S 0049 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT'IDENTIFICATION
ILDING ADDRESS: // SANITARY NO. PI'LICA'1'ION SUIiMITI'AL DA'I'S
�-O / 111A f'4LAMOS CU !2 ND fE �T�YJ/T S -1-kCC]
WNER'S NA E: , 1� PH07JE: x/ A LOB'S#AML. ��/ LIC NO:
W d) C N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: DRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELFT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEL•
I hereby affirm that l am licensed under provisions of Chapter 9lrommemcing JOB D,SCRIPTION
PERMIT ISSUANCE
with Seat inn]WO)of Divisima3 nfthe Bmierss tied P..deems Codr.mnd my license is RESIDENTIAL:
� in full home and effect.
t-Z�UW-� Lid.N ❑SFDWL KITCHEN REMODELN 6 Date
tLicense Class Cormlor APPLIANCES—RESIDENTIAL ❑AUDITION ❑PLUMBING RF.-PIPE:
6
ARCHITGCFI'S DECLARATION ❑MIJLTI-UNIT ❑STRUCTURAL
ZOvnZ I understand my plans shall he used as public recnNn PANELS MODIFICATION
OZ-, UPTO2WAMPS [I INTERIOR El CHIMNEY REPAIR
F�~4� Licensed Professional 201.10MAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH RFMODEIJREPAIR ❑DEMOLITION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
x 3 LL U following reran.(Section 7031.5,Business and Note svions Code:Any city nr count, SIGNS ELECTRICAL E3 OTHER �f
which requires a permit o construct,miler,improve.demolish,or repair any stracmre
F'LL-O prionu its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCU IT/MISC.
sE�> lhatheislicen¢dpunuantto NCPmvisiomefthe Conincmr's License Eyw(Chapter9
M� (commencingwiNSectinn]oo0)of Division3ofthe Businessand Professions CWe)or TEMP.METER OR POLE INST. COMMERCIAL:
d p,M y' that he is exempt Therefrom end the basis for the alleged exemption.Any ematinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC 4.art Section 7031.5 by any applicant for a permit subjects the applicant lou civil prealtynf POWER DEVICES ❑T17NANT ❑FOOD SERVICE,
[—ZP not mite than five hundred dollars(550(1). IMPROVEMENT
xq6 0 Las svnerofthe propany,ormy employees with wages as Neirsolecompermntion, SWIMMING POOL ELECTRIC
LC wdlJmhcwmk,endNe umnure is not intend#oro@rcdfor sale lSce.]f)44.Business DOTTER
alland Professions Code:The Cionewh is License Law does net apply to ea owner of OUTLETS—SWITCHES—FIXTURES
properly who builds in impmvet]heranu and who lows such work him,If or through
his own employees,provided that such improvements sore not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within one year ofcompletion,Ne SQ.FT.FLOOR AREA SISQ,FT.
ownerbuilder will have the burden of moving that he did not build or improve for Ped,
pose of sale.). p
❑ 1,an owner of the prgnny,a xclusivcly contracting with licensed contractors In TOTAL: PA
ID
construct the project(Sec.71144,Business and Probational Cade)The Ccmracors Li-
cense lxw does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE (I/(A� ^�
who contracts for such projects with a contmparuau
ctods)licensed snn the Contenders ��uyy��(.� a �[pr�
License Low. PERMIT ISSUANCE R[(I 111
❑I am xempt and Sea 'C for �1
Owner Da 1 4
ACT HE—DRAIN&VENT—WATER CA) C 'V'10N
WOHKF. COMI'EN. DECLARATIO BACK FLOW PROTECT.DEVICE
I hereby affirm under pemd1,ub,rnury one of the following declinations:
01haveand will maintain a Certificate of Comsento self-insure for Workers Common- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sun i.ns provided for by Section 37INI of the Labor Code,for the perfori urce of the
work for which Nis permit is issued FIXTURES—PIJR TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of Ne Labor Code.for the pcifnerance ofthe work for which this permit is issued. GAS—FA,SYSfENI-1 INC.4 OUTLETS OCC.GROUP APN
My Werker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No, GAS—EA SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASFIINUUSTHL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This ueionnccJ net In completed if Nepernd is fee..hundred dollars(SIM) GREASETRAP
or less.) PLANCIJF.CK ITiE
I acuity that irt,performened milia work far which this ponuit is issued,I shall SEWER—SANITARY—STORM IEA.NMI FT.
not employ any person in any manner so as to become subject to the Wmkers'Compete ENERGY FEE
.Z satimn Laws of California.Date WATER HEATER W/VENTMLECTR GRADING FEE
O Applicant
.N.0 NOTICE TO APPLICAN'E IL aper making This Certificate of Esconsion,you should WATER SYSTEMOFREATING
a � necome suhject In the Workers Compensation provisions M the LUMx Code,you must SOILS FEE
W forthwith comply with such provisions or this p mens shall be dermad revoked. WATER SERVICE
4Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.l9'. PAID
p Z Ihereb ffirmthat Nere iseennztmetion tendon for the Homaancc of Date Recalls
y e g agency pe
V I"
the work for which this pernil it ismaal(Sec.3097.Civ.CJ
l'" Laaleia Nnnm 'IY)TAL:
lU[I Lender's Address TOTAL:
y 1 certify in.,1 have recall application and state that Ne abeve interaction is BUILDING HE
y amps.P agree m comply with all city and county ordinance,and one laws mlming m QTY. MECHANICAL PERMIT FLEE
V huildingco strueiogand herebyanharive representatives ofatheityo emterupon the SEISMIC FEE
above-mentioned properly for inspection pmpras. PERMIT ISSUANCE
(We)agree to save.indemnify and keep harmless the City Of CuPrame against ELI!C'FRIC ME
liabilities,judgments,costs ata A,ames which may in any way acclurittim asaid City ALTER OR ADD'10 MECH.
PLUMBING FEE
in consequence of ther
gating of this pemdt.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI.I,NON-POINT APR HANDLING UNIT(TO I0J)MCFMI
MIiCfIANICAL I1:0
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IO,INIO CpM) CONSTRUCTION TAX
Signature rob ApplicantsComracmr Data EXHAUST HOOD OYMUCIj
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or future huilding occuparealone or handle hazardous material 1113ATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Gude,Chapter 9.12,and the Health and Sudety
Code,Section 25532(x)' HIEATING UNIT(OVER I W.OfN)It FU)
❑Yes ❑Nn VENTILATION PAN(SINGLE RFSID) PAID
Date RecciplX
Will the appRcam or future building occupant use equipment or devices which
I-` enait Inventions air conmminnms ns Adinal by the Bay Arca Air Quality Maoogement BOII.P.R—COMP(3HP OR 10Q(NNI B'N)
TO'T'AL:
District? BOILER—COMP(OVER 1 W,OW BTU)
❑Yes ❑No
I have read Nc hazurdns maser it),miummmetns under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
Lorna Ile:dth&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MELD, SQ.FI'.
building does not curxnlly[save a tenant,that it is my reslxmsibility In notify the occupmnt
of the requirements which most he met prior to issuance of a Cerilicate of Occupancy,
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE TIT06