S 0445 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PE MIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF,CIIANICAL 0445
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITIAI,DATE
oto Ti�To Gni. - 2 �r
WyNER:S NA ^ 5 I -: RACfOR'S !� .M D LIC NO:� N/C CON['ROL0'
Wb S
� 6 97
ARCHITECfICNGINEER: LIC NO: /1&(t /V4 �s ❑
CONTACT: PHONE: 7 BUILDING PERMIT INFO
3 S—p O ) ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC I
LICENSED CONTRACTOR'S DEcC..LLARATION QTY ELECTRIC PERMIT FEE
I Lamb,re irm that I am licensed under provisions of Ch,,e,9(commencing JOB DESCRIPTION
OCZ with Sectian'/1100)of Division 3 ofthe Businessand Professions Cu ,admylicenseis R SIF DFNTIAL,
won PERMIT ISSUANCE
,I in full forte mdeRem_ � ❑SFUWI. ❑KI'I'CHIiN REMODEL
�UU Liansc Cl Lie.M APPLIANCES-RESIDENTIAL CADDITION ❑PLUMBING RE PIPE
F a a Dam Cnnlmctnr
VI ARCHITECTS DECLARATION ❑MULT1.UMT ❑STRUCITRAI.
F uttZ I understand my plans shall be used as public records PANELS MOIJIIgCA'f10N
�Z-In UP TO [I INTERIOR ❑CHIMNEY R1711AIR
r 4.~.W Licensed Pmfessitml I 201-11gX)AMPS IMPROVEMENT E]SWIMMING FOOTS
OWNER-BUILDER DECLARATION
C W 4 1 hereby affirm that I'am exempt from the Contractor's License Ww for the OVER 10X1 AMPS ❑BATH REMODEVRF.PAIR ❑DEMOLITION
O a U fulkaxid Section 9031.5,Business and Profession Cde:An t t OTHER
g mason.( y city or county SIGNS ELECTRICAL
R13 LL H which its ms a permit to construct,eller,improve,demonist,fi ea sir any structure J�
F-�'05 prior mit immdj also res the appBcmrfor mchractor tofile
Use
SPECIAL CIRCUR/MISC.
} Our he is littnsed pursumuo Nc provisions of the Contractors Lire.¢law(Cbapmr 9
W{Yp0 (commencing with Section 7000)of Division 3ofthe Business and Professions Coe)dor TEMP.METER OR POLE INST. COMMERCIAL:
d C that he is exempt th rafirm add the basis far the alleged exemprim.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
^y Section 7031.5 by any applicant for a permit subjects the applicant to a civil parody of POWER DEVICES []TENANT ❑FOOL)SERVICE
not more Nan five hundred dollars(5500). IMPROVEMENT
�zQE]1,as uwnerof the property,or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC
p=. will came work.and thesuucture is rat intended ondlircd formlc(Sm 7044,Business ❑OI II LR
rind Professions Code:The Contractor's License Law docs not apply ns an owner of OUTLETS-SWITCHES-FIXTURES
property who builds nr improves thereon,and who docs.such work himself or through
his own employees,provided that such improvements am not intended or ofrmd for NEW RESIDENTIAL ELECTR SQ PT.
00,
sale.IL however,the building or improvement is sold within one year of completion.the SQ.FE FLOOR AREA l;/SQ.IT.
net-builder will have the burden of proving that he did nor build or impmve for pur-
pose of sale.).
