29816 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
PBU�ILD�INGADDRESS:
RTINO o BUILDING-ELECTRICAL PERMFFNO. 2 9 81 6
ISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L V4 �X! lY/�
BUILDING PROJECT'IDENT'IFICA'TION
S. SANITARY NO. APPLICATION SUBMITTAL DATE
p PHONE: CONTRACTOIfS NAME: LIC NO'.F- �SG Oe—y — )Z'j_ N/C CONIAOLp
ARCIi1TELT/ENGINEER: LIC NO: ADDR17SS: ,
CON'rACr: PHONE: BUILDING PERMIT INF
/'+.fes ❑
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEB
I hereby afrrm that Into f(beRi volar proviaoaa of Chapter v(rommerems JOB DESCRIPTION
00 with Section 711f1I1)of Division 3 of the Business end Pndessinna Code,and my license is
PERMIT ISSUANCE RESIDENTIAL
I. in full farce and effort.
aUZILr Lim, aClass - Lie Or ❑SFUWL [I KITCHEN REMODEL
�Q Date - Contractor APPLIANCES-RESIDENTIAL ❑ADDITION - - ❑PLUMBINGRE-PIPE
F7 mPANELS ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O >❑ I undvcaand my ns plashall he used os public records .MODIFICATION
OZO UNTO POO AMT'S ❑INFERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000A1PS IMPROVEMENT
ay+� OWNER-BUILDER DECLARATION AVER LIN ML'S
"+Cf Yhercby affirm Nat 1 am exempt from the Contractor's License Law for the El BATH REMODEUREPAIR (]DEMOLITION
3 a U following reason.(Section 7031.5,Hmelress and Professions Cole:Any city or County SIGNS ECTRICAL ❑OTHER
LLC which requires a permit to construct,aher,impmvv,demolish,or repair any shucmre _
prior to in issuance,also militates the applicant for such Permian file a signed statement SPIA LCIRCUIT/MISC.
ysy} that he is licensed pursuant the provisions of the Convector's license Low tt
19 In (commencing with Section700B of Division 3 of the Rosiness and Professions Code)or EM . �TEBORPOLEINS'E COMMERCIAL:
ere
a y o K that he is exempt thfrom
and the huffs for the alleged exemption.Any violation of EINE BLDG/ADDITION ❑DINOLITION
..ySection 7031.5 by any applicant for a permit subjozs the applicant to a civil penalty of POWER DEV El TENANT ❑FOOD SERVICE
F z y not more Nan five hundred dollars($Sotq. IMPROVEMENT
SQ C1,m owner of me property,or my employees with wages as their sole compensation. SWIMMINGPOOLE -C7HUC
will do the work,and the structure is not intended mothered for sale(See 7044,Holiness ❑OTHER
' and Professions Code:The Contractors License Law does not apply to an owner o1OUT ITCHES RES
pmpcny who huilds or improves Nercun,anJ who doe such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW Al PIAL I7LEMR SQ P.
salt.If.however,One building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FF.
owner-buitdcr will have the burden of proving that he did not build or improve for F ur-
pose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:57_ ,
construct he project(Sec.7144,Business and Professions Code:)The Cnnuacwr's Lt.
