S 1750 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CNY OF CUPERTINO BUILDING-E.LEC`FRICAL PEtff No 1750
nUn,nINC UIVIs1DN APPLICATION/PERMIT PLUMBING-MECHANICAL. `V
BUILDING PROJECT' DENTIFICA'I'ION
BUIL DI�DRESC: SANITARY NO, AP(/PLLICATION SUBMITTAL.DATE
C Lk
Iwo
NaD
PHONE: ONT :-UIt;Sj.'AMIi: ,ICN r VKill ,VLA! NIC CONI' OI.»
I*PE INS
^.
IIITEC`UENGINEER I LIC NO: C-I ❑
)N1'A'CfII
/: ,A PHONE BUI❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PERMIT
'NPO
NI
Consultant
NV L� ❑ V ❑ C9�
LICENSED CON'fRACT01t. ECLARATL N QTY, ELECTRIC PERMIT FEE
here y 7000)of
that vis I pm licensed under provisions of Chapter Y(commencing JOB DBSCRII'TION
Z with Satian]IX)f)lof Division Sof the Business and Professi�nsCde.and mylicensc is RFSIDENTIAI:
IW-c� LJlfmccandeRecl.p � L4 Il II PERMIT ISSUANCE
�UV License Class `O0 Lic.N 1 `�'`�� ❑STOW, [I KITCHEN REMODEL
tFiOU Lice Conm,anr APPLIANCES-RESIDEN'I'[AL []ADDITION ❑PLUMBINGRF.-PIPE
F.D m PANELS MODIFICATION
ARCHITECTS DECLARATION ❑MULTI-UNIT ElSTRUCTURAL
O Z.N.Z 1 understand my plans shall be used as public recto
Ms
UP'I'02(N1AMP5 � ❑INTERIOR ❑CHIMNEY REPAIR
W Lueemed Professional 201-H)D1AMPS IMPROVEMENT []SWIMMING POOLS
G F`�
OWNER-BUILDER DECLARAI ION OV13R II1f10AMPS ❑BATH REMODEIIREPA1R El DEMOLITION
1 hereby ulDrm)hal 1 um exempt from the Contractor's License Law for the
52Xp6V following reason,ISectinn 7031.3.Rosiness and Professions Cale:Any city nr county SIGNS ELECTRICAL [I OTT
R
W3
LLE` which requires a permit to construct.Whet,improve,demolish.or of any ,met.. N
ElyO prior to its issuance,also requires the applicant lural pemlino lileaslgnedaaameal SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of one Contrumora License Law(Chapter 9
(commencing with Section 7000)ofDivision 3 of the Businessand ProfmionsCde)or 'I'P.MI'.METER OR POL6INS'1'. -OMM R IAL: J C
a ty o K thin he is exempt therefrom and the basis for the alleged emmplion.Any violation of ❑NEW BLDGIADDITION LJ DEMOLITION
ern
Section 7031.5 hynnyapplicam fora pertnitomjectstheapplicam tea civil penahyof MOWER DEVICES El TENANT ❑FOODSERVICE.
�y nt mom than tivc hundred Jollurs($50T. IMPROVEMENT
Q 0 Lmownerofthepmperty,ur nay employees with wages us pelade compcnuation, SWIMMING Pool,ELECTRIC
E- will do thavi,el and the nmcmreis not imendedoroB'ered forcule(Sce.]IWL Business El OTHER
d3 m and Professions Coe:The Central License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES '
property who hold,or improves thereon,and who does such work himself in through
his own employees,provided that such improvements arc nal intended or offered lin NEW R17STDENTIAL ELECI'R SQ FT
svle.If.howeve,the huilmal Improvement lssdd wiomoncycarofennggctim.the SQ.1 'I OR AREA $/SQ.FE
ownerouilder will have the burden of proving that he did nal build or improve for plus
putt of soled.
L as owner of the property,am exclusively contracting with licensed conttnctors to t]TAf. /
cn r,run Ne project(Sec 7044.Business and l'n,feeshom Code:)Tbe Cantractod,Li.
