S 0990 (2) AISPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECTRICAL,L. J a71g11T N°. 0990
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
IIUILOINO ADDRESS: // Iy�y�-�' c�/{/y/�� SANITARY NO. APPLICATIIOyN SUBMlITTAL DATE
qqbOWNER'S �C TRACE R' LI O://?� Z V /
/E NIC CONTROL.
CHITFCTMNGINEER: LIC NO: ADDRI8 '` ' /',-. / ❑
CONTACT. PHONE: U BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE E:1 ID ij ED
1 hereby attitude,I am licensed under provisions of Chapter 9(economical,ical, JOB DESCRIPTION
00 with'dolon]W0)m Sof the Business.. Professions Co e,ondmyliecowls RESIDENTIAL:
is full force.. R PI?NMIT ISSUANCE
�UfyF ---- �� ❑SFDWL ❑KITCHEN REMODEL
U L'mense Cl l.lf.k APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPIT
h 4 Dare Cnntmco r
ARCHITECTS DECLARATION YL ❑MULTI-UNIT ❑STRUCTURAL
F D m PANELS MODIFICATION
Z p n Z I understand my plans shall be u.d ns public records
Oz,"O _ UPT02MAMPS C3 INTERIOR ❑CHIMNEYREPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
s OWNER-BUILDER DECLARATION Com ito OVER I"AMPS ❑BATH REMODEUREPAIR (]DEMOLITION
F r t 6 I hereby affirm that 1 am exempt from the Cnn mobs., License Law far the ❑❑OTHER
�S O y U following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL \i�rl�F—
F�0 F' which requires a permit m cnnntmch alter,improve,demolish,or repair any stmnure
that he
prsarequires thevisions o for ContrurmiuLiscom Law
w(mmment SPECIALCIRCUIT/MISC.
"5�+;!j py.. rhathe fisting it pursuant 70th)of Divisionf the Contactors Littre Law(Chapter9
j.I y,.pO feat he
xemitthomirral and the
basis
ofr th the Business prion.AnyvisCWq nr TEMP.SIFTER OR('OLE(NST. COMMERCIAL:
4{y m eG that he is exempt therefrom and For .peis for the alleged exemption.Any violation of ❑TEN SLUG/ADDITION ❑FOOD SERV(
iG 4. Section in..file
any eomdom.($50rmit mhjeas the npplicnm mvcivil penalty rel ('OWER DEVICES ❑TENANT C1 FOOD SERVICE
ZY m mare than fof thundperty. r my
IMPROVEMENT
0 ❑ Lo The wor"nall property.or my etnntendedwith offereef for
e(Sees their compensation. SWIMMING POOL ELECTRIC
and Pr Nc work and e: swcmre is nor intended,Law do for sale(See]Din,nosincaner ss
of OTHER
W�� and Profexsions Code:The Contractor's License Law Jars not.pply m an owner of OUTLETS-SWITCHES-FIXTURES
property whn builds or improves therum,and who does such work himself or through
his own employees,provided that such improvements ere not imcnded or offered for NEW RESIDENTIAL.ELECER SQ Fr.
sale.If.however,the building or improvement is sold within one yea ofcompletion,The 0 50 SQ.FT.Pi 00 'A 5/SQ.FT.
owner-builder will have the burden of funding deal he did not Wild or improve for pur-
oDEC� Tn8 se of sale J. TOTAL: V
❑I,as owner of the anpeny,um exclusively commcfing with licensed contractors; f�
construct the project(Sec.'IMn,Business and Professions Cade:)The Comrvemrs Li-
a �s re Law does not apply to an owner ofpmKny who builds or improve$ LU
themon,and QTY. PLUMBING PERMIT FEE . VITT7� (�
Uh
who contracts for such project with a mntramodsNicenud pursuant to the Contractors �VPtf{I�N/'s
License Law. PERMIT ISSUANCE V
❑ I am exempt uader See. ,B&P C fonhis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK.LOW PROTECT.DEVICE
I hereby ill maiunder penaltyte perjuryone of dc following Worker's
Co
Ihaveand
will for byneCion 3700 ofConseal for Workers Comgn- DRAINS-FLOOR.RODE AREA.GOND. STORIES TYPE CONSTRUCTION
s.1 as, rI provided for by Section 3]I0 of the Luton Calc,for the performance of the
or have
ad this permit is issued. FIXTURES-PER TRAP
hove and will Permit
Worker's Comgnsmion Insuruncc,us raluircd by Section
of Cabo CMe,( e pert. antt ofwork for which Nrs rani.issued. GAS-EA.SYSTEM-1 INC..OUTLI?'fS ROUP AYN
My Wo rth .rednd rorty
Carrier: oliby Nn.:AQbt GAS-EA.SYSTEM-OVER n(FiA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINDUSTNL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sxtion need not becompleted ifthepemth is forone,hundred dollars(SIIIO) GREASETRAP
or less) PLANCHF.CK FEE
I extiify that hills,permormace ofthe work for which this .it is issued,)shall SEWER-SANITARY-STORM EA.2W FT.
not employ any Person in any manner so ax m become subject to the Workers Compen- ENERGY FEE
O Z no.Law,of C.1if num.Data WATER HEATER WNENT/ELECTR GRADING FEE
Z 0 Applicant
NOTICE TO APPLICANT.If,after making This Certificum of Exemption,you sluald WATER SYSTEW)FULATING
(, femme sobject the Workers Compensation previsions of Nor e LabCade,Yen must SOILS FEE
forthwith comply
with such provisions.,,his permit shall be Acemed revoked. WATER SERVICE '
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT, PAID
U z "amebyvRrm Nauhere is a construction lending agency for the performance of Date Recciprp
LL. [[[Crrr the work for which this permit is issued(Sm.31YJ].Civ.C.)
0 Isnders theme TOTAL:
Lender's Address TOTAL:
11 1 certify that 1 have read this apgirwion and sate that the olmve information is BUILDING FEE
VI correct.l agree to comply with all city and county nrdlnances and state laws relating to QTY, MECHANICAL:PERMIT FEE
U;4 building construction,and hereby authorim representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(WO) ret save,Inde t y d keep harmless the City of Cupedina against ELECTRIC E
habildies,ju gee s,toms and xpenseswhich aeyho prey way uceme.,wrasaid City ALTER OR ADD TO MECH.
in minuet act egroaram tthe`nit. PLUMBING FEB
APPLICAN' ON RST D ND ILL PA",Y WITII ALL NON-POINT AIR HANDLING UNIT(TO 0,000 CFM)
e..R�EI/gl OF I MECHANICALEE
AIR HANDLING UNIT(OVER 10,(X0 CFM) CONSTRUCTIO A%
plicanVComruE%IIAUST HDOD(W/DUCT) HOUSING MITIGA ON FF.F,HAZARDOUS MATL'RIALS DISCLOSUREapplicvma or handle hazardous material HEATING UNIT GO I W."BTU)
e CaNdino Municipal Cotte.Chapter 9.12,and the Health and Selety
CMe,Section 25532(a)1 HEATING UNIT(OVER 100,IXX)BTU)
❑Yes E]No VENTILATION PAN(SINGLE RESID) PAID -
Date ewipt tt
Will the applicant or future building occupant use equipment or devices whichBOILER-COMP QHP OR((0,1%0 BTU) -
nir Luxurious air comandnana as defined by the Bay Area Air Quality Management TOTAL;
DistricY7❑Yea No BOILER-COME(OVER 100,001)BTU) _
I have teed the hevdommi nidwask requircmemx under Chapter 6.95 of Na Call.
AIR CONDITIONER ISSUANC DAT
fomia Health&Safety Cone,Seen.8505.25533 and M
25534.1 uerstand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a alar.,ilia,it is my rcsptnsihlllry to notify the occupan,
of the r,-{uimmems which must be and prior to ix verce of a Certificate of Occupancy.
Owner or auteorizM agent Date TOTALISSUEDBY;
OFFICE