cause Ls,does not apply it)an owner of property who huilds or improves thereof,and QTY. PLUMBING PERMIT FEE
who connums for such projects with a conwcludid licensed purauantfo the Connommr's
Licenw law, PERMIT ISSUANCE
❑ 1 rim exempt under Sec. ,R&P C for this reason
Owner Dae ALTER-DRAIN&VIiNT-WATER(HA) VALUATION
WORKER'S COMPHNSAI'ION DECLARATION BACK PLOW PROTECT'.DEVICE
I hereby affirm under penalty of perjuryane of the following declarmimax
' -1I have and will maintain a Certificate orComent to self-insum for Workers Conlon. DRAINS-FLOOR.ROOT.AREA.COND. STORIES TVPE CONSTRUCTION
Minn,as pmvlded for by Section 3900 of ton Labor Code,for the perlbnnarce of the
i. work for which this permit is iuucd. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Cale,for the performance of the work for which this Permit is issuW. GAS-HA.SYSTEM-I INC,4 OUTLISI'5 OCC.GROUP APPS
My Workers Compensation Insurance tardier and Policy number are:
Carrier: Put icy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASULNDUSTRL WASTE INTERCEPTDR
(This section need not be completed iram permit is for one hundred dollars(SIM) BUILDING DIVISION FEES
or less) GREASE I'RAI'
1'LANCHCCK IrEE
Icerify that in the Performance of One work lorwhich this Permit IS is issued,Isbell SEWL'R-SANITARY-STORM EA. FT.
nm vnrploy any n any mann }}pps mpacqgto nW�c i the Workcri Cnmpen ENERGY FP.0
,Z satiun Laws n i n D t e 7 T L / —1
ars r
O Applicant rY9 LaI {'(�5 C WATER HEATER WNENT/ELECTR
O
o GRADING PEE
f�q NOTICE TO APPLICANT:IL after making this Cenllien a of Exemption;Y.L.should WATERSYSTCM(TREAI'ING
a; become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
LkI forthwith comply with such Provisions or this Permit shrill be deemed revoked WATER SERVICE
Q
� Z CONSTRUCTION LENDING AGENCY s NEW RESIDENTIAL PLMB. SQ.14. PAID
I hereby affirm construction there is a consetion lending agency for the performance of Date ReceiptM
me work for which thLs permit is issued(Sec,31197,Civ.C.)
U Lenders Nanta TOTAL:
Lender's Amlrcns TOTAL:
1 certify that 1 have read this applicalinn and atom that the above informmom is BUILDING FEE
CA correct.I agree in comply with all city and county ordinances and mate laws relating t0 QTY, M17CHANICAL PERMIT FEL?
U buildingconsttnmion,and hereby authorize reprcsenniivesof Nis city to enterupnn the SEISMIC FEE
atnve-mentioned propery for inspection purposes. PERMIT ISSUANCE
(We)ngrte msave,indemnify and keep harmless the City of Cuprti
eagainst ELECTRIC Fri... 5
liahilhies,judgmenrs,cos",rad asticaes which may many wayaccom ii,mosletid City ALTER OR ADD TO MECH.
in rotNLIFam min of is permit. - PLUMIIING PEP.APPLDE TA DS ND WILL COMPLY WITN ALL NONd'OINT pIR HANDLING UNIT(TO 10,0K1 CFM) MLCHANICAI.FEE
ATI t S.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCr10NTAX
Signw nl Applicant/Contrm or Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicam.,far..buildingnecupnntsom or handle hazardous material HEATING UNIT(TO 100,(10(1 BTU) 1, •` 4
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety 61 �Y
Cala Semon 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑YesNo VENTILATION FAN(SINGLE RESIDE PAID
Rc ei
0511 the applicant or future building oecupam mm cgoipmem or devices which
emit hazardous air contaminants as defined by the Be,Area Air Quality Management BOILER-COMP(THE OR 101,000 BTVI TOTAL:
District] /+ITV fir r.l .,I...,,
Yes HOILIiR-COh1P(OVCR 101.11(0 BTU)
L have made h m ads],requirements order Chapter 6.95 of the Cali- AIR CONDITIONER ' •'" - ISSUANCE DATE
fomi -ala &Safer ode Sada s 25505,VEB3 and 25534.1 an J rand tl t if Ne NEW RESIDENTIAL MECH. SQ.FT.
bni in d, snot cu n YM1u cute m.Nat h is rnyorSiomihirnymm lythe capon,
of e m tbe am to issuance of a Canine fOcc ancy
z
Ow er or emhorized agent ate TOTAL: ISSUIiD BY.�_ L'- RJ CC• r
OFFICE