B 0145 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY A
CITY OF CUPERTINO BUILDING-ELECTRICAL t PERMIT NO.�O TS
RUILDING DIVISION APPLICATION/PERMIT PId1MBiNG-FIECf1ANICAI. SOOOI ,6
WILDING PROJECT IDENTIFICATION
BUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATE
DD9S Tess —/ —� f
O)a ' 'S NAM& P NE: / ��,�x TRA DR'S NAe/ME ,f // 1 /� LI x NIC CONI'ROI.k
ARC(ITECI'/ENGINEER: LIC NU:{/J.�L ((�J A D 'S J _ ,S �( .J7 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
C11 ❑ Consultant Fees Pail by Applicant(Initial) BLDG ELECT0PLUMB MOx
lr�ftor *L LICENSED that I)CONTRd TORunder previsions
ECLA ATION QTY, ELECTRIC PERMIT PEG
1 hereby vBirm that I am licensed under pro ns of Chapter (commencing JOB DESCRIPTION
�ZZ with Seclian]001Division 3of(heBusinsssan Code and my license is
W 00 PERMIT ISSUANCE
F U.� in full farce and effect. 33� DWL El KITCHEN REMODEL.
�UFUU Liccnse�Is Lc.p APPLIANCES-RESIDENTIAL, a C1 ADDITION ❑PLUMBING RE-PIPE
F-ZZ W Date. -/-/-{-a —Conwcmr.
f- 0. / ❑MULTI-UNIT El STRUCTURAL
FOy ARCHITECTS DECLI RATION PANELS
1 understund my plans shall be used as public records MODIFICATION
CZ-0 UPTO211)AMPS [I INTERIOR ❑CHIMNEY RI?PAIR
(4tw License Professional 201-I000AMPS IMPROVEMENT C]SWIMMING POOLS
S F,�
OWNER-BUILDER DECLARATION OVER IfN111AMP5 ❑BATH REM I/ F.P ❑ LMO.IT N
�! W Q I hereby affirm that I am exempt from the Contractor's License Law for the
O4 U following reason.(Section 7031.5.Business and Prolbxaions Cade:Any city or county SIGNS ELECTRICAL (] TH R
u+a 0.I"' which requires a permit to construct,alter,improve,demolish,or repair any stmurectWA F
0 primunium....cordon,requires theapplicam for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
Z (commencing
sed pursuant loth)of Dsion 3fthe Business
Preel.aw(Chnpmr9
W GAO (c. he ise xe pt therefrom
KKB of basis f rthe exampt Professionslationde)or TEMP.MISTER OR POL NS'T. COMMERCIAL,
that(he is exempt thereftnli wJ the basis for the cathalleged exemption.Any it penton of ❑NEW BLDG/AUDITION ❑FOOD SERV[
a�G y
Section 7031.5 by any applicant fornpemtit subjects the applicnmmacivil penelryM POWER DEVICE TENpNT ❑FOOD SLRVICE
f. not more(true rive hundred dollen(S50p. IMPROVEMENT
� C ❑1,as owner of the pmpeny,m my emplgecs with wagesaz(heir sole almpemm�ion, SWIMMING LELECTRIC
will doth)work,end the smtcmre is not intended m.dcred for.[a(Sec.74 Business jl�lOTHER
IRi1�� and Professions Cale:The Commcmrs License Law does not apply to an owner of Ol1TL1: -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 NP RESIDENT(AI.ELECTR SQ FT.
sale.If,however.the building nr improvement is sold within one year of completion.the SQ.FT.FLOOR AREA LSQ.t1t
owner-builder will have the burden of proving that he did nm build or improve 1 pur-
pr eofmicJ.
1,ax owner of the pmp)rty.um exclusively convecting with licensed commerce,to AZ
construct the project(Sec.]044,Business and Professions Gde:)The Contmnoes Li-
came Law door,.,,,apply rc anownerof property who builds.,improves dwoosn,and QTY, PLUMBING PERMIT
who convects for such pmjav with a nmtmemr(s)licensed pursuant t.the Glmmcmr's
License Law. PERMITISSUANCE
❑Iamexemptvole,Sec. ,B&PCforthisreasun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data 3
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 heroby affirm under parity of perjury one of the fostre or Wmkmex C :
Ihvv)and will main mynaction 37M of the L em 1.Code,
Workersce of the
DRAINS-FLOOR,ROOF,AREA,CON STORIES 'TYPE CONFTRDCTIDN
cation,r provide for by Section flW of the labor Code,for the Performance of(hc
wok for which this permit is issued. FIXTURES-1'ER TRAP
1 have end will mainwin Wnrkets Compenmtion Insomncc,as requirW by Sec(inn (trt�te
3]Wn(th�aeflxa�bosrfCody�ea�,for Jth9e7 Ppe1�rty'r5mence of I c overt forwhich thope xe,issued. GAS-EA.SYS'I'EM-I IN L,IT
OCC.GROUP APN
Cartler��"IINJys/w"""cartie Policy No,/--=�e—lY GAS-EA.SYSTEM.OVF 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP:ASFJINDUSTRL .E
j COMPENSATION INSURANCE —BUILDING DIVISION LEES
(This vection need not he complete if the permit is formic hundred dollars 0 IIM)) GREASF.TRAP
or less.) PLANCHIiCK FEE
I certify that in the recommence mfthe work forwhich this permit is issued,l shall SEWER-S ITA
not employ any person in any manner so as to become subject m the Workers'Cnmpen- T(}l�9TDRM CA.�1d11 Iq. ENERGY FEE
ZZ satian Laws.f Califomia.Dam WATER � TER WNENT/ELECTR GRADING FEE
Q Applicant )
�-+ NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should Wp SYSTF.M/IREATING SOH-S FEE
b¢nme subject tre the Workers Conspirator.provisions of the labor,Code,you must
av ti forthwith comply with such provisions or this permit shall he deemed revolod. ATER SERVICE
WQ
p❑. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
-- z I hereby affirm that them is a construction lending agency for the perfmmance of Rmetp(N
iIw the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL:
pU Leader,Name
W Lenders Addmss TOTAL: -77
Ey 1 certify that 1 have mad this applicadon and stem that the abov)opermon.is BUILDING FEL r 90
to correct l agree to comply with all city and county ordinancexandswe Izwimlatingto QTY, MECHANICAL PERMIT FEE SEISMIC FEE
V Z building consvuctlmn,and hereby authorize representatives ofthis city it enter upon the
rat aMve-mrntionW pmperty for inspection purposes. I WISSUANCHUANCL ELECTRIC FEE
(We)agree tu fore,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said CityDDTOMECH. PLUMBING HE
in consequence of(he grining of this pen .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTINGUNIT(TO10,OOCF ) MECHANICAL FEESOURCE REGULATIONS. ING UNIT(OVER .aft CFM) CONSTRUCTION TAX
SLguesture ofArldronVCintrai Das IOOD(WMU IOUSINGITIGATON IEE
HAZARDOUS MATERIALS DISCLOSURE.Will the applieam or future building occupant store or handle hazardous materialNIT(TO .Xk BTU)us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(10] NIT LR 100,0110 BTU)
❑Yes E1 No VENILATI PAN(SINGLE RESIDI PAID
Doe Receipt M
Will the applicant or future building oceupnt use equipment or devices which BOILE COMP(3HP OR 100,1X10 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
�Dis(rict] BOI R-COMP(OVER 100,010 BTU)
❑Yes C1 She
I have read the hszalloos ma¢ri do requiumcros under Claque,6.95 of the Cali R CONDITIONER / J SUA 7 ^(/y 5j11DAF,
forma Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FL. f7 l/ (/
building Jces not courtly have a mnam,thatit is any tesporenility m notify the acopant
man requirements which must be met prior to issuance of a Certificate of Qeuponcy.
Owner.,nth
uorixed agent Doc TOTAL: ISSUED BY:
OFFICE