30585 APPLICANTTOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY•OF CUPERTINO 'r ,BUILDING=ELECTRICAL PERMITNO.
BUILDING DIVISION APPIACATIONlPERMIT 'r1GRINr.=MECHANICAL. OC C
IUILDINGI'ROJE(]TIDIiNTIFICATION J 5J
BUILDINGADURPSS: SANITARY NO. APPLICATION SUBMITTAL DATI.
OWNER'. AMC: PHOlB C A ORS ME: .,LIC NO:
v—wT G NIC _ CONIROLM
RCHITECVENNG�IINEEHR: LICNO: _ ADRESS: -�>p - ❑
CONTACT: PHONE: . - , `lam g C.�SGJ/ BUILDING PERMIT INFO
. ❑ Consultant Fees Paid by Applicant(Initial) BLDG p PLUMB'- MECH
r .. ..
❑ ❑ ❑
LICENSED itIle CONTRd met..5 DECLARATION QTY. ELECTRIC PERMIT FEE
1 Imreh uffimt thus 1 Itis licensed under nrvisions of Chapter 9 cnmmencin ,
v r r L � g JOB DESCRIPTION
On'Z with Section]Ilgl of Division Sof the Business and Prdcs,h C andiahereacis `
>'_ - RESIDENTIAL:
u)00 i PERMIT ISSUANCE _ E
FUU in ❑SPDWL ❑KITCHEN REMODEL
r U U Livens x Lic.N - -
aFZQaLL`• Dae Contractor uANCCS—RESIDENTIAL� DADDITIGN ❑PLUMBING RE-PIPE '
CHUECI'SDECI. WNN ❑MULTI-UNIT, ❑STRU
8URAL
'ZDV1 PA lily , ,
Or�_Z ' IunJersleh
nJ my plans sholluseJ ax records cnrda - M FICATION
OZ—' UP TO 200 AMPS
Licensed Pmfx,emal El INTERIOR IIIMNEY REPAIR
* 201-1000AMl'S.-; IMPROVEMENT ,}
� , OWNER=BUILDER DECLARATION , OVER 1000AMP5 C1 BATH REMODEDREPAIR ❑DEMOLITION
Y
Q' 1 hereby affirm that I.nln exempt from,the Contractors License Law for the
�'O y U fallowing reason.ISectitin]031,5,Business and Pfafeasmm Cede:Any city.,County SIGNS ELECTRICAL (LI OTHER
3 LL F' which requires a permit to construct.alter,improve,tanolish,or repair any someone
fain,to it,N,cona'r.skemquires dirti,lic itlis such perniun file aligned amtement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
CCO (commencing with Section 7000)of Division 3oRM1e Business and Pmfessinna Cale)x TCMP.MFTERORPOLEINST. COMMERCIAL:
moc' that he'is exempt therefrom and the basis for the alleged exemption.Any violation of r ❑NEW BLDGIADDITION ElDEMOLITION
yxn4.•
Section 703 L5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES
W^'m , - ❑TENANT - ❑FOODSERVICE
not morewan tldt.cve bloodied
ampe y.or toy
�Sa ❑ Lo the wer of the properly,or mycmntended unmarred
aatheir sole nmrpcnsaion, SWIMMING POOL IiLECTRIC OTHER IMPROVEMENT
FO will dothcwork,node he Contra pots Liccudornfterdos of apply )INS,Buneros - � ❑OTHER
and Professions Code:imp Contractors Llmnse Lew Jars not apply s if owns, h. OU'1'LCTS—SWITCH NS=EIX 12 iS -
a' hpropcityis own who builds or improves tbetean, ar who tines such work himself or through. '
hinawnowever,the provide)[batprove ent is sold within
oat intended nr offered for. NEW RESIDENTIAL.F.LP.CTft .y SQ
sale.
um,buwevcatheve7dre hmlmprovemem is solhedid lac Yeurofcnmplainn,the• • 'SQ;FT.PI.00�AIi@A" SISQ,Irf.,
er-builder will have the burJennf proving that he did not buildrnimprove for our- - P CHH-- LLNN
• PmdisLwlc)a +• � - "
❑I:as nwrterof the pmKrY,um esciusively commning with licensed amtmnnrs m T L' DECLaws
Oto es not neat(Sec..a. holiness and Py who
Care:mrna Commcmr'a Li- G161996 .
whocoswdceor such plyiuun with
afofpmpcny whosedpda rrimproves Contacturs QTY. PLUMBING PERMIT F�•
' who contracts for such projects wihanmtmmnr(s)licensed pursuant the Cnmmctora - - _
Lirmie,Law." - PERMIT ISSUANCE ^Y i INV I
❑I am exempt under Scc' ,B N P C for his reason .V�IV Ur VUrCt'1
Owner " -• Datc ALTER—DRAIN&VENT—WATER(FA) VALUATION
WORKER'S COMPENSATION DECLARATION. BACK FLOW PROTECT.DEVICE
I f...hy nffi,m t oder priedy of perjury one of the following decluraiom:
Fl I have and will maintain a Certificate ofConvent to self-iinatice finfWarker's Compen- DRAINS—FLOOR.ROOF,AREA.COND.
