S 0404 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. Pli IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUA1mNG-MF.OHANICAI. 0404
BUILDING PROJECT ID k1N'FIF'ICATION
BUILDING ADDRESS: 11 SANITARY NO. APPLICATION SUBMITTAL DAT]
O R'S NAME: PHONC: CONTRACTORS NAME: LIC NO:
NIC CONTROI.p
ARCHITECT NGINFER: LIC NO: ADDRESS: ❑
l
CONTACT: PHO E: BUILDING PERMIT INFO
L{IS13`a2'�' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
� U ZSZ. 4 v ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby of on,that I am licensed under provisions of Chapter 9(commencing JOB D SCRIPTION
"Z F
with Section? DofUivision 3 ofthe Business and Profession.,Code,and my license is RIDDENTIAL
1400 PERMIT ISSUANCE
F� ftilfotceandelfeet. ❑
SFDWI. [I KITCHEN REMODELU� License Class Lic.M
Q U APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
Zu7 Da¢ Con DELL
�F�i6a ❑MULTI-UNIT LI STRUCTURAL
ZO y ARCHITECTS DECLARATION PANELS
vv�2 Z l understand my plans shall be used..,public re,nrds CHIMNEY
REPAIR OZ:40 UP T02(g1AMPS El INTERIOR ❑CHIMNEY REPAIR
F-,4t Licensed Professional 2014000AMPS IMPROVEMENT ❑SWIMMING POOLS
.•', OWNER-BUILDER DECLARATION OVER III(xl AMPS ❑BATH REM DE iEPAIR HMOLI
y tIa� 1 hereby affirm Nat I am exempt from the Convmmr'x License Law for the
x L U ]'allowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
YI a Oe which requires a permit to Construct,alter,improve,demolish,or repair any structure
prio,.lu iuuance,ulso requires the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC.
p�} 'bathe is licensed pursuant to the provisionsofthe Connectors License Law(Chapter 9 - COMMERCIAL;
�Qf (commencing with Section 7000)of Division 3ofthe Business and Professions Code)m TEMP.MITER OR POLE INST.
a q e that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i� Sation 7f131.5 M1y eny applicant fnruµrmit subject,theapplicam'..Civil peaaltl-f POWER DEVICES CTENANT ❑FOOD SERVICE
act marc thin five hundred dollars($5(gD. IMPROVEMENT
,+GCI,us owner of the property,or mycmpinymnwith wages astheir wle mmpenm'ion, SWIMMING POOL ELECTRIC El OTHIiR
will do the work,and the swewre is not interdiction offered forsale(Sm.TA,1.Business
L a and Pmfessinns Code:The Commerce.License law does not apply to an owner of OUTLETS-SWITCHES-FT S
property,who builds or improves Hereon,and who does such work himself or through
his own employees,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELEOTR
aide.If,however.the building or improvement is sold within one year ofeumpation,the SQ.Ff.FLOOR AREA S✓SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for par- /4
poseofsule.). TOTAL: PAto
D
❑I,as owner of the progeny,oro exclusively conwc'ing with Iicenud contactors m
emixtmm the projeet(See.7044.Business and Professime,Cale:)The Cadman,x Li. AUG
cense law does not apply'.an owner of progenyq who builds or improves thereon, QTY. PLUMBING PERMIT FEE 9�
who contracts for such projects wird a c.ntractodn)licensed pursuant m the Contractor's Fj �4sA
License law. PERMIT ISSUANCE ❑ITL rev
❑lama qRt^I ufacr5ec./ .B&PCfor isrcamn Dry OF
Game,/� DIrs, ALTER-DRAIN&VENT-WATER HA) 'tll( ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE V
I hereby affirm under penalty of perjury one of the following declarations:
I have and will mainmin a Cerilicate M Consent to self-insure for Workers Compete. DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPECONSTRUCf10
sation,a,provided for by Section 3700 of the Labor Code,for the perfnmmnec of the
work far which this Permit is issued. FIXTURES'-PER THAT
El 1 have and will maintain Warkars Compensation Insurance,as required by Section
37q)nf be LalorCode.far the performance.('he work for which this pcmtit is issueJ. GAS-F.A.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier end Policy number me:
Careiee Polley Na.: I GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiASU1NDU5TRI,WASTE INTERCEPTOR nulytw❑ IS )N f2R5
CThis section need not becompletadHate permit is Intone hundred dollars($100) GREASETRAP
or IasJ - 1'IANCHI7CK FE'
I cenify Nm in the perHsrmance of the work for which this permit is mied.I shut] SEWER-SANITARY-STORM EA.2W FT.
oat employ any person in eny manner sou t.become subject m the Workers'Cnmpco- V FEE
sation Laws of Califomia.Date WATER HEATER WNENTIELECTR
Applicant
y NOTICE TO APPLICANT:IL afro,making this Cmificate of Exemption,you should WATER SYSTEMILREATING
(•': become subject m the Workers Compensation provisions of the labor Code.you must E
pWG forthwith comply,wird such provisions m this pamitshall be deemed revoked. WATERSERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. Doe Receipt q
'7 '� Ihercby efErte than there iso Construction lending agency for perfnrmontt of
U the work for which this permit is issueJ(Sec.301 Civ.C.) TOTAL
Q Lender's Name
Lcnda's Address TOTAL'
f},at y 1 cenify'h n 1 have read this application and state Nat the above mficar mann is G
Lf0 correct.l agree m comply with all city end county ordinances and,tam laws re luting to QTY. MECHANICAL PERMIT FEE FT:
U 7- building Conswction,and hereby euthorin repres,nwtives ofthis city to enter upon the
alwve-mentioned property for inspection purposes. PERMIT ISSUANCE FEE
(We)agree m save,indemnify anti ke<p hennless Nc Ciry of Cupertino xgaia,I lumilides.judgments,costs and expenses which may in any way seem,agalnn slid Ciry ALTER ORADDTO MECH. GFin menCricnce of Ne granting of this permit.
APPL NT UNDERSTANDS AND WILL COMPLY WITH'ALL NON-POINT AIR HANDLING UNIT(TO I0.00)CPM) ICAL FEsiernCF .GUI.A'I'I S. AIR HANDLING UNIT(OVER IO.gM1CFM) UCTION TAX
Signature ofAppli... Comm"or O Date1 EXHAUST HOOD(W/DUC) HOUSING MITIGATION -E
HAZARDOUS MATERIALS DISCLOSURE ow
Wlltheapplicamorfmurehuildingoecupanlsmrtorhandlehwrrdou,material NIT(TO 101,0010 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety NIT(OVER ilg),g1U BTU)
Code.Section 8532(x)^
❑Yes ❑No N VAN(SINGLE RESIII) PAID Ua¢ Rmeiplg
Will the applicant or future building occupant use equipment or devices which COMP OR 100,000 BTU)
humrdous air contaminants as defined by the Bay Arta Air Quality Management TOTAL:
Oramn, OMP(OVER 100.00)B9'U)
C Yes CNo
I have rand the hxvudous materials requirement,under Chapter fi.95 of the Cali- TIONER - ISSUANCF.DATE
far .Health&Safety Code.Sections 25505,25533 and 25534.I understand that acre ENTIAL MECH. SQ.Pr.
buildingdoes not currently have a tenant Na'it is my responsibility m notify the occupant _
of the requirements which m oho at prior to ismxnceofa Certificate.(Occupemy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE