30203 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMITNO. O
TTY DIG VISI IND PLUMBING-MECHnbBcal.
BUILDING DIR'ISION APPLICATIONIPERAIIT BUILDING PROJECT'IDPNTHICATION
BUILDINGADDRESS: s.-, f� SANITARYNO. APPLICATION SUBMITTAL Di
Ses!/J\J / /— �6
OWNER'SNAM a ' s�U pHON CONTRACTOR', NAMEef 0`1 i LIC NO: lLl
U �!/ l/.// 1/ NIC CONTROL
•ARCHITECTIENGINEER: LIC NO: SS: ❑
1-6
CONTACT: PHONE: BUILDING PERMIT INFO '
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alum thus 1 am licensed under provisions of Chapmr Y(commencing
108 DESCRIPTION
��Z with 5mion]I IT
Oivizion3ol the Business and ProfessionsCWe,unJ my licence is
YW� Lifull force and eR PERMIT ISSUANCE RESIDENTIAL:
Littnx Lica 3 d7 ❑SFDWL ❑KITCHEN REMODEI
N<a Dae Ce Inctm APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
,MG` DECLARATION PANELS ❑MULTI-UNIT ❑STRUCNRAL
Z O�? I understand my plans.hall M used as public records T RUCTU TION
O Z- UPT02MAMPS
E-y F tC
Licensed professional ❑INTERIOR hINEY REPAIR
±Ill-Intp AMPS IMPROVEMENT
CCC OWNER-BUILDER DECLARATION OVER IIs111AMP5 ❑BATH REMODEUREPAIR [I DEMOLITION
row Q 1 hereby affirm that I am exempt from the Cssions o License Law for the
Sg 3 a U which following mu remna(Section]oJ15.Business and Professions Cede:Any city orcountySIGNS ELECTRICAL ❑OTHER
LLl u.n< which requires a,asw re construct,alter,improve.demolish,or repair any structure
hon,OJ pri�rm ib issuance.also rcquims the applicam for such permit to Dkasigned sndemem SPECIAL CIRCUR/MISC.
� and he is licensed pursuanno the Provisions of the Commends Licence Law(Chapter 9
LLZCO (commencing with Sectlor7")of Division]of the Business and Profesionscedetor TEMP.METER OR POLE INST. COMMFRCIAL.
a K n z Nos he is exempt Nertfmm and the basis for the alleged exemption.Any violaion of ❑NEW BLDG/ADDMON ❑DENOLMON
wmm Sectian]DJ LS by any applicant fora pemus subjecuahe applisanamacivil pemlty of POWER DEVICES
a more about Eve hundred dollars JS5oi []TENANT ❑FOODSERVICE
f=C ❑ I.mowner ofthe propem,or my employees with wages m Heir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
pe F- attentive work,and the soucmm isnot intculadmoRered for wale(Sm.]PW,Business OOTHER
W3 and professions Code:The Ciera License Law does nm apply to an...in of OUTLETS-SWITCHES-FI%TURE
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold within one'.ofcompletion,the FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did nm build or improve for pur-
pose of sale.(.
