S 0206 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY //�
CITY OF CUPERTINO BUILDING-ELECTRICAL. H§ITNO OL
O6
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S
BUILDING PROJECT IDENTIF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICA'1'H)N SUBMI'ITA%DATE
a0-T15- STeV � CT eek �v��" /yy
OWNI!R'S NAML:^•_1 ` PHONE: C NQACTOR'S��F. LIC NO:
IgW'4 NIC CO a
]HITECTILNGINEFR: LIC NO: ADDRESS: ❑
}C�ONppTA�C7E PHONE: BUILDING PERMIT INFO
C w,06 WIDOW sIo _{UT+j# ❑ Consultant Fees Paid by Applicant(initial) BLDG 'LF.CT PLUMB Mfi011
EJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PIERIM .EEE
1 hereby aRrm ohm 1 am Limine)under pmvisin to of Chapmf 9(commencing - JOB DESCRIPTION
pWOZ with Section 1001Bof Division 3 ofthe Busintesand Rufecsumn Code.onCmy Eicenseis RESIDENTIAL:
WOO wr PERMIT ISSUANCE
F lye on full force and effect. ❑519)WL [I KITCHEN REMODEL
�UU License Cl ss Lic.X— APPLIANC17S-RESIDEN1 Al. ❑ADDITION ❑PLUMBING RR-PIPH
hGd Date Cnnbaelaf ❑MULTI-UNIT ❑STRUCTURAL
F O V A CHITELT'S DEC I. I( PANEII S
ZO Z I understand my plansshell he used as pub is rccordz MODIFICATION
0 Z`��'Q UP TO 200 AMPS C1 INTERIOR [I CHIMNEY REPAIR
F.5 W Licensed Preessi...I 201-6010AMPS IMPROVEMENTE]SWIMMING POOLS
� y? OWNER-BUILDER DECLARATION OVER IOWAMPS ❑BA'L'M REMOU' FPAIR ❑DEMOLITION
OOUuGG]]st I hereby affirm that I ren exempt from the Contummr's License Law for the
3 U following reason.(Section 1031.5,Badness and Profession+Code:Any city or county SIGNS ELECTRICAL ❑OTHER
i1la
a+3 U.ien which requires a per it to Conswct.alter,improve,demoll.+h,or repair any swewre
.] pmouiire issuance,nkm requi-Ohpapplicam for,mb peno.to file.signed umemem SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions ofthe Contractoes License Luw lChupmr9
CCO Romment,mg with Section IIgO)of Division Jofthe Businesxand Pmm,,ianx G.de)er 'TEMP.MINER OR POLE INS'll COMMERCIAL:
d m C Ill.,he is oxempl then( ono and the hasis bathe alleged exemption.Any violation of [I NEW BhDCIADI]ITION ❑DEMOLITION
+ --y
Section 1011S by any upplicom for a permit subje,"Ne applicant to a civil penalty ofI`OWLR DEVICES ❑TFNANT ❑FOOD SERVICE,
= not marc Than fvehundreddoll.rxyempl. OIL[FR F.h1E t--
;?� ❑I,us nw..rrise hundred dolrmyemployces with wages.theirsole compensation, SWIMMING POOL ELECTRIC s[;f
2KiKKK will do the work.and lhcwmcmre isnm intendedoroficuM for.mle(See AOW,Business ❑OTHER
Wh "�
and Priduxsions Code:'I'he Contractor's l.iccnst Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves dommh and who docs such work himself or through
his own employees.provided thin suchiimprovcmpnts are not intended or offered for NEW RESIDENTIAL ELECTR SQ P.
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.En
nerhuilder will have the burden of proving that he did not build or improve for par #2 A i
pone of sats). D
DIAL:
E] 1,its owner of the propery,am exclusively contracting with licensed coni a tum so
construct the propel(Sea.THQ Business and Professions Cale:)The Contractor's Li-
cense Low does not apply it)an owner of property who builds or improves ohcheon.and QTY. PLUMBING PER ! FEE v(J,tl 24 X -_
who contracts for such projects with a Courtrooms)licensed Pursuant to the Cnntracmrx /s)) REG
License Law. I'F.RMI"E'ISSl/ANCF. Vl/Y Ut.
❑I nm exempt under See, ,B&P C lir this mason Lur
ALT HR-DRAIN&VHN'I'-WA IFR CA) VAI.
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW 1'IiGI'ECT.DIiVICF.
