S 1069 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP
BUILDING-ELECTRICAL PE§ATI'NO, O
69
BUILDING DIVISION APPLICATION/PERMIT 1•INGROJECT IDWOFI51. (u5
BUILDING PROJECT Il1BMTIFICATION
T
SANITARY NO, APPLICAION SUBMITTAL DATI
LDING ADDRESS:
67 C
OWNER'S E: YI10NE/: CO RA/Cfp/µti LIC Q� / e
fi- db 6 O/OV /�/`�Q /V•• 9 — p SIC CONTROLM
ARCHITIECTiENGINEERP LC NO1El
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PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EIEC' PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION eu
ELECTRIC PERMIT FEE JOB DESCRIPTION
irm that 1 am licensed under provisions of Chapter 9(commencing
QOZ )of Divisi.nJoflhe Business eml Profecxi.mx Code,vulmylicenxeisRESIDENTIA_G0Rec{^ ANCE ElSFDWL ❑KITCHEN REMODEL
aVU `-'— Lic.g 'M wr «,. S-RESIDENTIAL []ADDITION ❑PLDMHING RE-PIPIT
W Date Lic.If can "
Fly -ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
IundclsmnJ my atoll est v u records MODIFICATION
Z C)n MPS ❑INTERIOR ❑CHIMNEY REPAIR
F� Licenmd Process,.nal s P$ IMPROVEMEiNT (]SWIMA GPOOLS
YOWN'R-BUILDER DECLAft ' ON MPS ❑BATH R 'VR' R 'M N
ad I hereby of som Thal 1 am exempt from the Co tractor's License Law for thesaf
>0 U fNlawing reason(See
oar 7031.5.Business and Professions Cwlr.My city or county SIGNS ELECTRICAL i11F.R
Yl•3 which rcyuircs v permit m constructalmr,improve,demolish,or repair uny stment.
prior to its issuance,also requires the applicant forsucmti
ch pt to flea signedamtemenl SPECIAL CIRCUIT/MISC.
} that he is licensed pursand to the provisions attire Contractor's License Law(Chapter o> COMMERCIAL
(commencing with Section 70010 of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
6 that he is exempt therefrom end the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION DDEMDLITIQN
Section 7031.5 by any appEcom for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ee
Out more than five hundred dollars($500). IMPROVEMENT
�O ❑ Las owner Of the property,.r my cmpinyecs with wages us their sole compensminn, SWIMMING POOL ELECTRIC
El OTHER
ill do the work,and the studstudent.cm is net intended.,uttered far We(Sec.]OW,Business
and Psioax CodConvector's Carlo The Cotor's License Law does not apply 1.an owner of OUTLETS-SWITCHES-FIXTURES
mfes
propeny who builds or improves thereon,and who does such work himself or through
his own employem provided Nat such improvements aft not intended or offered for NEW RESIDENTIAL ELECfR SQ P-L
sale.If.however.the building or improvement ix sold within"a,
year of completion the PSAF�F60R AREA SISQ.FT.
eOFuilder will have the burden of proving that he did not build or improve for par-
pair,ofsale.). _ TOTAI.:
❑ 1,as owner of the property,um exclusively contracting with licensed commands to CT 24 RECD
cemouctthe Project&..7W.Business and Professions Codep The Contractors Li-
c ae Law does not apply to an owner of property who builds Or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a comm chans)licensed pursuant m the Cmdraccor's /�
License Low. PERMIT ISSUANCE C1 Ur GUVEH TINO
❑1 am exempt under Sec. ,B&P C far this reazun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Game, Date
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following dedarr ism.
Fl I have and will maintain aCenificam of Consentto self-insure far Workds Compen- DRAINS-FLOOR,RO)P.AREA,COND. STORIES 'TYPE CONSTRUC IC
.arm,m provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is stand. FIXTURES-Plitt TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3]00 of NC LN+CMrCde.))fordre performance of Ne work for which rythis permit is issued. GAS-EA,SYSTEM-I INC.i OUTLETS OCC.GROUPmy APN
Carrier. 1('alnsurence carie Polcy NO..:and Policy r5 O�/o Oct GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sex,mazxd not be cnmplemd ifthe putmit is forma,hundred dollars(SI OB GREASETRAP PLANCHECK FEE
or less.)
(certifychat inare Performance rofare work,01bec for which this thePermitWiaixsued.I'COmshall
n- SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
not employ my person in any manner so us m become subject to the Workers'Compen-
sationLawsofCalifrricDam WATER HEATER WNEWIELECfR GRADING FEE
O Applicant t
Cr NOTICE TO APPLICANT:If,after making this Cenificam Of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
(~ '�N" become subject m the Worker's Compensation provisions of Ne Labor Code,you..If
�+ fonhwithcamply witbsuch pinvasions an this pcizatsha11 W deemed revoked. WATER SERVICE
SJ Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAIII
."7. z Dam Receipt p
V0 rook
.I,,i isaed St,ctionle,Cie.ageney for the peAonnance of
� IM work for which this permit is issued tBoc.3!19],Civ.CJ TOTAL:
ULenders Name TOTAL:
{Ta Learbes Address BUILDING PEE
I certify that 1 have read this application and state that the atxwe information is
I,, cored.l agree to comply with all city and county ordinances and intra laws mining to QTY. MECHANICAL PERMIT FEESEISMICPLC
Wilding construction,and hemby mandm mprcxemmives of this
V `Z bucityo, ,,upon the
above-mentioned pmpcny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEF.
(We)agree to save,indemnify and keep hamsless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way ecctuevgaina said City ALTEROHADDTO MECH. PLUMBING FEE
in consequence of the Imaging of Nis permit.
APPLICANT UNDERSTANDS AND L COMPLY WIT ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCERF LATI
/��� AIR HANDLING UNIT(OVER 10,11!10 CFM7 CONSTRUCTION TAX
SitaccurArSfApp an can for L Dole EXHAUST HOOD(W/DUCI') HOUSING MITIGATION FEF.
HAZARDOUS MATERIAL. LOSURF. '
Will the applicant or future building Occur t store or handle hazardous material HEATING UNIT(TO 101.000 BTU)
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 W.aN)BTU)
Cale,Section 2553260?
O Yr,s ❑No VENTILATION FAN(SINGLE RESID) PAID
Dale ReceiplM
L
1 the applicant or future building compact use equipment or devices which BOILER-COMP(3HP OR 101A0)BTU)
ous air contuminents as defined by the Bay Amu Air Quality Marromenl TOTAL:
BOILER-COMP(OVER 100.000)BTUIes ❑No
ave read the hazardous materials reqirements under Chupmr695 ofRN Cali- AIRCONDITIONER ISSUANCE DATE
lth&Safety Cede.Stttions 25505.25533 and 25536.1 understand that if the NEW RESIDENTIAL MECH. SQ.FTs nm currently have a tenant,that it is my responsibility to notify the oecupumimmems which must e met prim to issuance ofa Certificate of Occupancy.
Tam TOTAL: ISSUED BY:
authorized agent -
OFFICE _ _ _