I,as owner of the Property,an exedmively contacting with licensed ondexamrs to TOTAL:
contact me project(Sec.7RW,Beat.,,and Professions Cde:)The C.....—s Li-
ection Inw does not apply to an owner of property who builds or improves Nand,and QTY, PLUMBING PERMIT FEE
who contact for such projects with a contaadons)licensed pursuant o the Contacmr's
License Low, PERMIT ISSUANCE -3_57,
❑I am exempt under Sec. .B&P C for this mason
Owner Dare ALTER-DRAIN&VENT-WATER IEA) VA TON
WORKER'S COMPENSATION DECLARATION BACK ITOW PROTECT.DEVICEAl q A �99(I(19
I hereby affirm under penalty of perjury one of the following declarations: Ir' 2 4
❑ I have and will maintain o Certificate of Carmen,,,self-insure far Workers Cnmpcn- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONS'IRUCI'ION
satin.,as provided for by Section 37M of the Labor Carle,far the performance of Ne
work for which this permit is issued. FIXTURES-PER TRAP
Fl 1 have and will bounuin Workers Compensation Insurance,as required by Section `l
3700of Ne Labor Cde.for the perfomance ofthe work far which has permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS J APN
My Worker's Compensation Insurance carrier and Policy number ac:
Career. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ORL!ASMNDUSTRL WASTE ING ERCEITOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need not Is,completed ifthe permit is parade hundred dollars($100) GREASETRAP
or YLANCHECK FEE
Lem.)
I certify that In he performance oflhe work or which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FI'.
O not em ploy un��nin on nn�r ran us lykepnn�s icn In rhe Workers'Compen- I!NI!RGY FEL!
,� armor Luws nl lirmin. /y _I` OVAL Elk BEATER WNENT/ELECI'It00
zO Applicant i , p GRADING I9CI1
ti NOTICE M A PLICAN f,after making this Cer ircate of Exemption,you should WATER SYSTEM/BEATING a SOILS FEIi, become wbjoet to the Workers Compensation previsions of the Labor Code.you must
forthwith comply wimiuch provisions ar Nis pennitshtil bedeemed marked. WATER SERVICE
as CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PATO
U Q Ihertby utirm Nat Nem isaconswclinnkding agency fonhc perfomwreof Dc Recciprp
F the work for which this permit is issued(Sec.3097,Civ.C.)
OLender's NameIII TOTAL:
U I<ndcr's Address A
P.i I certify that 1 have read this application and elate that he above information is BUILDING iti'
rQji correct l agree t.comply with all city and county ordinmecs and stare laws relating to QTY, MECHANICAL PERMIT FEE
U rZr Wiliingerommomion,and hereby aothon,cm,mom.ivesaf thiscitynr emmupon the SIiISMICFz
abawe-nmntioncd po,,,Iy fur inspection purports. PERMIT ISSUANCE
(We)iaam to save,indemnify and keep bun ium the City of Cupertino ugainsr EhI!CI'RI'PEB
liabilities,judgments.costs and expenses which may in any way acerae against said CityALTER OR ADD TO MECH. PLUMBINAFfir. �
in consequence of the granting of this peanut.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Al R HANDLING UNIT(TO I TOM CPM) MECHANICAL FEE
SOURCF GULATIrJ 1.
1// AIR HANDLING UNIT(OVER 10,000 CPM) CONS'TRUCOON TAX
Sig tom of ApplremUComat.1 ( '] Date EXHAUST HOOD OVIDUCT) IHOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havallous material HEATING UNIT(TO IW,IXp BTU)
as defined by the Cupertiou Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532nd? HEATING UNIT(OVER 100,000 BTU)
❑Ven f1fYVo VENTILATION FAN(SINGLf!kL'SIU) PAID Dom Receipt Of
Wiit the applicant or future building occupant use equipment or devices which BOILER-COMP(3111'OR IOf.001111'U)
mit hazardous air contaminants as darned by the Bay Amu Air Quality Management p
�Dis and BOILER-COMP(OVER 100.000 BTU)
❑Ycs fiH.'o
Js/ AIR CONDITIONER
d have and the hewdous materials requirement under Chapter 6.95 of Ne Cali- s1 —ISSUANCE DA
ford.Health&Safety Cde.Scrims,25505,25533 tad 25534.1 uderstad that if the NEW RESIDENTIAL MECH. SQ.PT. /- ISTNCE 9
buildmIdm rotcurren0y have a mrum.Nat it is my responsibility m notify One occupant (J
ofOW trcnaw tial /�tbe Rtet primm asuatucufa Ceruficateo-fy/C�Wncy.
O1�randan " .gem DIY Uam TOTAL: ISSUI!U BY:
OFFICE