S 1173 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAI. PIiRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 173
BUILDING PROJECT IDF.NTIF'ICATION �J i
BUILDING ADDRESS: �Q ITpO G f AHI w SL`E SANITARY NO. APf PLICATION su5mITAL DATE
LL (( v 1wb11 2 1 Cts
OWNER'S NAME: PHONE' CONTRACTOR'S NAME: LIC NO: NUC CONTROL#
EAI INHER NO 5
'ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
GW/1Yf,�Tf.`U1 a� Crr2
01'S 6 �a L4 CSI` S v+Q-LG �t
CONTACT. PHONE: I BUILDING PERMIT INFO
I ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL PLUMB MECH
Na,
LIC17NSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JO DES PTION
— ED El
1 hereby affirm that I am liccenad under provisions of Chapter 9(Commencing
Qa'Z th Sectlnn 7000idDiskinn 3ofthc Businessland PndessuaACcieondmy license is RESIDENTIAL
mpg w' PERMD'ISSUANCF. ❑SFDWI. ❑KITCHEN REMODEL
At W in full force and effect. �. /�Z
aUL LicenselClass Lich APPLIANCES-RESIDENTIAL DDITION C3 PLUMBING R&PIPE.
NZ g, Daley '� Contractor 13
F.DH MULTIANIT El STRUCTURAL
ARCHITECTS DECLARATION PANELS
MODIFICATION
oZx I understand my plane shall hs used as public records
G UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
r43� 1Licensed Professional 201.1000AMPS IMPROVEMENT C]SWIMMING POOLS
� OWNER-BUILDER DECLARATION OVER IIKK)AMPS [I BATH REMODr REPAIR 0DEMOhITI
I hereby affimh that I um exempt from the Contractor's License Law for the
fgx� W U following reason(Section 7031.5.Rosiness and Pmfcs.+ions Code:Any city or county SIGNS IiLECTRICAL - �OTIIE
W 3 LL f' which requires a Easeful to construct,thin improve.demolisb,or repair any structure
prior to its is-soaace,also requires the applicant for such Permit to plan signed statement SMCIALCIRCUIT/MISC.
YSC� that be is licensed pursuant to the Provisions ofthe Cona-,roe's License Law(Chapter 9 gla
OMMFR IA
W—M0
(commencing with Section 7001)of Division 3 ofthe Busine+r and Professions Code)or TEMP.MFfIiR OR POLE INST.
L y saed that he is exemth
pt therefrom and the basis for e alleged exemption.Any violation of F1 NEW BLDG/ADDITION ❑DEMOLITION
4X7 Section 903 L5 by anyapplicam farapemhit subjects rhe-Indicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
u-
^ not than free hnndrN dollars 1451X)1. IMPROVEMENT
00 owner ofihe propeny,or my employees with wages as their sole compensmien. SWIMMING POOL ELECTRIC ❑OTHER
HE Jo the work,and the structure is not intended otuffered boodle(Sec.]1134,Business
L 3 and Professions Code:The Contractors License Liw does not apply m an mune,of OUTLETS-SWITCHES-FIXTURES
propeny,who Wild,rte improves thefnm,and who does such work himself or through
his own employees,provided thin such improvements an not intended if,offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building orimprovement is sold within one year of completine,the $Q.Ff.FLOOR AREA E/SQ.Ff.
owrg,l udder will have the burden of proving that he didnot buil
prrseofmle.k d or
impimprovevs for pur- TOTAL: v® A p
I �
1,as owner of the propeny,am exclusively contracting with licensed commaats m
construct the project(See.7014,Business and Professions Code:)To,Comn sofa Li-
cense Law does not apply to an owner of genially who builds or improves thereon,and QTY. P1,U MfINO FEE
who contracts for such nemesis with a conal licensed pursuant to the Contractors �•P
R _g .A1/(keaw
License Low. PERMIT ISSUANCE
❑l am exempt un .1f&P C for this reason p
ec -3 ALTER-DRAIN&VENT T-WATER(EA) ('��IYALIIAI]ON
net Dam
RKEW.-COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 have
and will mountain
o under penmryof ofConnncofthufnsurc,Rgdeclum'inns: J
I bave and will mnimnineCenifcme ofCanwm to self-insum for Woher's Compem DRAINS-FLOOR.BOOK ARIt.GOND, STORIES TYPE CONSTRUCf10N
train.,as provided far by Section 37W of the Labor Code,He the psrformance of the
work for which this permit is issued. FIXTURES-PER TRAP
E]I have send will mainmin Workers Cembemeion Insurance,as acquired by Section
AW of the labor Code.for the performance of the work for whiclnbis .it is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Worker'.Compensation Insurance carrier and Policy number are:
GAS-EA.SVSTIiM(IVER J(EA)Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSfRL WASTE INTERCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is for one hundred dollars is Im) GREASETRAP
ar It..)(This FF.F,
I certify that in the performance ofthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to become subject m the Workers'Camper- ENIiRGY FEE
Z satin.laws of Ccilifsina.Date WATER HEATER W/VENT/ELECTR GRADING I'EE
O O Applicant `
rjJ NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEMffRHAT'ING
h become subject to the Workers Compensation provisions of the Labor Cede,you must SOILS ME
"r7•r funhwilhcmmply with such provision or this permitshall he deemNfevokcd. WATER,
APAID
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL.PLMB. SQ.IT. Dam Receipt#
U O I hereby aftien that them is a cmn.ametion lending agency for the performance of
11r F the work(of which this Permit is issued(Sse.3097,Cih,C.) TOTAL:
OU Lenders Name
L1.1 Lender's Address TOTAL.
I rectify that 1 have resit this application and state that the above information is BUILDING FEE
i.. In correct.l agree m comply with all city and county ordinances,and stole laws relating m QTy, MECHANICAL PERMIT FEF, SEISMIC FI?E.
U Z building construction,and hereby umhorim representatives ofthis city ah enter upon the
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC THE
(We)"Ecce to save,indemnify and keep humbles,the City of Caperton against
habihies,judgmcros,costsand expenses which may in any way aceme against said City ALTER OR ADD TO MECH. PLUMBING FEB
in consequence of the groming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IQDW CFM) MECHANICAL FEE.
SOURCCRE FJou�,
O�+_d6_ Q[ IAIR =0R1N).N)0
NIT(OVCRIQMMICFM) CONSTRUCTION TAX
grain eofAp 'cam/Commcmr V DateODUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi applicant or future buildingccupam store or handle hazardous materialO I00,IX10 BTU)as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 VER ITO 000 BTU)❑Yes ❑No N(SINGLE RESID) PAIDDate RecctWill the applicant or future Wilding occupant use equipment or devices which "T OR 100.000 BTU)
emit baiard.bs air consortium,as defined by the Bay Area Air Quality Management TOTAL:
District! BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505.M533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT
building it.ern currently have a tenant that it is my retrymeibility to motif y the occupant
of the recummmems which must he met prior to issuance of a Certificate of Ovxlgancy.
Owner m mall oozed-gent Date TOTAL: ISSUED BY:
OFFICE