S 1865 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERS U al
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 1865
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
6092-30
C R'S NAME: PHONE: CO RACT(lR'S NAME: /y ,` LIC NO'.
7Z —t-7 �� k/.�kKy` NIC CONTROL#
qW.ARCIII E /ENGINEER: LIC NO: ADDRES ❑'
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
p, 53-0615 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Wata mn9 otnm
QTY. ELECTRIC PERMIT FEE
1 hereby affirm that l licensed ander pmvi.inr chapter 9(eenelnK JOB DESCRIPTION
OO with Section 700T.f Div191un 3u171he Hin and Pmficomr,Codr,vnd my license is RESIDENTIAL'
C W in full force and effect, PERMIT ISSUANCE ❑SPDWI. [I KITCHEN REMODEL
aUV Dan.Live Class _ Comp APPLIANCES-RESIDENTIAL El ADDITION �MBING RE-PIPE
yQL Dan.-TS DEC,
ARCHITECTS be
DECLARATION [3 MULTI-UNIT ❑STRUCTURAL
PANELS
0 z l understand my plans shall M1e useJ as public records MODIFICATION
O Z.-� UP T021111AMPS ❑INTERIOR [I CHIMNEY REPAIR
F'a'..tul Licensed Professional 201-1000AMPS IMPROVEMENT
.l ❑SWIMMING POOLS
Y OWNER-BUILDER from
DECLARATION
C�� I herehy xffinn[hal 1 am exempt from the Comracmr's License Law fur the OVER 1 El BATH REMODEUREPAIR (]DEMOLITION �
O ti U following mason.(Section]031.5,Business and PrCode:Any city or county SIGNS I - ❑OTHER
W a a y which reyuire9 a permit m const....,alter,improve,demolish,or wadi,any-slanere
�og'tainr,oit,issuance,also naloae9theapplicant fa ,arhpermitlafilensignedontement SPECI LCIRCUI'I LSC.
rthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
X 00 (commencing with Section 9000)of Division 3 of the Business and Professions Code)on TEM METER '-1 sT COMMERCIAL: ,
c.W o c .hot he i9 exempt therefrom and the basis for the alleged exemption.Any now, ❑NEW BLDG/ADDITION ❑DEMOLITION
kso
4. section 7031,5by any uppllenm for a broad sabjat,the it,licantm a civil penalty of Pf) CES ❑TENANT ❑FOOD SERVICE
F y y nal more than five hundred dollars($500). - IMPROVEMENT
QM T.a9 owner of the tragedy,or my employees with wages a9 their sale compemeaion, SWI
HO will do 0ewmk,and nt
lhestemmi,not intended or offered forsale(Sec.1044,Business -. El OTHER
63 m and Professions Code:The Contractor's License Law daps not apply to an owner of OUTLETS-SWITCHES-FIXTURES
^ progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided[het such improvements are am intended or offered for NEW RESIDENTIAL ELECTR SQ FT-
sale.If,however,the building or improvement is sold within one year ofcompletion.the SQ.FT.FLOOR AREA $/SQ.FT.
er-builder will have the burden of proving that he did not build or improve for par-
paw of'ale),
❑ I,as own,,of do,properly,ora exdusivnly contracting with licensrd cnntraem,s to TOTAL:
conamct the project(Sec.1000,Basins.and Pont.sien,Cadeq The Comrade,,Li-
wlmseLaw docs not apply toanownerofp..bray who builds or improves dmreon,dad QTY. PLUMBING PERMIT FEE
conmaras rnrsuch prsjeets with u contractors)licensed pm,not to Ire Comradou's
Ltec aw. PERMIT ISSUANCE
lam exempt under Sec. ,B&PCfer.h)9reawn
Owner DoleALTER-DRAIN&VEST-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby olFrm under penally of perjury one of the following deelamtions:
[have and will mainwinaCenifcme of Gmsem to self-insure for Worker's Compen- DRAINS-FLOOR ROOEAREA.CONE. $TORIES11 TYPE CONSTRUCTION
sati,a,as N for by Serino 3900 of the Labor Cade,for Ne perfnnum.of the
which this permit is issued. FIXTURES-PER TRAP
wort hove and will maintain Warkcr's Compensation Insurance,as retained by Section
3100ca he LaborCode.fonhe pedinmanceofthe work far whichtbis peril is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP ARK
MyWor 'ti nsur�hce and Policy
Cartier: amtR °"hey No.:/�9 ]9601 GAS-EA.SYSTEM OVER 4(EA)
CERTIP ATEOFEXEC IONFROMWORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION_FEES _
(This section need not he completed if the permit is game hundred dollars($1WE GREASETRAP
?r less) PLANCHECK FEE J
1 vanity that in the performance o[the work for which this permit Is issued,l shall
al employ an person in an amnnefso m m became'a ect to the WorIw"'Gmt SEWER-SANITAkY-STORM EA. FT.
n
Z satin Laws of California,Data
] pen- ENERGY FEE
O Applicant I WATER HEATER WNENTTLECTR GRADING FEE
F-t [meq NOTICE'CO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMG READING
b-t became surjecf m the Wonkeds Compensulinn provi,oup of the Labor Code,you mart SOILS FEE
.. forthwith comply with such provisions or permit shall he deemed invoked WATER SERVICE 3
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL SIDENAL PLMB. SQ.FT PAID
:D z hereby affina that is u consumption landiagagency for the perrormance of Dale Receipt#
4;. 0 the work far which,hi,permit m omed(Set.3091,Civ.C.)
C)U lenders Name �� TOTALWLeader's Address IOTA
I unify that I hove read this application and state that the above inf..them is BUILDING FEE
;Zi correct.i agree to comply with all city and county ordinances and state laws relating.. QTY. MECHANICAL PERMIT FEE ' -
U banding consumption,and hereby amhorim represecGives of this city to enter upon the SEISM FEE,
above mentioned pinpeny far Inspection°puryn9as.
(We)agree to save;lndrmnlly and keep harmless the City of Cupertino against PERM IT ISSUANCE ELECTRIC PEE
Imbil'aies.judgmen.9,caslsend expenses which may irony way accmeagain9t said City ALTER OR ADD TO MF.CH, PLUMBING PEE
in onsetue a of the Kmnlio,of this permit.
APPLICANT UNDERSOS ANISW MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,0011 CFM) MECHANICAL FEE
URCE REGU
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signmum anU rampant
mem V Dome EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE:
ill the aptlicmt or future buildingact...rustereo,handle hazardous material HEATING UNIT(TO 100.000 BTU)
is defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safely
Coda,Section 25532(°)^. HEATING UNIT(OVER 100,000 BTU) „
❑Yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID -
Date Receipt#
Will the air
matador building by the
Area
Air
Management
BOILER-COMP QHP OR 100,000 BTU)
emit ervrtlous air rnntmninunt,s as defined by the Bay Area Air Quality Management .OTA 0
DI9trICR
F7 We EINa BOILER-COMP(OVGR 100,000870)
I have read.h Imeardamsnmle'aL requirements under Chapter 6,95 rAIR CONDITIONERlhe Cali- ISSUANCE DAT///E���
fomia Health&Safety C d Sections25505 25533 d 25534 1 underhand that if the NEW RESIDENTIAL MECH. SQ.FT ,�/ ` Q�
buildingdoes til flyh tenant.had l:my rydnsibltyt notify the ncculen (p Le
of the y ' ..which m IM1e atpris t of, rfl cote fOtoate,
Owner or authorized ages.. Dates TOTAL: ISSUED BY:
Q
OFFICE