99070050 �. APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O -S o
a BUIITYLDING
UPVISION Bun.BING.MECHANICAL
ECHELEC` MICA P
DIVI6ION APPLICATION/PERMIT 1'WMIROJ�M[BRING IC
� 'BUILDING PROJECT IDENI'IEICATIDN
DRESS: SANITARY NO. APPLICATION SIIBMLTTAL DATE
732G-C:: P ON': CONTRACTORS NAME: LIC NO:
N/C CONTROL#
NGIlINNE�EER: :IC NO: ADDRESS:GL }is.3 76�3 r 'BUILDING PERMIT INFO
��rr�� ,As�a �� [ �6 /!� ❑ Consultant Fees Paid by Applicant(Initial) BLDGCECT PLUMB MECH
rr`F r�
El 'W ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMITi' hBE
1 hereby affirm that L am Icensed under provisions of Chapter 9(commencing .. JOB DESCRIPTION
%]tYtZ with Section 7000)of Dlvisir 3ofdr,Business and Professions Code,and my),cense is RESIDENTIAL
PIiRM1'1'ISSUANCIi
F W F in funs force and eOem' ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Lie. APPLIANCES-RESIDENTIAI. ❑ADDITION ❑PLUMBINGRE-PIPE
Dae Cormier
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
Z p n Z 1 understand my plans shall be used as public records PANELS MODIFICATION
Oy—O UP TO 201 AMPS El INTERIOR [I CHIMNEY REPAIR
��2t LicensedI'mfe„ional 201-1000AMPS IMPROVEMENT (]SWIMMINGMOLS
OWNER-BUILDER DECLARATION OVER UKOAMPS ❑BATH REMODEUREPAIR El DEMOLITION
Q I hereby affirm that 1 nm e.acmpt from the Contrrmor's License Law for the
y U following mason.(Section 7031.5,Business and Professions Codi Any city m county SIGNS ELIiCTRICAL ❑OTC HER _
laiF which requires a permit to consumer.ahec improve,demolish,or re,or any or etere
1-!!:0
prn
iooits issuance.also requires the applicant forsuch permit to Bled signed statement SPECIAL CIRCUITIMISC.
R j that he is licensed Immuane,,the provisions ofthe Contractor's License Law(Chance I
at at 00 (commenting with Section 91100)of Division 3 of the Business and Professions Code)or T,MP.ME,Hk OR POLF INST.. �si�/` (]
6 X c c that he is exempt therefrom and the basis for the alleged exemplind.Any violminn of ❑NEW BLD /ADW z( ITION�
4•
Section 7031.5 by any applicant for a Permit subjects the applicant d civil penalty of FOWL DC•VICCS
W^vs ❑TENANT SF ��
=O tan more than five hundred dollars($50al.
�I,ns owner of We property,nnnyentpinyees win wager as(heirs,lecompensr(ion, SWIMMING POOLBI.ECTRIC IMPROVF.ME /
F willdafhcwork,nnJ the stmnure is notimended nroffercJ for sale(Sec.7044.Basines, ❑OTHER
L3 and Pzofessm's Code:The Contractor's License Law dues not apply to an owner of DTLET$-SWITCHES-FIX'N
property who builds or improver thereon,and who does such work himself or through
his own employees,provided that such improvements arc not imen ted or offered far NEW RESIDENTIAL F.LECTR OF CRT,
IF sole.IL hnweverJhe building orimprnvemem is sold within unc yearof completion,due SQ.FT FLOOR All EA $SQ.FT.
toxned-builder will have the harden of proving Out he did not build or improve for our-
L;Irosale.).
se_,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
conswn the project(Sec.] uoness ane Pndcssions Coda)The Contractor',Li-
are -
cerise Law does note tom ot propcny who huilA,o'improves mareon,nnd Q'ry. PLUMBINGPERMIT FEE'
who contracts fa user odea ith a commmogs)licensed putsuamm me Contractors -
License Law PERMIT
PERMIT ISSUANCE
❑lam as Mit der ,B&PC for this rcrorm
Da¢ ALTER-DRAIN&VENT-WATER(EA) VALUATION
ner RKER'5 COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
emby affirm under penalty of perjury one or the following reductions:
❑I have and will maintain v Cerifcam of Consent mself-imure for Workers Co.,.- DRAINS-FLOOR.ROOF.AREA.COND.