STORIES, TYPE CONSTRUCTION
sutian,nv ",tied for by Section 3700 of he Lobo.Cade,for the pedormunce of the --
w k Melinda permit is issued FIXTURES—PER']RAP
_ oe an
d will maintain Worker's Compensation Insurance,as required by Section _
. Cnrri La rl'the work or which thio pernllt la issuud. GAS—EA.SYSTEM-1 INCA OU'I'LEfS OCC.GROUP APN
371X1 a1'll•Lab or Cole,for the perfnrmancm
MyW r Cmp ti tamer and Poll'�y,,fr.lpdfe� '11 �I,�(� -
PolicyNiri GI��T6TT GAS—EA.SYSTEM.OVER i(EA)
CERTIFICATCOFEXEMP3EONI'ROM WORKERS'
COMPENSATION INSURANCE GRF.ASUINDUSTRI.WASTC INTERCEITOR
t -- BUILDING DIVISION FEES
' 'TroisWli
son neral not hu congilmed Rita,is,rohmine,
ia hunJred Dollars is 1007 ..
or less) GREASE TRAP " PLANCHECK PCE
I nfy lh t nth p K nfth kt which th p asst r- aucq],hall - -
note ply anypc on in_y commer stiantohearaim subject to dan Workers'CareSEWER—SANITARYSTORM IiA.20B IT
O ,Z can.W of Catharine.Dat pen- r _ 'ENIiRGYi'liE
WATER HEATER WNCNT/ELEC R
Z Q Applicant ' - - - - GRADING 2B
I�%1 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS'I EMIfREATING '
a 5 become,ubjnet to the Worker's Compensation provisions of the Labor Code,you must - SOILS FEE
tN "
moms comply with such provisions or this permit shall be deemed raveled. WATER SERVICE
a
CONS'I'ItUCT10N LIiNU1NG AGENCY' NEW RESIDENTIM.PLMIL S
,Z 1:
_ Q.FT•„' - PAID
U
U O
W N hereby them isoconstruction
nEnding agency for the performance oL DaraReeptp
he work fr,hich hisprosis is issued(See 315], ,
Civ.CJ
O U [.entireTOTAL'.
Name .
Lender's Accirms TOTAL:
I nifyfythat I I se madlh' Ipl to a ad.tme'but the chmsafrmul nil - BUILDING FEE
MECHANICAL PERMIT FEE
Va7t. marect legreet mply -1n II ly unJc my' Jnanms and t ml .mat gto QTY. a
U G building constriction,and hereby a tuacm representatives of ttis city to enter upon the, SEISMIC FEE
above-mentioned property,for inspcet ion purposes. ' . PERMIT ISSUANCE -
(Wm agree itsave,indemnify and keep harmless the City of Cupertino against ELIiCTRIC FEE
Iiahilitics,judgmcnts,msis andexpensm which may in anyway accrue ticimstaaid City ALTERORADDTOMF.CII.
onsegoence of the graining of hix permit. PLUMBING FEE '
APPLICANT UNDERSTANDS'AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IBM)CFM) t
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signomer.f ApplicanVComenumr Data - EXHAUS3'HOOD(WIDUCT) HOUSING MITIGATION FEB.
HAZARDOUS MATERIALS DISCLOSURE
Will due appllcuml or] lure buildargor,itional,lr.or handle h....taus oneco.l HEATING UNIT(101000)0 RTI 1)' -
adefircal by th C Peron Murucspr Cal Ch pt 9 12,and the Heahh and Sa fcty' '
Codes t 25532(ay HF.A1 ING UNIT(OVER 100,00d BTU)
C]Ye VENTILATION FAN(SINGLE RISID) -
PAID
Date ReceiptY _
Will the applicant or Lima,hu' g"cc
upanl use
impotent or device,which
emit brosishuiair contaminants it fine)by th,Ilay Area Air Quality Management BOI1AER—COMPyHPORRXL0()0BTU) -
TOTAL:
Oianicfl BOILER—COMP(OVER 100,000 BTU[
❑Yes No
I have read the hnzaNuu mats under Clulicrb.JS of Cali- AIR CONDITIONER '
mquiren p .r ISSUANCE DATE'
intent Code,Sections 25511•25533 and 2553).1 understand ht if rhe NEW RESIDENTIAL:MECH. SQ.'ETncurtenlly hove tcnoI hat n' my tcpmtaibillty a funny he occupant
h tact poor nt suneeofuCenificaeofOccupancy.Owzed gent Date TOTAL: ISSUED BY:
OFFICE