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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' , IUILDING- ELECTRICAL. -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICNI'ION
PERMII'No.
29477
BUILDING ADDRESS:
r --C- r
SANITARY NO.
APPLICATION SUBMITTAL DATE
—.22—C14 -
OWNERS NAME: PHONE:
T' A I U „155-x{68
I
MEACf
CONTRACf011'S NAMC: LIC NO:
AI I C VC. A C
"'C
❑
CONTROL
'
ARC :NGINEF.R: LIC NO:
ADDRESS:
9.57 GrvsYleocse Dr. Sslin ?ase
CONTACT.. PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELIiCP I'LUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECof Chapter
I hereby umrm Am 1 am Rthe Ha under provisions ten o s Coyer 9 (commencing
with llfume]deffeeDivision Jof the Busineasand Prnfessinm CWe, nnJ my licensees
LaPoll farce and <Bect. 1 A'
Latina Cl Cl s 0 Lic.# 69ID0
Dme Contractor
ARCHITECTS DECLARATION
I ima erstand my plans shall be used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
El SHAWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
STRUCRAL
❑MULTI -UNIT ❑ U
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR DEMOLITION
[-]OTHER
')4�
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPTO200AMPS
Lensed l'rofessianal
OWNER -BURDEN DECLARATION
1 horchy affirm that I em exempt from thee Camnmmr's License Law for the
flawing mason, (Section 7031.5, Business and Professions Cale: Any city or county
which acquires a permit as ronmrnu, eh,,. improve, den olish, or repair mry nmllam
prior o is issuance, also requires the applicant lin xuch lcrntinO file a signed statement
that he is licensed pursuant to the provisions of the Conuannrs License Low (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cale) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penally, of
not ..,.,ban five hundred dollars (SSW).
❑1, as owner of the property. or my employees with wages as their sole compensation.
will do the work, end theary nim, is not intended a offered forsole(Sec. 7194, Business
Old Professions Cele: The Contractors License law does not apply m an owner of
property who builds or improves thereon, and who docs such work himself or through
his Own empinyus, provided that such improvements are not intended or offered for
sale. lf,however, the building or improvement is sold within one yearol'compledon,the
owner -builder will have the burden of proving that he did not build or improve for put -
Iowa of sale,),
❑ 1, as owner of the Factually, am exclusively conwming with licensed contractors or
,unquiet the pmlect (Sec. 7044, Business ansl Pade,,iorn. Code:) The CanlraeOrI Li -
,lose Lawdus, noiupply Iran owncrof p,,,,my who builds Or improves thereon.and
who contracts for such projects with a emorsormus) licensed pursoamuo the Contractor's
License Lou.
❑ I am exempt under Sec. ,B&P C fm this ..,an
202-10MAMPS
OVER 1(X10 AMPS
SIGNS ELECTRICAL
SPFCI AL Cl RCUIT/MISC.
TEM P. METER OR POLE INST.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT 0FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL CLEC'
OUTLETS -SWITCHES -PIXY
NEW RESIDENTIAL ELECTR SQ
SQ. FT. FLOOR AREA
¢/SQ, FT.
'
A
QTY, PLUMBING PERMIT •;E
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
Owner pate
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affum under penalty of perjury One of the following declamtions:
❑ I have and will maintain a Cenificateof Consent to self-houre for Workers Camper.
sation, as provided for by Section 37W of me Labor Cafe, for the performance of me
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700O1% the Labor Cale, for performance Of the work for which this permit is issued.
My Worker's Compensation Insurance carter and Policy number ore:
Carrier: Policy No.;
CERTIFICATE OF EXEMVI'ION FROM WORKERS'
COMPENSATION INSURANCE
('Ihissectian need not bc,nmplemdif the pomth is Laurie hundred dollars(510,0)
or Iaxs.)
ed Canapall
Icerify thatinthe an, assionw ofAewark forwubje this the unit Workers
not employ may person io any manner sn as m become wbjcct m the Workers' Compen-
faun Laws o(Calilamia. Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLUOR, ROOF. AREA, GOND,
STORKS
OCC. GROUP
TYPE CONSTRUCTION
APN
FIXTURES - PER TRAP
-
GAS -EA.SYSTEM-I INC. 4 OUTLETS
-
GAS - EA. SYSTEM -OVER 4 ON)
GREAS19INDUSTRL WASTE INTERCEVIUR
IIUILIlINO DIVISION FEES
- GRIiASE'1'RAP
PLANCHECK FEE
SEWER-SANITA BY- STORM EA. 211E FT.
ENERGY FEE
WATIiR HEATER WN[M/ELECfR
GRADING FEE
NOTICE, TO APPLICANT. If. after making this Cmificam of Exemption, you should
become subject to die Workers Compensation provision, of the labor Code, you most
forthwith comply with such provisions our this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affrm that there is a construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
WATER SYSTEMTREATING
SOILS FEE
WA TER SERVICE
PAID
Data Receipt#
NEW RRSIDENUAL PLMB. SQ. 1'1
TOTAL:
Lender's Address -
1 ,,oily Ilnat 1 have read this application anti sone that the ..........................
atrcel. I agree to comply with all city and county ordinances and state laws relating m
building construction, and hereby authorize representatives of this city m enter upon the
above-mantioned property, for inspection purposes.
(We) ogre m save, indemnify and keep harmless he City of Cuperin, against
liabilities,judgments, son,,md expenses which may ninny way ucmcridiu st said City
in eir cqucuc gtannng Of thispamiL
APPLIC UN R N A W C WITH ALL NON -POINT
SOU RF
�J C
��_
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
I'IiRMI'1' ISSUANCE . SZ
ELECTRIC FEE
ALTERORADDTOMECH.
PLUMBING FEE
AIR HANDLING UNIT(TO Iff0WCFkU
MECHANICAL PEP.
s ,,.
AIR HANDLING UNIT (OVER IQ000 CFM)
CONSTRUCTION TAX
Srgnaterc of Appli... YCOnwcmr ii D
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicanmr forum building oocupam nom or handle hmmmus material
as defined by the Cupertino Municipal Code, Chapter 9,12, anti the Health and Safety
Cn le. Section 25532(0)'1
❑Yos 'o - '-
Will the 0 limuu or future building
rp g by the Be,l. Ail emot Management
emit haxuNnus air cnnmminunts as defined by the Bary Area Air Quality Management
District?
El Yes X10
I have hand the h7. ous materials requirements under Chapter 6 95 of the Cali-
fomite lieaim& Yi! tions 25505,25533 and 2S5W.1 dcrsand and if Ne
building tit ucurrent ten yAm iPyAy respoyiFKyyTOpgfyQre occupant
EXI IAUST HOOD(W/DUCT)
HOUSING MITIGATION FZC
DENTING UNIT TO 100,00 BTU)
-
HEATING UNIT (OVER 100,000 BTU)
PAID
Y t N ip�
VENI'I[,At ION PAN (S INGLE RESID)
-
BOILER- COOP(3HP OR 100,000 BTU )
(`,i • UW s.rl l HPOTAL:
-/
BOILER - COMP(UVER 100,0100 BTU)
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE