S 0527 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICA], PERM IT NO.
BUILDING DIVISION APPLICATIONWERMIT PLUMBING.nr IDENTIFICATION
S 0 27
BUILDING PR(1JF.LT IIIF.NTIF'ICATION Jn��,.
LDING ADDRESS: SANITARY NO. API'LICATIO U VT
D�q e A14ZA 5Lv T
NER'S NAME: PH NE: CONTRACTOR'S NAME: LIC NO: NI C C INTRO
111T6n N oN 8lg s�$SS$ N dr✓ S ❑
R HITCCTBaRGINEER: LIC NO: ADDk SS: (,/� ,
SD r 12 62 260 S. bion&I I o
l DNTAC. PHONE: BUILDING PERMIT INFO
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C� —V __�51�(j ❑ Consultant Fees Paid by Applicant(Initial) .DG ELECT PLU B MECH
/ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FP' JOB DESCRIPTION
1 hereby afLrm Bar I am licensed under pmvisinns of Chapter 9(enmmemcing
aZ withlieconn]0010mf Division Sof Bc Businesxsnd Professiore Cnde,vnA myliccnseis RESIDENTIAL
�0 PERMIT ISSUANCE ❑SFDWL KITCHEN REMODEL
mal in full force and effect. C11 A
aU Lt.. 'Lica APPLIANCES-RESIDENTIAL ❑ADDITION ED PLUMBING RE-PIPIT
�2a Dare Wo
Cnmmcmr_
< ARCHI'TECTS UECLA A9 )N 1��. PANELS ❑MULTI-UNIT
[I STRUCTURAL
MODIPICATION
1 undersand my plans shall he used os public uordx
pZ UP To 2(N)AMPS ❑INTERIOR El CHIMNEY RIiPAIR
F 41"cj Licensed Profesxinnal 201-IWOAMPS IMPROVEMENT 0SWIMMING PDOLS
�I OWNER-BUILDER DECLARATION OVER 11%X1 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
WQ 1 hereby aRrn that 1 am exempt from the Connector's License Law,for the ❑01HER
6 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
3 W Fy' which opium,a permit to consumer,altee improve,demolish,oT Tcpmr imy strum e
prior to its issuance,also requires the applicant for such Permit o file it signed stacment SPECIAL CIRCUIT/MISC.
�y that he is licensedpursuaattolheprovisionsofth,Contractorsfine..Low(Chaptery COMMERCIAL
I+Ia aOC (commencing with Stttinn]tXq)of Division3mfBe Business and Prnfasimns Csak)or TEMP.MITER OR POLE
d
that he is exempt therefrom and the basis for the alleged exempt
6 ca ion.Any violation of ❑NEW BLDG/A I.I MOION
>UnV.
Section 7031.5 by any applicam for u Permit subjects the applicant to a civil penalty of
POWER DEVICES ANT ' , IFOOD�iI(ICE
�rN ot m
am five hundred dollars 155/10). IMPROVEMENT �^^PP"��
F Q (]I,as owner of the pmpety,nr my CmPloytts wiBsvagceas theirxmlerompcnxmioq SWIMMING POOL ELECTRIC
5a 11 OTHER
will do Be w.,k,and the sweater.is not imendcdmoffered for We(Sec.7044.Business
W3 and ProRRsions.Code:'Me Contractor's License Law does not apply to an owner oy IITLETS-SWITCHES-PIXTU t
property who builds or improves thereon,and who does such work himself or through NEW RPSIDE IAL EL[CI'R S
his own employees,provided that inch improvements am not mandated or coffered for SQ.FT.FLOOR AREA 5/SQ.IT.
sale.If,however,the building or impmvemen is sold within one year of conspletimn,the
r-Wilder will have the burden of proving Bud he did not build or improve lin put-
pouofsxle.). TOTAL: a� 1ppl G
1,as owner of the property,am exclusively intimating with licensed entrains to p
consume,the project(Sec.]044,Business and Professions Code:)The Commemrx Li, Ip n VVV
cense law does not upply to an owner of property who builds or improves thereon,and QTY. PI.UMBIN RMIT FEE
who camnns for such pmjeme with a emaractor(s)licensed panuam m the CnntracInes i�fl�
_- Lice..Lew ,B&P C for Bis reason PERMIT ISSUANCE gYYF��a:O
I am eaemM under See.
