B 20283 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - Ph.
0283
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SID
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:/0 �G N SANITARY NO. PLICATION SUBMITTAL DATE
CLfa
OWNER'S NAME: PHONE: CO�CTOR'S NAME: LIC NO: N/C ONTROL0
ARCHITECf/ENGINEER: LIC NO. AD R Ss s ❑
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CONTACT: 2 PHONE: BUILDING PERMIT INFO
a y;A-1';'�' pcu 7'.391' ❑ Consultant Fees Paid by Applicant(Initial)
[S ELPLUMB MH
CECOO
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
�aZ with Secti.n]0007 of Division Sof the Business and Professions Cade,and my license is RESIDENTIAL:
Y1 O p PERMIT ISSUANCE
S 41 rF in full force and effec SFD ITL C:1 KITCHEN REMODEL
a-Q License Class �� Lle# C APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
F Z W Date Contmcmr S, 91
y¢a [I MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANELS
Z p m 7J- 1 understand my plans shall be used ns public records ryMODIFICATION
Oz-Q UPT02MAMPS [_1 INTERIOR �LCHIMNEY REPAIR
G4 j Licensed Pmfessional 201-11"AMPS IMPROVEMENT EJ SWIMMING POOLS
Va OWNER-BUILDER DECLARATION OVER IOOO AMPS 11 BATH REMOpr�y�,//REP IR ODEMp/LITION
I hereby affirm thin 1 me exempt immune Contractor's License Law for the OTHER "T/ ��L 'J^I'f"'��'
tO following reason.(Section 7031.5.Business aad Professions Code.Any city of county SIGNS ELECTRICAL - � J
31y,F which requires a permit t.construct,alter,improve,demolish,or repair any sweture -�r 1 r bYLe G� bL/�
y�y0y prior to In,ismance,also majolica the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. I/ni2f— I I'M J2 be
41y that he is licensed pursuant to the provisions of No Contractor's License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions C.de)or TEMP MP.TER OR INST. COMMERCIAL,
d y m a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X7 m SwIxis,7031,11yanyapplicialf a permit subjects the applicant m a civil penaltyof POWER DEVIL ❑TENANT ❑FOOD SERVICE
F Ont more than five hundred dollars(8507. IMPROVEMENT
❑I,as owner office property,or my employees with wages as their.sole compensation, SWTMMINq&OLELECTRIC
will do the work,and the structure is not intended or Mfered for sale(Seo.7044,Business []OTHER
unit Professions Code The Cmunn f's License Law does not apply to as owner of OUTL -SWITCHES-EN TURES
.. 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 NF RESIDENTIAL ELECTR SQ ET.
sale.If,however.Ne building orimpmvemenlis sold within one yam iddrnpletim,the SQ,FT FLOOR AREA 5/SQ.FL
caner-builder,will have the burden of proving that he did not build or improve for par- '
pont a sale.). 01
❑ 1,as owner of the property,am exclusively convecting with licensed contractors m TOTAL:
conso-uct the protect(Sec.760,Business unit Professions Cale:)The Cumin tors LI-
cense Law deal not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE _
who contracts for such protects with a eontrvctono licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE Q� 5351 a
I hereby Z.under penalty of perjury one of the following declarations: 5 J J
�❑I Internal will maintains Cenificam of Cnnsenuoself-Insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 370 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP 1
gq I have and will maintain Worker's Compensation Insurance,as required by Section
3700 little Labor C.de,for the performance of the work for which this permit is issued. GAS-EA SYSTEM-]INC.40UTLET OCCGROUP APN
C^ameorker� �Qltionlp M pcortle PolcY Noy`v-I�-o nU�1RY GAS-EA.SYSTEM-OVER4(EA) 04 p,1(1sD
CERTIFICATE OFEXEMPTIONFROM WORKERS' A Jggr GREASMNDUSTRL WASTE TERCEPTOR nil
COMPENSATION INSURANCE pp // QQyy BUILDING IVISIONPEES
(This section need not hecompletedtithe permit is for� ufiJmd�I��lEM110I - GREASETRAP
PLANCHECK PEE
or less.) �I11 Vt vt
I certify that in the prom uclue of the work for which this permit is issuad,)shall SEWER-SANITA -STORM EA.200 FE
net employ any person in any manner an as to become atOwt to the WorkersCooper- ENERGY FEE
,Z Indian Laws of Califarra.Date WATERHEA WNENT/ELECTR
0 Q Applicant GRADING FEE
,Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shoal WATER S EMIT REATING
^ lA SOILS FEE
a �^ become subject to the Worker's Compensation Provisions of the Labor Code,you must
W G forthwith comply with such provisions or this permit shall be deemed invoked.
WALL
SERVICE
Q
p" CONSTRUCTION LENDING AGENCY N RESIDENTIAL PLMB. SQ.fT. PAID Date Receipt#
'7 Z' (hereby affrm that isacnnstmction lending agency agency for the perfnnnance of -
{UO the work for which this permit is issued(Sea3099,Civ.C.) TOTAL.
QU Lenders Name
0 U Lender's Address TOTAL:
1t I certify that I have read this application and state that the above Information is BUILDING FEE
ti to c t.1 agree m comply with all city and county ondiaance,s and state laws relating to QTY. MECHANICAL PERMIT 'FEE SEISMIC FEE
Ll Z building ernstmetion,and hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,coca and expenses which may in any way accrue against said City ALTERORADDTOMECP. PLUMBING FEE
in....almn sof the gmntiug of this perm it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,00 CFM) MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER BI,I)C I CF CONSTRUCTION TAX
Signature of ApplicantlContracmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or building occupant store or handlehaz.rdous material HEATING UNIT(TO 100,003 B'
as defined by the Cupenlm.Munlcipel GNe;Chapter 9.12,and the Hwllh aad Sarety
Code Section 25532(.)^ HEATING UNIT(OVER 1A BTU)
❑Yes )&No VENTILATION FA INGLE RESID) PAID
Date Rweipt#
•Will the applicant or future building occupant use equipment or devices which BOILER-CO CHP OR 100.00 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
Dlsv¢t4 BOILER- OMP(OVER 10.00 BTU)
❑Yes 3l No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR DITIONER ISSUANCE DATE
Tarots Health As Safety Code,Sections 25305,25533 and 25534.1 understand that if the N RESIDENTIAL.MECH. SQ.FE
building does not currently have a tenant,that it is my resrymsibility m notify the occupant G Y S'1I d
of the: ma which m It a mel prior o issuance of n Ceniticate o Occupancy.
Owner orm sin gent ate TOTAL ISSUED BY:
OFFICE