S 0123 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT •PLUMBING-MECHANICAL. (� 01
BUILDING PROJECT IDENTIFICATION S
BUILDING ADDRESS: p -1 SANITARY NO. PLIC�ON 523
,AL DATE
/"T"I0 �cenC/ A
� CT
OWN[i); IPHONE
CONTRACTORS N/rM^ �'dI LIC NO�
17 NC CONTROLtl��� q� N
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
?.70 d a.✓III+11 f 1!' SSIJ
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ E-1 i . O
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm thin I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
X36 with Section 900()of Division3ofthe Rudimental Formedcons Code,amdmylicamris PERMIT ISSUANCE RESIDENTIAL'
F Wr in full forcerinfl tq6 t (��f(r.�. -- OSFDWL ❑KITCHEN REMODEL
�U License Ims UU Lic.# Y
N Da¢ Contra v •• q'rJ 'h 3 A PLIANCES-RESIDENTIAL ❑ADDITION [IPLUMBING RE-PIPE
ARCHITECT'S DECLARATION PA LS ❑MULTI-UNIT ❑STRUCTURAL.
Z O � I understand my plans shall be used as public records MODIFICATION
OZ— UPTO WAMPS - '[I INTERIOR El CHIMNEY REPAIR
F4 W Licensed Pofessiomal 201-1000 PS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
O d OVER 1000 PS ❑BATH REMODEL/REPAIR El DEMOLITION
�0 ad I hereby aff rte that I am exempt from the Contractor's License Law for the
?YG?55 U following reason.(Section 7031 5,Business and Professions Code:Any city or county SIGNS ELECTR L ❑OTHER
F. which requires a pernit to concoct,alter,improve,demolish,or repair any structure L.—)Qr'Cr
yy.......Jiii prior to its issuance,also requires the applicant nonsuch permit to file a signed statement SPECIALCIRCUIT/ C. Qj//•ke.w l.ir
y What he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W -•p0 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE ST. COMMERCIAL,
that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Setian]03LSbyanyppcan
alitforaper habjeastheappliwnnacvpenvyo
ttiilltf POWER DEVICES
nth rEl TENANT ❑FOOD SERVICE
not more than five hundred dollars SD . IMPROVEMENT 1]I,as nwnerof rhe property,or myy employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
.H. will do thewon,aad the he Continuum',
Fiverd or offered fu net
apply to aBusiness ❑OTHER
3 and Pmfesxions Code:The Contracmr'e License Law ems not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended m offered for NEW RESIDENTIAL ELECTR S
sale.If,however,the building or improvement is sold within one year ofcomplenion,the - SQ.FTFLOORAREA $/SQ.FT.
owner-builder will have the burden of proving that he did non build or improve for pur-
poseofsale.). - TOTAL: PAID
I,as owner of rhe property,am exclusively contracting with licensed cmeracmrs In
construct the project(Sec.70TL Business and Professions C...)I—Cmrtmnrore Ll- - JULrse Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT F FU -g
who contracts for such proems with a wmmclor(s)licensed purxmm to the Crnlramars
License Law. PERMIT ISSUANCE �1�(�(�
1 aexempt order Sec. ,B P C builds reamn / ftv
[_] m At (��- `•
ALTER-DRAIN&VENT-WATEREA) VALUATION
Owner Done
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
C -I hereby uffirn under penalty ofp jury one ofthe following declarations:
❑ I have and will maintain a Certilicnte of Consent to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA.COND.
so ion.us provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE.CONSTRUCTION
rk for which this permit N issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation hermarce,as required by Section -
aft heLabmCaJe,fortheps, rmnnce ofthe work for which x�th(is Permit(/is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP ANN
M,WCannot: Policy
"IcAumn u a carne Pnlidcy NicyAWO L�Vw1 •l GAS-EA.SYSTEMOVER
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASDINDUSTRL WASTE INTERCEPTOR -
(This a ctien incense be completed if thepetmit is future hundred dollars sI00) BUILDING DIVISION PERS
or less.) .. I GREASETRAP PLANCHECK FEE
I cerifythat in theperfonmanceofthe work for whichnhis pertain is issued,I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to Become subject to the Workers'Compen- ENERGY FEE
senior Laws of Califomia.Dare WATER HE W/VF.NT/ELECTR
Applicant t GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
abecome subjecrto the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such previsions or this permitshall be deemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUME. SQ.ET. PAID
U G l hereby affirm that there is v construction lending agency for the performance of _ Data Raccipe If
W H the work for which Nis permit is issued(Sec.3097,Civ.C.) -
O Lender's Name TOTAL:
Lender's Address - TOTAL:
LL I certify that 1 have read this application and state that the above information is BUILDING FEE
H V1 correct.I agree to comply with all city and county ordinances and seam laws relating to QTY. MECHANICAL PERMIT FEE
U 7 building conmruction,and hereby authorise representatives of this city to enter upon the SEISMIC FEE
ince-mentioned property for inspection purposes.
(We)agree tosave,indemnify and keep harmless the City of Cupertino against MIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme againstsaid City ALTE RADDTOMECH.
n quenceofthegr mgofthispertil, PLUMBING FEE Lt
A CANT UNDE ANDS AND WILL COMPLY WITH ALL NON-POINT AIRHAND GUNIT(TO IO,IXq CFM) MECHANICAL FEE
I CE REGO
(T-r1f—C,. � AIR HANDLING a(OVER 10,(IINICFM) CONSTRUCTION TAX
Signature of Applaturn Contractor Date EXHAUSTHOOD(W/ CT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle forearms material HEATING UNIT(TO Its), TU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cods,Section 8532(a74 HEATING UNIT(OVER IW.000 ) -
E]Ves ❑No VENTILATION FAN(SINGLE RESIGN PAID "-
Data ReceiptN
Will the applicant Or entre building occupant use equipment or devices which BOILER-COMP(3HP OR 100,WO BTU)
coir limitations air commitments as defined byythethe Say Area Air Quality Management TOTAL
District? -
Yes ❑No BOILER-COME(OVER 100,00)BTU)
❑
Kse rend the It smamrials AIR CONDITIONER
'yM' requirements under Chapter fi.95 of the Cali- ISSUANCE DATE
h&Safety Ede,Sections 25505.25573 and 8574.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
e not syyrr tlyhwe ttetTpBtyyts my rc pon.xibilityronrnifytheoccupantellfs li. . issue eonaf lypf upancy.om and agentagentDate - TOTAL: ISSUED BY:
OFFICE