,ream,as provided firs by Section 37W of the Labor Code,for the performance of the S'POR IS 'TYPE CONSTRUCTION
work far which this pemtit it issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3](0 of the Labor Gyle,for the performance of the work for which this permit is issued. GAS-EA,SYSTEM,I INCA GUILINS OCC.GROUP
My Worker',Compensation Issuance comer and Policy numberure: .i
CUMre Pol iay No.. GAS-EA.SYSTEM-OVER4(EA)
CIBITIFICATE OF EXEMPTION FROM WORKERS' 0 U
COMPENSA'L'LON INSURANCE GREASE NDUSTRL WASTE INTERCEPTOR
Obi sseclion need am he completed ifmapennitis lone hundred dollar,(SIM) s ,. BUILDING DIVISION FEES
or It,,.) GREASE'I RAP PLANCHECK HE
Icanify that nine perfnrmaneeofthe work force ichthis permit is issued,[shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject n the Workers'Compen- ENERGY FEE
oz scion Laws of Ceti Humin.Date WATER HEATER W/VFMAILECTR
O Applicant GRADING FEE
.`�. NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you.should WATER SYS'IEM/IBEATLNG
a ' become subject to the Worker's Compensation atwidnnc of the Luhur Code,you mux( SOILS FEE
WJ Innhwitb comply with inch prp,kionsor Or,permit shall to deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGIiNCY NEW RESIDLNTIAI.PCMB. SQ.FT. PAID
a
V I for
rte t permit i ls...d Sec.30lending agency for(he pert manceml Data Receipt is
the work for which this permit is issued)Sec.JO9].Civ,CJ
O Lender's Name TOTAL:
[U Leaders Address TOTAL:
I certify that 1 have rend this application and nate that The above information is � BUILDING HE
CAA correct.I agree to comply with all city and county ordinances and state laws elating to QTY. MECHANICAL PERMIT FEE
building conswction,and hereby authorize representative,ofthis City to enmru)mn'he SEISMIC HE
above mentioned p opedy lin Inspection purpoxen. PL?RMIT ISSUANCEELECTRIC PEE
(We)agree to si ify anti keep hinnies(he City of Cupertino againn
in
hahilities,judgme sesvnde nes which may in aacerae
tiny way against said City ALTER OR ADD TO MECH.
cup o the creation fthis permit. PLUMBING FEE
APPL,C T DERST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO Iq(HRCFM)
OUR TIO :. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,01 CPM) CONSTRUCTION TAX
Sig caMCommcmr Date 17XHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant sore or handle hazeMou,malarial HEATING UNIT(In IN),lato 111 U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)T HHATING UNIT(OVER 1011,1100 BTU)
In ❑Yea Fl No PAID
VENTIhA'I'ION FAN(SING 1.11 RE51D1 Date Receip(d
Will the applicant or furore building t use equipment or devices which BOILERCOMP UHP OR 110,000 BTU)
it hazallote
us air contaminants as defined by by the the Bay Arc -
Area Air Quality Management TOT t
DisdcR
❑Yes ❑Nn BOILER-COMP(OVER 10,O0 BTU)
I have toad mirrors metras under Chapter 6.95 mf the Calm AIR CONDITIONER
requlrr p ISSUANCE
forma Heal ,rf face.Scet ns+_5505.255A and 25534.1 undcrstanA Ihm if me NEW RESIDF.NTIAI.MECH. SQ.PT.
huilri ces rremly have nanL.toga is my respnnxibilitym notify meurcupant
of require none ichm met prior to is
ofa Certuddia,of Occupancy. �O
ra s t
Data TOTAL: ISSUED BY:
OFFICE f_