I hereby affirm under penalty of perjury one of the following W.1ce declamations
Ihuve and will for
eCion 37mof the Label
CCl ode,kardbor enfouncne of the DRAINS-ILWR.ROOF,AREA,CONDI STORIES TYPE CONSTRUCTION
sminn,as provided fpr by Ss issued.
3]W of the Whin CnJc,Iia the perlonnancc of the
work have
illnotimusid issued. PIXTUHEiS-PIiR TRAP
I have end will mainwin he effos Compensation work
]or hi h require)by Section -
J]W of the Lahr Cale,La the pcmormuncc of the work lire which this pemtit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GR(Illl' APN
My Werke Cpmpenzmimese carrier a oil Policy L��l1nnbe�rpr� ryLa�a
Cartier I Q� Pnlic "c1§ AUE3L#1SDIN GAS-HA.SY$TEMOVI7R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASTJINDUSTRL WAST Ii INTERCIEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IBES
("is section need not IN,complemJ Rine pem.il is for unchurched dollars($100) OREASETRAP
nr less.) PLANCI IECK PER
Icerifylhmin the performasnn fthe wm1cforwhich thispetnd isiswed.]shall SEWER-SANITARY-STORM EA.2(N)IT.
not enopiny any person in any mer a hep jCc,tothe Workers Compen- ENERGY FEE
Z sminn Lnwsaf Callfn i' I WATER HATERW/VEN'T/17LECTR
OQ Applicant C GRADING FEE
`t NOTICE .CANT:IL�f .nng this Cenifcute of Exemption,you should WATER SYSTIEM/IBFATING
f~ ; become su le n the WOrkCf1ER do"I'mion previsions of the labor Calc,you most
SOILS FF.F.
fothwio ply with such provisions or this permush.11 bcd.rded revoked WATER SERVICE
Q
IhvCONSTRUCTION LENDING agency
NEW RF.SIDIiN'fIAL PLMB. SQ.Pf. PAID
Qmby uff nn that]bpm isaanntracdnn lendingng ngcnucy for the perlbrtnuna of Ume RcetiplX
the work for which This permit is issue)(Sec.)091,Civ.C.1
C) I<ndcrs Name TOTAL:
U Lunde/s Address
- T(YfAI.:
1 certify that 1 have read this.pplication and some Italian alsrve information is BUILDING FEE
fan Comte'.I.gree mcvmply with all city and eponsy oNimmces trod score laws relatingm QTY.,: MECHANICAL PERMIT FIEF
U Z huilding amumdion,and hereby awhaivo represemetivex of this city menwr upon the SLISMIC I*EE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino Rgainst ELECIREC FEF,
ludilitiex.judgmems,costs and expenses which may in any way secure against said City ALTER OR ADD TD MECIL
PLUMBING FEE
in asequence of the granting of this permit.
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALI,NON-POINT AER HANDLING UNIT('1'D 10,000 CFM)
MECHANICAL FEE
SOU RCR REGULATIONS. CONST
. AIR HANDLING UNIT(OVIiR 10.000 CFM) CON$'1'RUCTION TAX
Signmanf Appliemuk2ortummr Dae EXHAUST 1 IOOD(W/UUC4 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future ballding oertmenlmorc or handle Mlzmlons matedul HE,A'TI NG UNIT(TO I OIIIXN)IIT U)
as Jefinul by the Cupenino Municipal Cale,Chapter 912,and the Ilealth and Safely
Code.Section 25532(.)2 HEATING UNIT(OVER 1a1,INX)BTU)
❑Yes 13a PAID -
VENTILA'EtONIAN(SINGLERESID) Due ReceiptX
Will the appliwnl of fumfa building uceupum use equipment or daviccs which BOILER-COMP(3HP OR 100(1 BTU)
.nit haxardoas air C Wounints asJelinal by he Bay Area Ah Quality Management (111IGIAL:
Olgir m 1 BOILER-COMP(OVER HN.olon BTU)
C]YC' Imo
I have read the ' oas Is w under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
quire
fomlu flca0h&B. Cala,- orrs 25545,2553?anJ 255]4.I undemmnJ that If the NEW RESIDENTIAL MRCII. SQ.IrT,
bulWing Jry ncnti ,Ibm it ixmy rceponsl Nhuy to noelylhenecupvm
nfthe stenos w d 'once of a CeCa
rnra ud agent (O TOTAL: ISSUED BY:
OFFICE