S 1758 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'liR`�}'IT NO.
BUILDING DIVISION APPIACATION/PERMIT III.UM1IIII NG-MECIIANICAL V 1758
BUILDING PROJECT IDWrIk'ICATIOY
BUILDI ApD S5: SANITARY NO. APPLICATION SUBMITTAL DATE
6 �-t ,OWNER'S NAME: P ONE: C A R'S NAN LI NO'.
NIC Cv — V
C IiCI'/P NT: )N(1: DD ItSS
G
CONTnCI': yyy HONE: BUILDING PERMIT INFO
Consultant Fces 'aid by ppHca�( iltial) L FLISCT PL MECH
LICENSED CON'OkACTOR S DECLARATIONs/V• V Q IiLECTRIC PERMIT' FEF.
I hereby affirm that 1 am licensed under provisions of Chapter 9(commenoing JOB DESCRIPTIONWoe, with Section Til of Division 3 of the Busidasond Professions Cale.ndmES
y license is ?ems•.^_ RESIDENTIAL
F n full far.and died. PERMIT ISSUANCE J J 'V
OUF License Class Lia# ❑SFDWL [IKITCHEN REMODEL
yZH Dote Contractor. APPLIANCES-RESIDENTIAL ❑ADDITION ED PLUMBING RF.-PIPE
ARCH1TECFS DECLARATION PANELS El MULTI-UNIT OSTRUCNRAL
OZ y 7, I undema nd my plus shall be used av Public record, MODIFICATION
P+ nF'M Licensed l'menitael Ill'T0200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
a5g X,,4 OWNER-BUILDER DECLARATION 2nLI0W AMPS IMPROVEMENT WIMMING POOLS
y 40 W Q 1 hereby affirm Ihdl I am exemp from the Cnlnmaorn License Law for the OVER I"AMPS ❑BATH REMODEL/REPM MOLITION
x 31Y F following.,an.(Section]031.5,Rosins,and Prolessimm Call::Any city or county SIGNS ELECTRICAL ❑OTHER
4F7 LL O N¢ which requires n permit la construct,aIle,improve,demolish,or repair any swcere
mJ
our to its issunce,also requires theepplicvm for ouch penniue Blca signed stmemem tiPGCIAL CIRCUIT/MISC.
G� that he is licensed pursuant o the previsions of the Contractors License Law(Chapter 9 ' Cho
O Onemenoingwhh Section 700l Division 3ofthe Boviness end l`mmVdonsCoE)or 'TIIMPME
. TER OR POLE INST. 3O•J V COMMERCIAL'
Gly c y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]0)1.36y any applicant tura permit subjects the applicant oacivil penalty of POWER DI?VIC[S
S, t mre othan live hundred dollar%(S5a0). ❑TENANT ❑FOOD SERVICE� C [:1Las oy,wner of the propertor my employees with wages as their sale compensator, SWIMMING POOL ELECT RIC IMPROV17MENT
_ wolf Bothe work.and theswaure is notimended or oRemJ tarsale(Sec.]1114,Business ❑OTHER
W 3 m and Professions Crde:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHP_l TURES
g. Property whit builds(ir improves thereon,and who does such work himself or through
his own employees,provided that such improvements um not imended or initial far NEW RESIDENTIALi? '1'R SQ Fr.
sale.If,howeve,thc building or improvement is sold withmoneyearofcompletion.the TFLOOR AREA Soso.Fr..
owner-builder will have the human of proving that he did not build or improve for par,
pow of.aJe).
❑1,as owner of the property,am exclusively contracting with licensed c0 tic 0 m TAL: SS„ UN 10 11NS D
eased the par.(Sec.]044.llusiness end Professions Cale:)The Conl—".'a Li� g uu FIFO
cense Law does not apply to an awncrofpropeny who builds mintpmves thereomadd QTY. PLUMBING PERM FEF
who,dents for such piajcds with n coma co-a(s)licenved puauum w the Cuntrvdors UC
Lice se Law.
