31109 (2) APPL16ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITV OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION
GILDING ADDRESSSANITARY NO. I APPLICATION SUBMITTAL 13ATI
o 44 LimidA V ;alt c I qa
ER$N MB:- PHONE: NTRACfOR'S NAME: LIC NO: NIC CONTROL#
ARCH r INBCR: �� LIC NO: DRESS: f rl
_ I -'Y7 YVI
NTACf: PHO E. Vy BUILDING PERMIT INFO
L E] Consultant Fees Paid by Applicant(Initial) 'BLDG ELECT PLUMB MEOH
N � 0<
LICENSED CONTRACT'OR'S DECLARATION y ELECTRIC PERMIT FEE
I hereby affof'Na I am licensed under previsions of Chapter 9(commencingcivis JOB DESCRIPTION
n00 wit Smiande)ol Division3ofthe Business and l4ofessinns Code,and mylicenu is RESIDENTIAL:
C-,-U in License
force lass, effect PERMIT ISSUANCE '❑SFDWL ❑KITCHEN REMODEL
s�a..0 Wcenu Clau CoLicntractor
APPLIANCES-RESIDENTIAL DOITION ❑PLUMBING RE-PIPE
#60. Date Cnnwctor .
ARCHHELTSDECLARATION ❑ TI-UNIT ❑STRUCTURAL
Z O 2 Z 1 understand my plans shall he used as public records PANELS MODIFICATION
OZ—Q UP TO 200 AMPS dkRJTERIOR ❑CHIMNEY REPAIR
gagLicensed Rofcseinnal 201-10N)AMPS C MPROVEMENT
.•.•1T OWNER-BUILDER DMIARATION
y�O W V 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000AMPS C3 BATH REMODEVREPAIR ❑DEMOLITION
(ixi5 G. fallowing reason(Section 1031.5,Business and Professions Code:Any ell,nr coumyBL ❑OTHER
construct,I+t'31a,F' which mind..is permit to construct,aha,improve,demolish,or repair any so eine SIGNS RC'TRICAI. p
prior m IN issuance,tikonquirestheapplicant for such permiva fileasigned staccom SPECIAL CIRCUITIMISC.
p. that he is licensetlporsuam totheprovisinnsofthe Cmadetols License Law(Chapmr9
—Op (mmmenciagwith Section 10010hof Division 3 of Ne Businessend Professions Code)or TEMP.METER OR POLE INST. t
a yyx e z that he is exempt themfmm and the basis for the alleged exemption.Any violation of NEW B1kM///A1�DDIT�N^N{JI PION
WI Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑T ANT"/ �J ❑ VICE
I-Z not more Nan five hundred dollars H500). PROVEMENTrCup,-
will
�/
0a ❑1.asowneroflbe property,or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC up,-
-
wJldothework.and theswcwre isnot intended moffemd far .[a(See 701 Nosiness THEN elT/N
" and Professions Code:The Connector's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL BLECTR SQ PT.
sale.If,however.the building or improvement is sold within oneyemmeompletinn,the SQ.FT.FLOOR AREA $ISQ.FT.
ncrvbuildsr will have the burden of proving that he did not build or improve for par.
Five or side.).
[❑1,as owner of Ne pri),icity. exclusively contracting with licensed contractors to
construct he project(See.704 .Business and Professions Cade:)The Conaaaor'a U.
rOyyRkAL
'
centic Law does not apply to an owner of property who builds or improves thereon,and QTY. PI. PER T FEE 2 U
who contracts forsuch projects with a contractor(s)licensed pursuanno the Grntedors
License law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C far this reason
Owner Data ALTER-DRAIN&VENT- (PA) I VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 (JN �/ .�� �►
I hereby affirm under penalty of perjury enc miles fallowing dcclaeJons: (f.. — 1 Lt
❑These end will meimain aComftcane of Conant no self-insure for Workers Comped- DRAINS-FLOOR.ROOF,AREA,COND.
union.as pmviMtl for by Section 37M of the Labor Cole,for the performance of the STORIES TYPE CONSTRUC ION
1 work for which this permit is issued. FIXTURES-PGR TRAP
❑I have and will maintain Worker's Compensation Inavenes,as reyuirsel by Section
3700 of the Labor Ced,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker' Com nation Insurance carrimmid Policy number arc:)
Cartier. Palley No.: �.t Y}/ GAS-EA.SYSTEM-OVER 4 WA)
'ERTIFIEXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE GREASEflNDUSTRL WASTE.INTERCEPTOR
I VISIONFBES
(This section mad not be completed if the permit is for one hundred dollars(41(g)) GREASETRAP or lesaJ PLANCHE FE 1 6C��
(certify that in the performance(it the work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200FT.
not employ any person in any manner eo es to become subjcn to the Workeri Compem ENERGY PN
OZ scion Laws of Califamia.Date WATER HEATER WNENT/ELECfR
z Applicant GRADING E
.y. NOTICE TO APPLICANT:If,after making this Certified.of Exemption,you should WATER SYSTEM REATING
became subject the Workers Compensation provisions of the Labor Code,you must SOILS FEB
Lakyforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY d NEW RESIDENTIAL PLMB. SQ.FT. PAID
(, 0 l for
rwhich affirm that there isaed(Seeti30 lending agency for per(omiance of Da Receipt#
Is. r Newark for which this permit is issued(Sec.3W],Civ.CJ '
O (•' Lenders Name TOTAL:
Lenders Address 1
1 certify that 1 have read this application and stale that Ne above informainn is BUILDING FEE �
LCA comet.I agree to comply w'iN ell it,and coumy ordinances wd mile lows rotating to QTry, MECHANICAL PERMIT FEE
V G building construction,and hereby authurimreprtsematives ofthis city mender upon the SEISMICFEF
above-mentioned property for inspection purposes. PERMIT ISSUANCE -�
(We)agree to save,indemnify and keep hatless the City of Cupertino against fPAID
CTRI
liabilities,judgments,costs and expenses which may in any way accme against said City AGWRORADDTOMECH. �'1/'s
in now,ticamof Ne gruntingof this permit M h E 20
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,ODB CPM)
SOURCE REGULATIONS. HA AL FE1 '120
R HANDLING UNIT(OVER 10.000 CFM). STRUCf10 TAX
Signature of ApplicardC tor Dam EXIIAUST HOOD OVMULTT HOUSINGMITI TION FEE
HAZARDOUS MAI ERIAIS DISCLOSURE.
Will the applicant or future building occupant store orhandle haysrdoos material HEATING UNIT(M 100p00 BTU)
as defined by the Calendar,Municipal Code,Chapter 9.12,end the Health end Safety
Code,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU),
❑Yes [3 No VENTILATION FAN(SINGLE RESID) -
Will thea applicant or future building n use mem or devices which Data
cipn N
pp gby then wuip BOILER-COMP QHP OR Ift"BTU)
emit hazardous air connaminams ss defined by the Bay Arca Air Quality Management AAL:
DisWnT
Yea ❑No I BOILER-COMP(OVER 104000 BTU)
❑
I have read the hazardous materials equiumcnu under Chapter 6.95 of thAIR CONDRIONEfce Cali- ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 8534.1 understand than if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdas not commonly have a anent,out it is my responsibility to notify its,cecapant
of the requirement which must be men prior to issuance ala Canificme of 0eeupaacy.
Owner or amhorised agent Date AL ISSUED BY:
OFFICE