S 0276 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
UITY OF UUPERTINO . : - BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 0276
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
10209 Carmen Road 1-21J.
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: . LIC NO:
Westernair Mech. 654579 NMC CONTROL If
ARCHITECT NGINEER: . LIC NO: ADDRESS:. ❑ ..
CONTACT: PHONE: BUILDING PERMIT INFO I.
- - ❑ Consultant Fees Paid by Applicant(Initial) -BLDG a PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION -
�Z with Section 7")of Division 3 ofthe Business and Professions Code,and my license is - R SIF DSI
in full force and effepr, PERMIT ISSUANCE
M] License Class —20 1# 654579 ' ❑SFDWL ❑KITCHEN REMODEL
�� Date��-}-6- -C��—Contra tnr�j�p�Q - _ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE -
[.py> ARCHITECTS DECLARA716fT�@-r ,PANELS ❑MULTI-UNIT El STRUCTURAL
z8vv1R Iunderstand my plans shall be used as public records 1 MODIFICATION
OZ%d� -. UPTO 200AMPS El INTERIOR ❑CHIMNEYREPAIR
Licensed Professional 201-!"AMPS IMPROVEMENT SWIMMING POOLS
'OWNER-exempER m the Comment OVER I(XIO AMPS - ❑BATH REMODEfJREPAIR ❑ •MOLITION
♦aj {{CC�4411 I hereby afFlnn that I R-exempt from the DECLARATION
License Low for the _
O F•U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to contract,aper,improve,demolish,or repair any structure
2y0 prior to it issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCULLMMISC.
a2a y that he is licensed pursuant to the provisions of the Contrector'a License Law(Chapter 9
Iar00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
V• Section 7031.5.by any npplicani for i peit subjects the applicant m a civil penalty of "POWER DEVICES ❑ ❑
ro m rmTENANT FOOD SERVICE
not mare than five hundred dollars($5110). IMPROVEMENT
❑1 as owner of the popery.may employees with wages as chairsole compensation, SWIMMING POOL ELECTRIC - -
L5. will Bothe work,and thestmeturo is not intended or offered mrmle(See 7(k,4,Business ❑OTHER
INSand and Professions Code:The Contraclor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES 7N,
.. property who builds or improves thereon,and who does such work himself or through _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT.
sde.If,however the building ar improvement is sold within one year of completion,the $Q.FT,FLOOR AREA .5/SQ.FC
owner-builder will have the human of proving that he did not build or improve for pur-
pose of oatene - - AL
❑sasowneroftheproperty, Bsinessi and confessions with licensed
mintran's i-
consumer the project(Secapply
o an warn ons and Professions bun Cmde:)no Contractor's Li-'
cense Law d«s not apply a an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE'
who contracts far such projects with a conwemr(s)licensed pursuant ro the Contractors
License Law. PERMIT ISSUANCE
& so
-
❑ 1 am exempt under Sec. ,B P C for this rean - _
Ownpare ALTER-DRAIN&VENT-WATER(EA) VALUATION
owner
WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT..DEVICE
1 hereby alB,m under penalty of perjury one of the following decimations:
❑ I haveand will maintaina CenificawofConsentt6self-insurefo,Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the - - STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for�wsbhich this permit is issued. GAS-EA:SYSTEM-I INCA OUTLETS � DEC.GROUP APN
Myata&S-_ lI1•eRl&nrsu&pce Carrier and Policy 6r77a1e:131 569 GAS-EA.SYSTEM-OVER 4(EA)
Gq Policy No.:V 7 1 1
HsIgYWOF PTION PROM WORKERS' s
COMPENSATION INSURANCE GREASF/INpUSTRL WASTE INTERCEPTOR
BUILDING pIVIS10N
(This section need mf be completed if the permit is formal hundred dollars($Im) FEES
ter less) GREASE TRAP PLANCHECK FEE
I certify that in the performanceofthe workforwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner ea as to become subject to the Workers'Compete- ENERGY FEE
0Z smiteLaws ofCalifornia.'Dam WATER HEATERWNENTMELECPR
Q Applicant - "� - GRADING FEE
izy y NOTICE TO APPLICANT.If,alter making this Certifcutc of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
W forthwith comply with such provisions or this Permit shall be,deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH SQ.FT. PAID
U 0 I hereby affirm that there is a constmclion lending agency for the performance of Dateces,tt
LL the work for which this permit is issued(Sec,3097,Civ.CJ __
Q (•" Lenders Name TOTAL:
WLender's AddressTOTAL:
L4 1 certify that I have rend this application and state that the ahavt infannatimn is BUILDING FEE
correct.l agree to comply with all city and county rush...cea and data laws relining to QTY, MECHANICAL PERMIT FEE,
building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Continuo against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. -
in cousequaten of the granting of this permit, PLUMBING FEE
AP LICANT-UNDERSTANDS VD WILL COMPLY WIT ALL NON-POINT AIR HANDLING UNIT(1'O I0,000 CFM)
S EC LLAT N5. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,tXl(i CONSTRUCTION TAX
ign.1me ol'ApplicurnifiCtimusluir - ate EXHAUST HOOD(WMDUCT) HOUSING MITIGATION FEE t
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building meupantstore or handle hazardous material HEATING UNIT GO 100,000 BTU)
as defined by the Cupertino Municipal_Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)4HEATING UNIT(OVER 100,000 BTU)
i
El Yes - )Nm' - PAID - J
VFNTILAI'IDN PAN(SINGLE ROSID) Data ReceiprM
Will the applicant or nt,a holding by the B use aqui it Qu or devices which
C emit hazardous air cmnaminatlts as defined by the Bay A.Air Quality Management BOILER-COMP LHP OR I00,000 BTU)
DistrictTOTAL:
❑[ ��, ////
Yes `�INo BOILER-COMP(OVER I0),(100BTl1
1 have rend the hazrralm s materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE "
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the oquh me ax which must M mel Moro issuance of a Centralia of Occupancy. L
Owner at,authorized agent' Date TOTAL: ISSUED BY: TD
OFFICE