S 0156 (2) APPLICANTTO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Prigirr NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 0156
BUILDING PROJECT IDENTIFICATION
BUILDING ADURCSS: ' SANITARY NO. APPLICATION SUBMITTAL DAI
WNER'. A1�: PH 1 CONTRACTOR'S NAME: LIC NO:
fGp.'1.1 I/-1, NIC CONTROL#
%RCH ECUENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P U MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alarm Nat I am licensed under provisions of Chapter 9(commencing JOB D SCRIPTION
Oat, with Semion]000)of Division 3ofthe Business and Professions Code,andmylicense is RESIDENTIAL,
ad in full force and effect. PERMIT ISSUANCE.U ❑ L. ❑
$FOWKITCHEN REMODEL
aV License Class 1.ic.p APPLIANCES-RESIDENTIAL. C1 ADDITION [I PLUMBING RE-PIPE
aDate Connecter
7m% ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O N Z 1 understand my plans shall be used as public record, MODIFICATION
OZ—, UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
P415 Licensed Professional 2011 IIDOAMPS IMPROVEMENT E]SWIMMING POOLS
.4 OWNER-BUILDER DECLARATION OVER IOfI(IAMPS ❑BATH REMODEUREPAIR [I DEMOLITION
W 6 I hereby affirm Nat I am exempt form the Contractor's License Law for the
�y(04 U following reason:(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
f�a WI" which reci ires a permit to construct,alter,improve,demolish,or repair any slmcture
0r3 prior in its issuance,also requires the applicant for such Permit to file u signed tenement SPECIAL CIRCUIT/MISC.
f } Nat he is licensW pursuanumhe pmvixinns of the Comracmrs Liceazetaw lChapmr9
W <0 ff
(mmmemcing will Section 100(h of Division 3,111h,Business and Professions CWcl or TEMP.METER OR POLE INST. COMMERCIAL:
a y o e that he is exempt therefrom and the basis for the alleged exemption.Any violation of F1 NEW BLDG/ADDITION ❑DEMOLITION
tsX7 4y
Section 7031.5 by any applicant for a penat subjects Napplicant e applicano a civilpe'nalty of POWER DEVICES CITENANT ❑FOOD SERVICE
FF..vnot ore than five hundred dollars(150(1). IMPROVEMENT
p?Q mCi I.us owner of the property, loses with woes as their sole com rtorion, SWIMMING POOL F.LECDUC C+O ❑ P Y Yemp Y 6 1'e
11 dothe work.and the structuress intended oroffierect Lawdof or apply to
a4,P.a,of ❑OTHIiR
W �_ and Professions Code The Cnnmacmr'e License Law does nm apply to an mvner of OUTLETS-SWITCHES-FIXTURES
It,3 property who builds or improves thenen,aad who does such walk himself or through
his own employees,provided that such improvements arc not intended m nlfemd for NEW RESIDENTIAL rI FCTR SQ PI'.
cale.lf,however.the building orimpnwcmem is sold within one year of completion,the SQ.FT.FLOORDARIiA ESQ.FT.
canerbuilder will have rhe burden of Proving that he did not build or improve fur par- A
pose of ma). P P
T(YIAI.
1,os owner of the propeny,tun ma exclusively comnng with lic,n¢d contemn,to '
unmet the project(Ste.7041,Business and Professions CWe:)The Contractors Li-t1a�G'
cense Law does nor apply to an ownerof progeny who builds orimproves thereon,and QTY, PLUMBING PERMIT FEE 'JUN z5 as
who contracts nonsuch projects with a contractors)licensed pursuant the Contractor's _ V r.�
License Law. PERMIT ISSUANCE !� Vur-rii INV
❑1 am exempt an;,S . .B&P C for this reason V I-
ALTER-DRAIN&VENT-WATER(EA) VALUATION
tar i Dem
WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT DEVICE
1 hereby affirm under Penalty of perjury one of the following declarations:
❑Ihuvmnd will maimainaCertifstint of Conserv ro sell-insure for Worker's Compen. DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TV PB CONSTRUCTIOI
cation.as providW for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work fur which Nis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS 9CC.CROUP APN
My Workers Compensation Insurance artier and Policy number arc:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION EEL'S
(This sectem
iannl nm m
bempleted ifthe permit is fnrnnehuodre dollam($IW) GREASETRAP
or less.) PLANCHECK FF.F.
I certify Than in the performanceof Ne work for whichnhis permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject o the Workers'Counter- ENERGY FEE
cation laws of Cal human.Date WATER HEATER W/VENT/ELF.COt
0 APPlicom l - GRADING FEE
y NOTICE TO APPLICANT.If,after making this Carotene of Exemption,you should WATER SYSTENETREATING
(, become subject to the Workers Compensation pa isioaz of the Labor Cade,you must SOILS FEE
LaTI forthwith comply with such provisions onhis Pertain shall he deemed revoked. WATER SERVICE
� z CONSTRUCTION LENDINGAGENCY NEW RESIDFNTIALPLMB. SQ.FT. PAID -Date Rcmilt#
I hereby aRrn that is s construction lending agency,for the performance of
U the work for which this Permit is issued(Sac,Jt19],Cis.C.)
U Lender's Name TOTAL: TOTAL
i<ndcrs AM.,,
fess 1 certify that 1 have read this application and state that the above information is NUILDING FEF.
Lf0 cortect l agate In comply with all city and county ordinances and net,laws relating to QTY, MECHANICAL PERMIT FEE
U 2a building construction.and hereby mutation,representatives of this city no enter upon the SEISMIC FEE
above-mentionW property for inspection purynses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liebilinieajudgmenq costs and expenses which may in any way manic against said City ALTER OR ADDIT)MECH.
PLUMBING PEI
in consequenceof Ne N thinpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,11011 CFM) MECHANICAL ME
SOURCE REGIILAT S. ^ 1 w
�l—W1.T AIR HANDLING UNIT(OVER 10,M)CFMI CONSTRUCf10N'1'A%
Signature( Applicurat/Connacmr V/ Date EXHAUST HOOD IW/DU(T) HOUSING MITIGATIONITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant at future building occupant since orhandlc haxallom material HEATING UNIT(TO 100,(01)BTU)
as defined by the Confirm Municipal CWe,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ HEATING UNIT(OVER 100,001 BTU)
E]Yes ❑Nn VENTILATION PAN(SINGLE RESIDI PAID
• Data Receipt M
Will the air amityant or future building by theaByse Area
Air Qument aig, vices wM1ich BOILER-COMP 1311P OR I(0,W0 BTU)
emit haxatdous air comaminants os defined by the Bay Area Air Quality Mnnagemrnl T(TI'nL:
Di,tnct] BOILER-COMP(OVER 1(111,(00 BTU)
❑Yee ❑No
I have read the Ima dso s materialsAIR CONDITIONER ISSUANCE DATE
mquimments under Chapter 6.95 of the Gli-
fomia Health&Safety Code.Sections 2.5505.M533 teal 25534.I understand that if Nc NEW RESIDENTIAL.MECH. SQ.FE
building does not currently have a tenant,that it is my reerymsibility,to notify rhe oecupam
of the n,im mono,which must he at Print to ismmce of a Certificate of occupancy.
Owner orauthnrixed agent Date
TOTAL: ISSUED BY:
OFFICE