❑ 1,as wnerm the property,am exclusively commuting wish licensed contractors to TOTAL:
ma- u l she project Sm.]DU.Business and Professions Code:t The Comricnrs Li- _
cense Law does not apply to an owner of property,who builds or improves Income.and QTY. - _ PLUMBING PERMIT FEE _ )'I�
who contracts for such projects with a comracmns)licensed purouam to me Cuntmctora
m - 7�
License Law. 1
❑ I aexempt antler Sec. ,B&P C for this reason PERPERMIT6/V ISSUANCE i9 Y^
Owner Dart ALTER-DRAW&VENT-WATER(E)) VALIAMION'J 1,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE •:.f
Ihcrnb affirm under '...J
y Penalty ofConeneofdaefallowingdorkars Ca
❑ phare poavand iddifll orbi Sen a Certificate ofconxm to Code,for
fie Workers Camper.the DRAINS-FLOOR.ROOF AREA.CONIC. STORIES TYPE CONSBCCTIO
salon, r phich ad farm Section J]l of she Labor Cade,(or Ne peKomunce of she
work for which this pemtit is issued. FlXTfIRFS_pFR TRAP
37 1 have and will maintain Worker's Compensation Insurance,h his Per by Section
J]lof the Labor Code.for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-1 WC.00l1TLEf5 OCC.GROUP APN
My Worker P examrracectrim and Policy nu ser
Comer, t policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKS S'
COMPENSATION INSURANCE GREASEoNDUSTRL WASTE INTERCEPTOR
(Thissecdan used not he completed ifthe pmont is for one hundrtNdollum4SI 0) '. (` " :'BUIIDINGOMSICNIMIS=„'j+.:
or less.) GREASE TRAP
I certify that in the perfomunceaf the work for which his PLANCH ME FEE
notem to an Permit is issued,lshall SEWER-SANITARY-STORM EA.+_I FT.
p y y person in any mannm x as m hcnnm subject to she Wmkeri Compen- ENERGY FEE
Q Z ppn Laws of California.Data
Z. LDAApplicant FEWATER HEATER WNENTMLECTR GRADING E
fq NOTICE TO APPLICANT:If,afmr nuking dais Ceinfi me of Exemption,you should WATER SYSITNUTREATING
a7 become subject 10 she Worker's Compensation provisions men,Lthor Code.you most SOILS FEE
fy
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
a0
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V Q Iforwhichido famomm issuedS ca 30G,ding agency far the peRormance of Dam Receipts
kL F the work for which this persaut is issued Isec.Jl],civ.C.)
Q V Lenders Name TOTAL:
� Lendeh Address TOTAL:
C I certify that I have and Nis upplicmion and Inde that the above information ex BUILDING FEE
V) correct.I agree to comply with all city and county ordinances and same laws relaxing to QT . MECHANICAL PERMIT FEE
L) Z building construction.and harmytiam..ue mpmxnndvesnfooschymmuntiperam SEISMIC FEE
above-mentioned property for inspection Purposes.
(We)a ree m save,indemnify PERMIT ISSUANCE ELECTRIC FEE
g y and Imp harmless the City of Cupertino againu
liabilities.judgments.coeds and expenses which may in any way acerae against said City ALTER ORADDTO MECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT SOUNEGUATIONSS.
AIR HANDLING UNRITO IO,ItBB CFM)
FE
LMECHANICAL E
`` .-.L �/// 10,000AIR HANDLING UNIT(OVER 10,000)CFM) CONSTRUCIIONTAX
Signs I A,fiet alCon/ Strac or / 'Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the up,thcom arPomre huildir,cer.punalmmorharml.havardou,muiuial HEATING UNITITO plants)BTU)
as diluted by she Cupertino Municipal Cede.Chafer 9J'-,and the Hadan and Safety
Code,Section 25532(at] HEATING UNIT(OVER Il.nt)B BTU)
❑Yes n
• VENTILATION FAN(SINGLE RESIDI PAID Data Receipt s
Will dthe air contaminants
in nts aure building niche B use ea Air a of devicex whim BOILER-COMP t3HPOR 1010.00(i
mit hatallous air cunnminanb us JninN by she Buy Area Air QualitY ManagementTOTAL:
Diwnef!
[D Yea doNoBOILER-COMP(OVER Int).ntNI BTU)
I have mwl the hatsexims materials requirements amder Chapter 6.95 of the Call, AIRCONDUIONER ISSUANCE DATE
forma Hmlah as Safety Code.Sections 255n5,25533 and 25574,1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building hic,nut embently have.aenam,thus it is my msrymsihlliay m nmily the tan,min
ol'the requirements which must be mea prim to Issuance of a Ccndicun of Oceopency.
Owner or uwhoneed agent Daae TOTAL:
ISSUED BY:
OFFICE