31306 (2) APPLICANTTO FILL IN INFORMATIONWITHIN RED LINES•USE.BALL POINT PEN ONLY
CITYO CCUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
.BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: r SANITARY NO, APPLICATION SUBMITTAL DATE
16 (Oq4f)
OWNER'S NAME: ' U - PHONE' � - CONTRACTORS NAME: )LI/C NIOL:n
�.e *V 7 ^.�� O /LZ`O SQ.C(/lar •�(oG103 NIC CONTROL# I .
ARCHITECTHNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Flacs Paid by Applicant(Initial) BLDG P UM MECx
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 hereby affirm that I am licensed under provisions of Chapte 9(commencing .JOB DBS IPTION
�C with Section 7")of Division 3ofnhe Business and Professions Code,and my license is - RESIDENTIAL:
W r in
full farce and effect, PERMIT ISSUANCE
Uz ULicense Glees Lic.# - ❑SFOWL El KITCHEN REMODEL
y6 Date ContractorAPPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
I. pti ARCHITECTS DECLARATION PANELS .�MNLTI-UNIT ❑STRUCTURAL
O X ra 4 I understand my plans shall h .s
eed e,puhlic records ' ,
pO UPT02MAMPS MODIFICATION
�+:, W Lmensed Profesvonal _ ❑INTERIOR ❑CHIMNEY REPAIR
pad .J OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
p", 6 I hereby aMrm,that 1 am exempt from the Contractor's License Law for the 5SIGNSELECTRIC
AMPS, ❑BATH R 2 O I 7
x O tY U following par'..(Section 7031.5,Business and Professions Code:Any city or county - ❑OTHER
'3 F TRIC awhichrq permh t0 .nmct al[ ,inprove,demolish or repair any samctmeprior to t '. ante Iso quires the pplicantfor such permitro file a signed statementRCUthat h 1 eased p o u th p nsof Ne(ovaor a Lmcnee Law(Chapmr 9 o (commenting with Sectio 7000) f Dlvson3 of Ne Business and Professions Code)., E POL COMMERCIAL•,
14 y C that he rs exempt therefrcm and the basis for te alleged exemption.Any vi om.of ❑NEW BLDG/ADDITION DEMOLITION
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty.( VICES
notmore than Bve hundred dollars($SBd) ❑TENANT ❑FOODSERVICE
Q ❑LawnerpePOOL ELECTRICIMPROVEMENT
will do Ne wmk,and rheswctum is not intended oroffered for sale(Soc.7044',Business EIOTHER
nd Professions Code:The Contractors License Law does not apply to un owner of 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 or offered for NEW RESIDENTIAL ELECTS SQ FH
sale.IL however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR ARIA $/SQ.PT,
caner-builder will have the burden of proving thin he did not build or improvefin"an,foun- P'
p2 I
Arse of sale.). ^
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 4J "
consumer the project(Sec.7044,Business and Professions Coale:)The Contractor.Li- (��,p: �
c e Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE -`�1. 199
whoom ractsforsuchprojectswithacommcmr(s)licensedPrommintoothcCommetin's Cl�y�
License Law. , PERMIT ISSUANCE I O
❑ 1 am exempt under Sec. ,B&P C for this reason �- VVr
Owner Date - :1L
IN&VENT-WATER(EA) V ON
^ WORKER'S COMPENSATION DECLARATION PROTECT.pF.VICE
I hereby.Rrm mdu penalty of puj.ry one of the following duluretions: -
1have and will maintain aCertificateofConsen00self-inure fin-Workers Camped- OR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 37M of the Labor Code,for the performance of the
work for which,hi,permit is issued ER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Cade,for thesppeerrRformaanncce off the work for which Permit is issued. TEM-I INC.4 OUTLETS DCC.GROUP APN
My cr:r �ORaL/ J/{L�CR )/Nin.YJ 'SV Q TEM-OVER4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
(This sermon need not be compleied if the permit Is forone hundred doll.($100) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK FEE
Icertify Perhat in the perforan,
of the lecorork mwhich this permit is iesued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner s0 as to berome suhject to the Workers'Comped- ENERGY FEE
Applicant
Laws aY California.Da[e��^L�- '
0 WATER HEATER W/VENT/ELECI'R GRADING FEE
y O Applicant
A ti NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
N , became subject to the Worker's Compensation provisions of the Labor Cmle,you must SOILS FE8
[aLIQ foMwith comply wi[h suchprovisionsonhispermitehell he deemed revoked. WATER SERVICE ,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
us 2z Thereby affirm that there ixaconsnruc[i�n lending.gencyfortheperformunceof Dale Receipt
the work for which this permit is issued(Sec.3097,Civ,C.) ,
U Lenders Name TOTAL:
yy 4T) Lenders Address TOTAL:
Icertify that 1 have reed this application and state that the above information is BUILDING FEE
V1 cortwc I.gree m comply with all city and county mdi...ces and sit a laws relating m QTY, MECHANICAL PERMIT FEE
LI7- building concoction,and hereby authorize repreaventivea of this city to enter Upon the SEISMIC FEE -
alum e-mentioned property for inspection purposes.
;
(We)agree to save,indemnify p yo pe g PERMIT ISSUANCE
g ynnd kee`harmless the Cir fCu rtinoa ainst ELECTRICFEE'
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY LTH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGU.A IONS. MECHANICAL FEE
/ t � � AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCf10NTAX
'Sg re M AdjulicanVCommanor Date EXHAUST HOOD(W/DUCf) ,HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thehpplicannv future building rearpordo.mor handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety _
Code.Section 25532(a)7 , HEATING UNIT(OVER 100,000 BTU)„ .
❑Yes _ ElNo
VENTILATION FAN(SINGLE RESID) PAID '
Will the applicants future building.tarpons ase equipment nr devices which Date , Receipt k
enut hazardous air contaminants as defined by the Bay Arco Air Quality Management BOILER-CONCH CHP OR 100,000 BTU)
Dicmit TOTAL:
❑Yes �No BOILER-COME(OVER 100,000 BTI,
1 have read the jeciad is materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER e, ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDEMIAL MECH. SQ.FT.
,at
dee,nm currently have a reason,that it is my respmsibility to notify the occupant
of the requirements which must be mer prior to as
of a Camden,of Occupancy. -
Owner or authonuit agent Dale `
SSUED BY:
OFFICE