cause Law does not apply to an owner of property who holds or improves thereon,and fy
, 1 BI .RMIT FEE
who contracts for such projects with u contractur(s)licere l pursuantto the Contractor's
License law. PERMR ISSUANCE ! C
0 Iumexemptunder Sec. ,B&PCfa,hisreason
AL:TIiR-TRAIN&V13NT-WATI,R(IiA) VALUA ION
Owner Data
WORKER S COMPENSAT R N DECLARATION RACK FLOW PROT[CT.DEVICE
1 hereby affirm under penalty of perjury one of the following declaatiom
I have and will,aaimaina Cenifcme of Consent to self-imure for Workers Compel DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
n,as provided Tsar by Section 3701 o1't)ae Ladwr CaIl for the perilunate of be
work for which this permit is issued FIXTURES-PER TRAP
I hove and will mafmain Worker's Compensation brothers,m required by Section
]IXLoftheLuba Cacti the performance of the work for hictolan.p�ermiitt ifsissued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCOROUP APN
My Wor 'o, Im'j,r art randy No,^J'WpFe•blt."7 I"L7[J
Currin �Pmicy No, ' 1 GAS-13A.SYS'fI1M-0VER4(EA)
Cli FICATF OF EXEMPTION FROM WORKERS' GRIiASE%IND US'TRL WASTIi INTERCF.YfOR N�
COMPENSATION INSURANCE A HUILDING DIVISION PERS
(This uctionnmdnot bemmplemJ i(Ihc permit is for vnchvndral Jnllars(Elq)) GRI?ASE TRAP
nr less) L. FEE
Loy anytpatlnin perrnnnnerols t bee for which this perthe al Wi.vissued,r.%Co posholl %SEWER-SANITARY-STORM EA.201)Fr.
not employ any person in any manner so as na become subject to the Worker'Cnmpen- ENERGY PEa
Z cation laxsof Calif9miv.Date WATER HEATER WNENT/ELF.CR
O ,�RAttING PEE
OI.. NO[IApidE s
rn NOTICE TO APPLICANT IL alae making this visoul of of Bxemption,you ehmulJ WAT13R SVSTI3M/TREATING �� J SOILS FEE
a ; femme subject to the Wardens Compensation permit
hal of the rnbm Code,you tete,
�
forthwith comply with such provisions or thin permit shall be Jeemd revoAcJ. WATER SERVICE
as
CONSI'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
O 0 I herebynflirm that lherc is a eman tin i lending agency to, perfnrmenmof Date R eip
L) - the work for which this permit is issued(Sec.3091,Civ.CJ
Lenders Name OTA,.
O CUS1 Lender's Addmss TOTAL:
I certify that 1 terve real this applicmion and sate tion the above information is BUILDING IRE
ftl correct.I agree to comply will,d1uhy ane em,my rNinunms mW msec htwa relating In QTY. MEC)IANICAL.PERMIT FEE
(J Z bteddi cnnstructinn,and hereby nmhorim represenatives of this city mentor upon the SEISMIC PEIi
ahtrve-mentioned property for inspection purposes. PE MIT ISSUANCE
(We)agree 1.save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,resistant expenses which may in any wayaceme against said City ALI 13R OR ADD TO MECH.
at asequence o1'the counting of this perm,. PLUMBING TEF.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH AL1.NON-POINT' AIR HANDLING UNIT(TO 10.(XX)CFM) O
SOURCE REGULATIONS. //!! p� M[CHANICAI.FEE
y AIR HANDLING UNIT(OVER 10./100 CFM) CONSTRUCTION TAX
Signature of Applici NContmcn Date, 0 EXI IAUST IIOOf)(WIDUM) I ROUSING MITIGATION VIiE
AZARDOIIS MATERIALS DISCLOSURE
Will the applicant or tun.building rccupam,tore w handle h Zaaka s material liiA'1'ING UNIT'(70140,11011 RTU)
as defined by the Cupettina Municipal Cdc,Chapter 9.12,and he Health and Safety
Coda Section 2111fUl )? HEATING UNIT LOVER 100,00 BTU)
E]yes [-1 No PAID
VENTILATION PAN(SINGLLs RESID) Dam Recei tN
O W511 the applicant or labor,building occupant u¢cgvip ram or devices which
.it haadom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMI'(JHP OR IW.fI(10 BTU) T AL.
istrim^, HOILER-COMP(OYER 110,01X)BTU)
❑Yen 7 N
I have read the hmzNnm mammals requirement-under Cloutier 6.95 of the CutsAIR CONDITIONER —/2-
'.-'a'
'ISSUANC(E7pATE
fomia Health&Safety Coude,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDE N'I'I Al.SUCH, SQ.FT. t — Z 7 (lam'
bmHd na one,sen harmer,have a ucnams,hall k my no,a abday lm semi 11 me ovemoul
of the acquirements which mull be mel our to issuance nl'a Caudill of Cerea ncy.
Owner tor amhorimd agent Data L: ISSUEDBY:
OFFICE