ALTER-DRAIN&VENT- 'T fF,A) VALU
Owner Data /��.��a�Iy� _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LII aJCy'��
1 hereby affirm under Penalty of perjury one of the following declarations: V
❑Those eml will maimoine Cetiicmcof Cmnscnun nclbinmmfor Wnrkcrs Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTIO
Roind.m provided for by Second 3700of the Loan,Calc,fur the performance of Be
work for which this permit is issued. FIX'1'URIS-PCR TRAP
1 have and will maintain Workers Compensation Insurance,as inquired by Section
3]W ofthe Labor Cale,for the perfnamineoflhe work for which this ppS5Rf���n�sivsucd, GAS-EA.SYS'fEM IINC.40UTLETS OCC.GROUP APN
My Work�Cnmprnaminn lnsur ce earlier and Po Ii n r res NWG GAS-EA.SYSTEM OVER 4(EA)
Currier: + e1 Policy No.: �' Q
CERTIFICATE OF EXEMPTION FROM WORKERS' V GREASHANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVIS
(This vection need not be completed if Bo permit is forma,hundred dollars($list)
GREASETRAP
PLANCHECK FEE
nrI x.)
Toy any thatinin any
mrce of as
work for subjectch to Permit ixissueoI shelfmpen.. SEWER-SANITARY-STORM EA.200 FT.
nm employ any person in any manner so ns m become subject m Be Workers Compen, ENERGY PEE
,Z Ration Laws mf C.1if rd.,Date WATFR HEATER W/VENT/ELECT R GRADING FEE
Z2 Applicant t
N NOTICE'DO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM,TREATING SOILS FEE
become subject to the Workers Compensation provisions of the Labor Coca,you must
tyi forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
z7 Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U z Dam Receipt p
V Q kforw affirm Bmthere i.xsued(Seeti30 len ding agency for the Performance of
{Io Bc work which this permit is issue)(Sec.1(197,Civ.CJ TOTAL:
Q f" Lender's Name TOTAL;
>a LUkI Lenders Address BUILDING ME
4k, I certify that 1 have real this application and state that the shove information is
.Fa h correct.I agmen comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT SEISMIC FEE
U 7 building construction,and hereby addiction representatives of Bis city to enter upon the
alwve-mentioned pmperty for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way section against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,"CFM) MECHANICAL FFE
SOIfRCE RF.G �e\ ^'I'q(VJ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SigmitmemApplicvn/Comnemm Data EXHAUST HOLD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtbeapplicent or fumrc building occapan.smre or handle haarmoos material HEATING UNIT(TO 100.0001 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00)BTU)
Cade,Section 2553'2007 _
❑Yes ON. VENTILATION FAN(SINGLE RF.SID) PAID Use Revci a
\� Will the applicant or future building occupant use equipment ordevicexwhich BOILER-COMP(3HPOR I00.00013TU)
emit hazudon; is contaminants as defined by the Bay Area Air Quality Management TOTAL:
District] BOILER-COMP(OVER 10HODO BTU)
❑Yes ON.
I have read the hazardous materials relmocro d,under Chapter 6,95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fmmia Hearth&Safety Code.Sccuonx 25505,25533 and 25534.I umdeatand that if the NEW RESIDENTIAL MECH, SQ.PT,
buildingd�ax nrn currently have s m�unt.IMl it Ls my nexpnandidiry m notify the oaupant
- of the requiremcnu which must be met prior to issuance of a Certificate of Orcapncy.
Owner r authorized agent Dae TOTAL: ISSUliO BY:
OFFICE -- -