Rofeaninns Cmlc,and mylieenseix RESIDENTIAL:
F�� in full forromm effctl. PERMIT ISSUANCE
W - ❑SFIWI. El KITCHEN REMODEL
�Uyy Vx LicenClass Lia# APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
Z 6 G Oare Common,
1..7'/) ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
oz UP l.nderstand my plana shall he records as public recos MODIFICATION
UP T021XIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�{qFW Lt,r,;ed Pmfoseional 201-1000AMP5 ROVEMENT E]SWIMMING POOLS
S 2,i OWNER-BUILDER DECLARATION OVER IIKI(1AMPS TH REMODEVRh;I'AIR DEMOLITION
r�CE W�6 1 hereby affirm that I am exempt from the Contractor's License Law for the _
W 3 IL U following reason.(Section 7031.5,Business and Professions Cade Any city or county SIGNS ELECTRICAL ❑OTHER
k Fv� which requires a Doinit to tonslmcl,alter,improve,demolish,or repair an)slo cture
F�yOy prior to its issuance,also tedium(he applicant for such permit it)filen signed statement SPECIAL CIRCIIT/MISC
kJ that he is licensed pursuant to the provisions offm Contractors Licence Law(Chapter 9-
��QQ (commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INS'L COMMERCIAL:
6 q o N that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W"m
Section 71131.5 by any applicant for a permit subjects the applicant m.civil penallyof POWER DEVICES [-]TENANT ❑FOOD SERVICE
F iy oat more than five hundred dollar,($500). - IMPROVEMENT
Q ❑I,ae nwnerof lite properly,ar my employees with wages as their mle compensation. SWIMMING POOL ELECTRIC
FQ will detho wsmk,and the structure is not mated,dimm'srcd far sale(Sri.9044,Bushes _ ❑OTHER
and Professions Code:The Committees License Law does net apply into owner of OUTLETS-SWITCHES-FIXTURES
4i property who hands or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or olfered for NEW RESIDENTIAL E TR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FI�
o v,s r-bodder will liam the burden of proving that he did not build or improve for pur-
pove of sec').
❑L as owner of the property,am exclusively contracting with licensed commemrs m TOTAL: P AlM D
construct the (See 7044Holiness and Professions Code)The Cmaracmr's Li- - -
cense Law does net apply to an owner of property who bullas or improves thereon.and QTY. PLUMBNOP FEE'
who communta or_sueh projectswith scontractor(s)licensed pursuant to the Contractor's ��� v Q ANS License Law. PERIOD'ISSUAN
❑lam axe. adiFfSo ,B&PCforthisrealme - -
Owner Date ALTER-DRAIN&VE ER(FA) - VA UA'1'ION
Ut— Uj VffU I1O
WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVI
I hereb firmunder Penalty of perjury one oftbe folmwtng......... ...
❑Ihave and will mvmmaln aCenificateef Qs..cut bvel4imme,firs Workers G,mpen- DRAINS-FLOOR,ROOF,AREA,COND.
sumion,as provided for by Section 37")of the Labor Code,for Onto performance of the STORIES TYPE CONS'fItUCTION
work for which this permit is issued FIXTURES-PER TRAP .,
❑ 1 have and will malnmin Workers Compensation Inwmnce,as inquired by Section
3900ofthe Labor Code,for the peinummor.f Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Weakens Compensmien Insurance noontime Policy number aid
Carter: Policy Ism, GAS-EA.SYSTEM OVER 4 MA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF9INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(TI'xsectimiced not be compleled FIN,permit's Temno hundred dollars($I00) -
mho".) GREASETRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM BA 200 FT.
not employ any person in any manner so as to become subject la the Wmbo,'Compcn- ENERGY FEE
O Z satin.Laws of C.1hurniv.Date WATER I IEAFER WIVENT/5LF.CTR
Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this a C ar oficate of Exemption,you should WATER SYSTEM/BEATING F' become,object m the Workers Compensation pmv s of the Lahor Code,you ams, SOILS FEE
W >� R..hwim comply with such....kimns nr this pennitehnll be deemedrevoked. WATER SERVICE
Q y
CONSTRUCTIONisLENDINGAGENCY NEW RESIDENTIAL PLM9, SQ.FT. PAID
V Q Th [B
ereby emvhm thereemis oumvtmnion lending agency for the perfarmaneo til Dole cel #
LL H the work for which this Permit is issued(Sec 309],Cis.C.)
O Lender's Name TOTAL:
0. Lenderanddre. TOTAL
1 toffy that I have read this nppliwlinn and some that theabnve inforlazai n is BUILDING PEE
.�". h corut.l agreemoe,mply withml airy and coumyofinancrs vnasmm htwsrelating to QTY. MECHANICAL PERMIT . FEE
U z building construction,and hereby authorize representatives uflhis city to enter upon the - SEISMIC FEE
alxwe-mentioned property for inspection pmpores.
(We)agree'.save,indemnify and keep harmless the City of Cupeninoagalnsl PBkMI'1'ISSUANCB ELECTRIC FEE
- lizbililiev,judgments,costs and expenaes which may in any way acerae against sodCity ALTER OR ADD'10 MECH,
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON IT(TO I(L"CFM)
MF.CHANICAh Fli
SOL�\\ERF��p{J.ATIONS..e_{�_("I� '\
AIR HANDLING UNIT(OVER IO,IMN)CFM) CONSTRICTION TAX
Signaturai,fApp"ant/Conlmctor Dam /ll EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
AZARDOUS MATERIALS DISCLOSURE
Willth li til or fummbuilding ocenpant more nr handlelmzadonsmmed.1 HEATING UNIT GO 100,0I0 BTU)
as defined by the Cupertino Municipal Cade,Chapter Alt,and the Health and Safety -
Code,Section 25532md? HEATING UNIT(OVER 100,000 B'I'U)
7 Ycs ON. VENTILATION FAN(SINGLE RESID) PAID
Dme Receipt#
Will rd the applicant or b;a building by the B use equipment or devices which BOILER-COMP(3HP OR IN),000BTU)
mil hazardous air contaminants ea defined by the Bay Aren Air Quality Management TOTAL:
Dialncl°. - BOILER-COME(OVER INDXa)BTU)
❑Yea ❑No
�. I have read the hazardous materials requiremenls under Chapter 6.95 of the Cali- AIR CONDITIONER _ ISSUANCE DATE
forma Health At Safely Code,Sections 25505,M533 and 25534.1 understand them if 0e NEW RESIDENTIAL MECH. SQ.FT.
building does not urrently have a levant,that it is my responsibility to notify the occupant
of the mquircmnents which most le mel prier to issuance of a Cenificate of Occupancy.
Owner or authorized agent Dme TOTAL: ISSUED BY:
OFFICE