S 3076 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C76ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECTRI AL l`7
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLIC TION SUBMITTAL DATE
it 144
OWNER S N PHO ;; CONTRACT'OR'S NAME: LIC NO,'� 1 11 ^ ` NIC CONTROLM
• ARCHITECT/ENGINEER'. LIC NO: ADDRESS: _{1O PV ❑
l N LW �o
CONTACT: PxorvE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
e l� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWay th Secdmnl00o)of Divnioa 3anheBnlnesaaaa Profeaahtna p,le,onto mL
yucamen RESIDENTIAL,
X100 WI PERMIT ISSUANCE -YJV
F W^ mull force an t Lk LQ 1 ❑SFDWL El KITCHEN REMODEL
ZUyr; License Cl ass _ act. _Lie# vG APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
y d ul Das Conor �•
F P w ARCHEI EC DECLARATIONPANELS ❑MULTI-UNIT ❑MODIFISTRUCURAO
z O m'z 1 understand my plans shall be used ns public records MODIFlCATIN
OzN,G UP'10200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F as F'W Licensed Profeaxinnal 201-1000AMPS IMPROVEMENT SWIMMING POOLS
M OWNER-BUILDER DECLARATION OVER 10(X1 AMPS El BATH RF,MODEIJREPAIR DEMOLITION
q6� X'd I hereby attar...that 1 roc exempt frena the Contractors License Law future
X O Q.
W U following ami n.(Section 1031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. THER
W 3 0.F which rectums a permit a Construct,alter,improve,demolish,or repair any structure �{ (J �G7✓ L1..1�.lk+li�-
F�O prionmits issuane,also qui Naappliwntfarsu uo len signednlutememt SPECIAL CIRCUIT/MISC. ktfL IC_
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter9
�J OO (commendng with Section9000)of Division 3 of he Business and Pr..fesslonsCede)mr TEMP.METER OR POLE INST. is COMMERCIAL:
0.apa e C that he is exempt therefrom and the basis for the alleged exemption Any violation of ) ❑NEW BLDG/ADDITION ❑DEMOLITION -
y Section 9031.5 by any applicant fo,ape.i.sub)oces the applicant to a civil penalty of POWERDEVICES / El TENANT ❑FOOD SERVICE
F.
e,more thin five hundred dollars($500). IMPROVEMENT
~=QUI,as owner of he
propery,or my employees with wages as their sole compensation, - SWIMMING POOL ELECTRIC THER
p• will dile work,and the 7,amre is nm intendedamlTered for sale(Sec.1044,Business
m and Professions Cade:The Contractor's License Law does not apply lit an owner of OUTLETS-SWITCHES-FIXTURES
propery who builds or improves thereon,and whe does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT
sale If,hnwevar the building or Improvement is sold within one year ofeompletion,the SQ.UP.FLOOR AREA $ISQ.FT.
mer-builder will have the burden of proving that he did not build lir improve for put-
[
sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
instruct the Dome,(Sec.9044,Buonmse and Professions Cole:)Tim Contr dors Li-
ns,Law does not apply m to owner of propeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contrecmrs)Iicunsed pnrsuanun the Crmwmors
License Law. PERMIT ISSUANCE.
E]I am exempt under Sec. ,B&P C fonhis reason
ALTAR-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DEVICE (( •�
I berehy affirm under penally ofpe Jury one ofthe following I I atim s �p
❑ I havered will maintain.Cenifrde of Consent toself-inure far Worker's Compen- DRAINS-FIAOR.ROOF,ARE ,GOND. STORIES TYPE CONSTRUCTION
satimn,as provided for by Section 3900 of the Labor Cade,for the peffnrmance of the
w rk for which this permit is issued FIXTURES-PERTRAP
1 have and will maintain Workers Compensation Insurance,as required by I&
00 of the Labor Code,for the penetrative ofthe work for which this permit is •��. -EA.SY T M-I I 74 UTLETS OCC,GROUP APN
M Work�tt y}�.aria jp� e ((�� and Polic
Cortico A�m•l0 nleltMOJ�Policy No,: t GAS- ASY -O 5A) -
CERTIFICATEOFEXEMPTIONFROMWORKERS' R A S INTERCEPTOR
COMPENSATION INSURANCENa BUILDING DIVISION FEES
(This sermon need not be completed tithe permit is for one
dolly 1001 GREASET
...less.) PLANCHECK FAP.
I cerify that in the performance of the work for which this permit is issue ,l shall SEWER-SANITARY-. MEA.200 FT.
not employ any person in any manner so as to become subject the Workers' or®ty- ENERGY FEE
Z scion Lawsof Califcmir.Dae J ENT LECCR
O Applicant GRADING FEF,
I NOTICE TO APPLICANT:If,after making this Ciminero,of Exemption,you should WATER SYSTEM,TREATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Cade,you must
{ai) forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID A k, Receipt#
1 berehy affirm thvuhac is a constructionlending vgemy Entire perfommncemf
U the work for which this petmil is issued Eire.3197,Civ.C.)
k" Lender's Name TOTAL.
L) Leader's Address TOTAL:
�" I certify then I have reatl this application rad emu thrt the above infmfmmlort is BUILDING
U1 correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z building construction,and hereby authorie,representatives of this city to enter upon the SEISMIC FE
above-mentioned pmpemy for inspection purposes. PERMITISSUANCEi
(We)agree to save,indemnify and keep M1armilio less the City of agalnsn ELECTRIC
Ishilities.judgments,costs and expenses which may in any way acerae agalaasaid City ALTERORADDTOMECH.
PLUMBING FE
in asequence cribs granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM) MECHANICAL FEE
SO, CE REGULATIONS
U,7-i �'S AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sincourreof ApplicantUistracmr Due`�, EXHAUST HOOD(WOUCf) HOUSING MITIGATION PEE
_ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant ammo,handle Novo national HEATING UNIT(TO 100,00(1 B'i'U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^. �✓ HEATING UNIT(OVER Egigh)BTU)
El Yes (tea VENTILATION FAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR Ica,"B'Cut TOTAL: z
District? BOILER-COME(OVER 100.00)BTI3)
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER 0ISSUANCE DATE
front Health&Safety Code.Sections 25505,25533 and 25534.1 understand ilea,if the NEW RESIDENTIAL MECIL SQ.PP.
building does not currently have utearn,that it is my responsibility to,notify the mecepanl
( enquire a which must be met prior to issuance of aCemificatc of OccuE,Y, y
Owner or alnhariud agent Data TOTAL: •(/� ISSUED BY:
OFFICE