31488 APPI�,.OTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT.PEN ONLY
CITY UPERTINO BUILDING.ELECTRICAL PERMITNO. J[^ 1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING AOORESS: /� SANITARY NO, APPLICATION SUBMITTAL LAG
Rasp, 2 . kt C7 �l2d l
OW(7LR'S M6: PHONE: C T AC ORIS NAME LIC NO:
K N/C CON'ROL#
RCHTTECf/ENGI ER: LIC NO: DDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB EC
❑ ❑
LICENSED COMRACTOR'S UCCLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm thin I am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
OW with Stella.l(g�l)nf Division 3oftbe Business and professions Codc,and my license is
W O PERMIT ISSUANCE /-yY RESIDENTIAL
UIn full force end aft, �z'(� lJl!
Lice v -Az Lia.N _ ❑SFDW L ❑KITCHEN REMODF.1.
MUS Dam ` S 1 C�nt� or APPLIANCES-RGSIDENTAI. ' ❑ADDITION ❑PLUMBING RE-PINE
(.,pmARCHITECT'S DECL AON ❑MULTI-UNIT ❑STRUCTukAL
2> W srecordsZOv G Iunderstamy plans all be used as public records s MODIFICATION
OZF�q I UP'f02110AMPS
FEntW Licensed Professional ❑INTIiI210R El CHIMNEY REPAIR
201d1NXtAMPS IMPROVEMENT
�aX'4,1 OWNER-BUILDER DECLARATION OVER]"AMPS ❑ ATH0. EP ON
y Ga 1 hereby affirm Nm 1 am exempt from the Contracmr's License Law for the
Sd a 0.V milowing.act.....(Section 7031.5,Business and Professions Coda,Any city or county SIGNS ELECTRICAL �HF.R /
47 WO which requires a.amort m cnnswct,alter.improve,demolish,or repair any strucmreo ��''
primm its issuance,also requires Ne applicant for such permifto Olaridgned smmment SPECIAL CIRCUIT/MISC.
ythat he is IicenceJ pursuant to the provisions of the Commences License Law(Chapter 9
GO (commencing with$emion].NNp of Division 3 ofthe Business and Professions Cartel or THMP.METER OR POLE INST. COMMERCIAL
d qe that he is exempt therafrom a.d the bmis for the alleged excmpiin i.Any viohnational. El NEW BLDG/ADDITION ❑DEMOLITION-^,m Section]031.5 by any applicant for a pandit subjects the applicant to a civil penalty of POWER DEVICES
or
not me than Bve hundred dolIms $500). ❑TENANT ❑FOOD SERVICE
F?6 E] 1.as owner ofthe pmpetfy,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
th
G willducwurk,uudthe structure ie not mended or.:'fared for sole(SccJ044,liusinese ❑OTHER
3� and Pmfessions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employea......idea that such improvements am oat intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one your ofcompletion,the r- SQ.FT.FLOOR AREA VSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun.
0 1 of salene
❑Lmi as the ofthe d(Sce.cny,a exclusively contracting Cob:)I tie licensed contractors i. 'TOTAL:
amswct the projeci(Sec.]fK4,Business and Professions Cale.The Contractor's Li.
use Law does not apply m an owner of property who builds'or improves thereon,and QTY. FIX&B-IAGPERMIT FEE
who contracts for such pmjems with a comractons)licensed pursuant to the Conaonofs
License Law.
PERMIT I N E
�f ❑1 am exempt under Sec. B&P C for this reason
a� ALTER- RpNT- VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK IpLOWP(0drVHVICE
T hereby affirm under penalty of perjury one of the following declarations
] I have and will maintain a Certificate of Consenuto self-insure for Workers Compen- DRAINS-FLOOR. 00 REA,39OND. STORIES TYPE CONSTRUCTION
\S .don,as provided for by Section 3700 ol'the Labor Code,for the perform......... -
work for which this permit is isued. FIXTURES-PER TRAP 71
Khave and will maintain Workers Compensation Insurance,as mqutred by Section
otula Code,for the Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wm Fensmiou I trier and Policy nu _
Carnia I o y , Policy No.Zz ����, GAS-EA.SYSTEM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMINTBUSTRL WASTE INTERCEPTOR
(This section need not he completed Ifma permit is for one hundred dollars($Into BUILDING DIVISION FEES
m less.) GRF.ASF:TRAP PLANCHIRCK FEE
Icerifythdimhe perfomtanceof thewmkfm whichmis Pemdt isissued,l shall SIiWi?R- ANITARY-STORM EA.2W FT.
but employ any person in any manner so as m become subject In the Workers'Compen- - ENERGY FEE
O ,Z ..tion Laws of Califomit.Data WATER HEATER W/VENT/ELE:CTR
O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Ccnifica¢of Exemption,you should WATER SYSTEMOREATING
abecome subject to the Workds Compensation provisions of Ne Labor Code,you must SOILS FEE
W forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENT[Al.PLMB, SQ.FT. PATO
U I here by emthi Nanhereisoed(Sec,
lending agency funhe performance of Date Receipt If
F the work for which this permit is issued(Sec.J09],Civ.CJ
DU Ledeis Name TOTAL:
Leader's Address 'TOTAL:
py, 1 certify that 1 have read this application and state that the above information is BUILDING FEE
VJ correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHAMCALPERMIT FEE
U building construction,and hereby anthamiu representatives ofthis city to enter upon the SEISMIC FEE
shove mentioned property for inspection purposes. ,
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiahilities,judgmenu,costs and expenses which may in any way.cane against said City ALTER OR ADD TO MECH.
n consequence of the Standing of this permit. PLUM BING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CF&D
SOI REGULATIONS. MECHANICAL FEE
5 AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTTONTAX
Si a orApplicantUoutracus to EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATEMAI.,d)L CLOSURE
Will the applicant or future builJingoccopem store or handlers omasmmenal HEATING UNIT(I'D 100,000 BTU) �,Ov
Code.defiMd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.3e.dinn 25532(01 HEATING UNIT(OVER 1011,001 BTU)
❑Yes 0 N VENTILATION PAN(SINGLE RESID) PAID
Date Receipt N
Will the applicant in nts to deebuilding by the B use equipment or devices which
mithazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
r _
Dinct? - TOTAL:
i ❑Ya F-1 No .. ., 801LER-COMP(OVER IfX1,BIN)BTU)
Ihavereadtheh ousmaurials AIR CONDITIONER ISSUANCE DAT
requ'vemenb under CTapdd 6.95 of the Cali
forms Health&Safety Code,Need...25505,25533 and 25534.I imderse nd load if the NEW RESIDENTIAL MECH. SQ,FT.
building docs nm curmlly have u mnant,,hot it i,,;,,ra,fiamihility m notify the moult....,
of be requirements which most be at prior to issuance of.Cetitie.te of Occuponcy. - -
Owner or omhorred agent Data TOTAL:5 ISSUED HY:
OFFICE