S 1149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY
OF
CCPERTINO BUILDING-ELECTRICAL. PE§pF NO.
BUILDING DIVISION APPLICATION/PER T I'LUMBING-MECHANICAL. �J 1149
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I SANITARY NO. APPLICATION SUBMIT DAT F.
J_ f-LF u C- S
p - PHONE: 0 RACTOR'S NAME: LIC NO:
-c IN— n b— _ y 01' J 7 N/C CO^N/TROCH
CHITECT N INE R: fY LIC NO: DRESS: d ❑ � L
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
RI ac-- �$- 65 ❑ ❑ ❑
LICF, SED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(cam umaing _ JM'DESCRIPTION
Daz with Section of Division 3 mdod Bminessand Professions Cade,and my license is RESIDENTIAL,
ulpp PERMIT ISSUANCE
FF n full fmcennd erect. ❑SFDWL ❑KITCHEN REMODEL
�UZV License Class �-4� Li0.M 515��� APPLIANCES—RESIDENTIAL ❑ADDITION L]PLUMBING RE-PIPE
to up>. Date Comractnr El MULTI-UNIT [I STRUCTURAL
Z O to to ARCHITECTS DECLARATION PANELS -
I understand my plain shall be used m,public records MODIFICATION
tOz 0 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Prnfessional 201-1000AMPS IMPROVEMENT []SWIMMINGPOOLS
•i OWNER-BUILDER DECLARATION OVER IOIXIAMPS Ll BATH REMODF.IIREPAIR DUGMOLITION
d O 1 hereby affirm that 1 am exempt from the Contractor's Licence Law for the
X 3 k U U foil g n.(Sect 7031.5,Busing d P f n:Cad A y city county SIGNS ELECTRICAL L1 OTHER
which requires aPermt to construct.alter,improve.demolish,or reP anystructure
prior to tissuance,al.so acq the pplt t for suchPermit t file a signed.tatement SPECIAL CIRCUIT/MISC.
d$. thathe is Ic dpurs tionic p sin I the Cal tr L' La (ChapterI COMMERCIAL;YI r.�O (commencing with Section")or Division 3 of the Business and Professions Code)or TEMP METER OR POLE!NST.
d y m[E that he is exempt therefrom and the basis rot the alleged exemption.Any violation of - [I NEW BLDGIADDITION ❑DEMOLITION
LLX7 do Section 701 IS By any applicant for a permitsuhjeits he applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
z Y not more than five hundred dollars($500): IMPROVEMENT
SQA ❑ I,as owner of the properly.or my employees with wages us theinnle compensation, SWIMMINGPOOLELECTRIC
will do the work,and the structure is not intended or offered forsale(See.7 k .Business 11 OTHER
a m and Professions Cade The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL FLECTR SQ Cr.
`\ sale.if,however.the building or improvement is sold within one year of arm"char.the SQ.FT.pif.d AREA $ISQ.FT.
\��`owner-builder will have the harden of proving that he did not build or Improve for pur- _ P „ ��JJ
poaa of sWeJ. - -
❑ h wi or,of the property,am exclusively contracting with licensed contractors to OTAL: n s
- construct the project(Sea 9044,Business and Professions Cadl Tho Contractor's Li-
cense JAN
Law does not apply to an owner of propertJAN wy who builds or improves thereon,and QTY. PLUMBING RMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Consumer's
License Law. PERMIT ISSUANCE C(sITY V� VU(CnIIIV
❑l am exempt anger sec. .B&P C far this reason
ALTER—DRAIN& — ATER(EA) VALUATION
Owner Dere
WORKER'S COMPENSATION DECLARATION BACK FLOW P DEVICE
1 hereby affirm under penalty of perjury one of the fallowing deolamdons:
[]'I have and will maintain a Certifcateof Consent to self-insure for Worker's Cooper AINS—FL OOE,AREA,CON STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the performance of the
or for which this permit isissued. FIXT F.S—PER
w I have and will maintain Workers Compensation Insurance,as required by Section
00ofthe Labor Code,for the Performance ofthe work for which this permit is issued. CAS—ESYSTE -11NC.4.0 T OCC.GROUP
rAPN
My Warkers Compensation Insurance carrier and Policy no mare:
Cameo 1STArA=a`40 Policy No.; 013 GAS—EA. S'TE -OVER
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASFJIN L C
COMPENSATION INSURANCE ASTE INT BUILDING IVISION FEES
(This section need not be completed ifthepermit isfareachundredde1lars($100) GREASETRAP
or IessJ PLANCHECK FEF.
I certify that in the perfarnanceoRhe work for which this permit ix issued.Ishii]] SEWER—SANIT Y—. EA.20
not employ any Person in any manner so as to become mbject to the Workeri Co.,a- ENERGY FEE
O z sudim Laws of Califibru a.Date WATERHEATF W T rR GRADING -
z Q Applicant
("t rNOTICE TO APPLICANT:If,after making this CertiOuate of Exemption,you should WATER SYSTEMITR TING SOILS EFC
became subject to the Worker's Compensation provisions of the Labor Code.......st Nr
Isla forthwith comply with such provisions orchis permitted]be dememmvoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM SQ.FT. PAID
UZ I hereby affirm that there is a construction lending agency forte Performance of I le Receipik
IILCyyy O the work for which this permit is issued(Sec.3097.Cie.C.) TOTAL:Lenders Name
U
Lenders Address _ TO AL
Phi I certify that I have read this application and state that the above information is NULL F.
rn correct I agree m comply whh all city and county ardinanaoa and ante rows remtins m QTY. MECHANICAL PERMIT 88
U building construction,and hereby authorize representatives ofthis city to enter upon the SEI
above-mentioned property fear inspection purpose, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Column against EL' T E
liabilities,judgments,costs and expenses which may in any way accrue against said City' ALTER OR ADD TO MECH. P UM N 17777EE
in ex me mune of the granting of this permit -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT CTO 10,000 CPM) MECHAN ALFEE
SOURCE ULATIONSc. _^ � -
/ I�� Y4�-J-/'/ ,'�3 n� AIR HANDLING UNIT(OVER IO.fNN)CFM) CONSTR Cf10N TAX
Signamreof Applicam/Con err 1,Date EXHAUST HOOD(WMUCT) HOUSIN MITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupamatore orhandle hazardous material HEATING UNIT TO 100,001 BTU)
as datined by the Cupertino Municipal Cads,Chapter 9.12,and the Health and Safety
Code.Section 25532009 + HEATING UNIT(OVER 100,100 BTU)
❑YesVENTILATION FAN(SINGLE RESID) PAID
/ Jn' Date RucaiptN
Will the appliceot or uT lure building occupant use equipment or devices which 1 BOILER—COMP(3HP OR 100,0001 BTU)azardom air contaminants as defined by the Bay Area Air Quality Management
TOTAL:
O9 BOILER—COMP(OVER 100,000 BTU)
` ❑Yes -
(have read the hazardous con enals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE E
femin Hearth&Safety Code,Sections 25505,25533 and 25534.I understand that if the NE W RESIDENTIAL SUCH. SQ.FT. u
building does not currently have tenant,that it is my restsura bi lity to notify the occupant
of The re71(/E mrd whJ'Lh muCSfy,e� et prior to issuance or a Certificate of Occupancy.
Owner or authorized ageni I Dine TOTAL: ISSUED BY:
OFFICE