❑ lam exam tun ,B&P farthis reason PERMIT ISSUANCE
ALTER DRAIN&VENT-WATF.R(EA)
Ila' VALUATION
w e R'S E SAT DECe folio ing BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
❑ I havennd will maintain aCenifteamofConsenuosclf-Insure for Worker's Compere DRAINS-1'LOOR.ROOF,ARHA.COND'
soden,as provided for by Section 3900 of the Labor Code,for performar.of the STORIES TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES-PER TRAP
C]1 have unit will maintain Workers Compensation Insurance,as required by Section _
11
3](10ofthe labor Gde,forthe performance ofthe work for which l hispemtit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS iOCC.GROUP ANN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: - Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRI.WASTE INTERCEPTOR
flhls sdlion ncaWtol to enmplomdif oho perntit is fnronehundred dollars(SLIM)) UILU DIVISION 1,'IS
or less.) GREASE TRAP
I cenify that in the performance aDhe work orwhich this fennit is issued,I shPLANCHF Kall t
SEWER-SANITARY-STORM IIA.2W FT.
nuion Law any alifou navy manner sen as to become snhjucuoIse Workea.'Cumpen- ENERGY FEE
Z Applicant
o(Califnmia.Dem
C)
O Applicant WATER HEATER WNENT/ELECTN GRADING F,
g NOTTCETO APPLICANT:Ir.after making this.,CeniOcae of Exemption,you should WATER SYSTCM/fRIiATING
a ; become wm )atolum, t Worker's Compensation pmvlsio,of the Luhor Code,you must 5(111.5 FF.H
forthwith comply withsdch provisions or this permit shall be deemed revoked, WATER SERVICE
d / -W
CONSTRUCTION UiNDINO AGENCY y'_ O'D
r�Tz NEW RESIDIiNT1ALl'LMH. SQ.FT. PAID - �g3xy0
Iherchydfinn that isncodmm.ion lead,ng agency far the perfnrmm�ceaf Uma Rocaipt -1
U the work for which this Permit is issued(See.3097.Civ.C.)
Vlenders Name _
� henJer'x Address TOTAL: TOTAL:
Fy I ccnify that I hove marlin,application and ,are that the drove Inf fitter is _ BUILDING FEE rill
N correct.I agree to comply with all city and away,ominances and state laws relatingm QTY. MECHANICAL PERMIT FEE
UZ building consnuminn,and hereby authorize representatives ofthis city toenmrugm the SEISMIC FEE
above-aaniunal feadny for inspdetion pa,, a,. PFNMH'ISSUANCI?
(We)agree to save,indemnify and keep handless the Cary of Cupertino ngaimt ELECTRIC Ilii?
IiahilitiecjuJgmerns,cosisaid expenas which may many wayummeagainst said City ALTER OR qUU TO MECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICAN9'UNDERSTANDS AND WILT.COMPLY WI'I'11 ALL NON-POINT' AIR HANDLING UNI'1'11010A)0 CFM)
SOUNCHR N5. M17CIIANICAL FEE
AIR HANDLING UNITIOVER 10.00JCFM) CONSTRUCTION TAX
Nig acres carA`Zruea ole I?XHAUST HOOD(W/UI1CD -
HAZARDOUS MATIiR1A1S D15CLOSUHH HOUSING MITIGATION FEE
futas Je411 y the Cupertino Muni building
Code, hapters 9.12r and the Health and Safety handle hatiaradma,..fit .[ HEATING UNIT(TO I(NI,IXp RTU)
Cade,Sooner 23332(a)'I HEATING INTI(OVER I00AXI BTU)
❑Yes FIN.
VENTILATION PAN(SINGLE RESID) PAID Will uthe rubdown or fuue buidin b aroPaeuecomplaint
Date RectiF,p
Our'hosumus air cmaminanrs as define)by the Be,Area AirQuality Management IOILER-COMP OR 100AR)BTU)
/ Sb
U 'TOTAL
Owner,
❑Yes No NOILER-COMPIOVER I0O,INN)BTU7
i have real the hmamaus materials AIR CONIHJIONER
requirements under Chapterrsta ofthe Cali
ISSUANCE DATE
fomia Health&Safety Code,Satins 253(15.8331 dal 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building Barsnotcurrently have amnat thatat isro resat a Calitytonotify the per,
nl the reyuirements whleh most M and priano issuance nl a C'nificata of Oceup:mey.
Owner or amhnnzed agent Dam TOTAL: ISSUED BY:
OFFICE