99080205 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY D ON S
Cj�TIY OF CuPRRTINO BUILDING-ELECTRICAL PERMIT NO.
ItUILDINGDIVISION APPLICATION/PERMIT PLUMBING-
MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING AOD,I SS: SANITARY NO, APPLICATION SUBMITTAL DATE
Ar A\je r3o �
D{�RS NAME: PHONE: CONT ACTOR'S NAME: \ LIC NO: WC CONTROLN
W� 7b Q
_CHITECT/ENGINE R: LIC NO: ADDRESS: \\ ❑
h®� 2 0 1 r CCee oM
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, "ELECTRIC PERMIT FEE
1 hereby affirm Char 1 am Imenvul under previsions of Chupmr 9(commencing - _ _ JOB DESCRIPTION
Q0Z with Section]OW)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
R70p y
F� F m full force and effect. PERMITISSUANCE
1 9 ❑SFOWL ❑KITCHEN REMODEL
QUU Liceetense 1 s I.ic.# APPLIANCES-RESIDENTIAL C1 ADDITION El PLUMBING RE-PIPE
y ul DCoutmetor
W ARCHITECT'S DECLARATIO ❑MULTI-UNIT ❑STRUCTURAL
Z o lA Z I understand my plains,h ill be used as public records PANELS MODIFICATION
UPT02MAMPS ❑INTERIOR 0CHIMNEY REPAIR
Licensed Professional 201-IOMAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IWO AMPS ❑BATN REMODEIJREPAIR (]DEMOLITION
0.'uCi a I hereby s%inn that 1 am exempt from the Contractor's License Law far the
C'L U following reason.(Section 9031.5,Busieess and Professions Cade:Any city tor county SIGNS ELECTRICAL ❑OTHER
El WO y which requires a permit m construct,alter,improve,demolish,or repair any structure
prior m is issuance,also requires the applicant far such Permit to file a signed statement SPECIAL CIRCUITIMISC.
Q that he is licensed promenrto the provisions of the Contractor's license Law(Chapmr9
❑❑ (commencing with Section 9000)or Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of 5❑NEW BLDG/ADDITION ❑DEMOLITION
i fmN. Section 70315 by any applicant for a Permit subjects the applicant m a civil penalty of POWER DEVICES ENA ❑FOOD SERVICE
F Z Y t mare than rise hundred dollars($500). VEMENT
QI,as owner of the property,or my employees with wages as theiraole compensation. SWIMMING POOL ELECTRIC
0 will do the work,and the structure is not intended or offered for sale(See.]044,Business OT
m and Professions Code:The Committees License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the buildlngodmprovement is sold within one yearofcomplatien,the SQ.FT.FLOOR AREA $/SQ.ET.
net-builder will have the burden of proving that he did not build or improve for par-
rose of to).
❑I,as owner of thepampeny,am exclusively contracting with licensed contractors to TOTAL'
nswct the project(Sec.9044,Business cad Professions Cade:)The Commands LI-
aseLaw does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cormarra(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I em exempt under See. ,B&P C for this rerun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dole
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 hemhy affirm under penalty of
perjury one of the followingimakerdeclarations:Co
Ihave and will for byneCertificateio370of the Lto eon,
Coalself-insureher Worker's Compen- DRAINS-PLOOR.ROOT,AREA.GOND. ST ps TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Cafe,fm the Perfomtance of the
work for whichthis permit is issued. FIXTURES-PER TRAP
❑I have add will maintain Worker's Compensation Insurance,as required by Section
3]W of me LahnrCMe,Ionhe performance of the work for whichthis tis issued GAS-EA.SYSTEM-I INC.4011'1'LETS OCCGROUP PN
My Werke ensaT d Pohc er 7 [/�
Cartier ®ncecartie GAS-EA.SYSTEM OVER 4(EA) x 4
CE TIFlCATE OOP�EXEMPTION FROM WORf�i3
COMPENSATION INSURANCE (( � GREASPJINDUSTRL WASTE INTERCEPTOR BUVLDWG QIYISION FEE$ '
(This eectitn need not be completed iDhe permit isfar one am($100) GREASETRAP
i
unless.) PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,Lchall SEWER-SANITARY-STORM EA.2W FT ✓";-
not couple,any person in any manner so as m become subject to the Workers'Crimper- ENERGY-FE,E d
z ,$ sation Laws of California Date WATER HEATER W/VENT/ELECfR
Q Applicata GRAD 'GTE
ti h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMlIREATING
become subject to the Workers Compensation provisions of the Labor Cale,you must .,11 Sc FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE �- (y
Q It
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. Ir' PAID Date Receipt#
1 hereby aTthi that mere is s construction lending agency for the performance M
W the Landcfk for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name _
V Lender's Address TOTAL: t
1 certify that I have read this application and state that me above information is �UILSING FEE
rFi V) correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U Z building....harden,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may unary way accme against said City ALTER OR ADDTO MECH. PLUMBING FEE
in asequence of the granting of this permit.
APPLICANYJJNDERSTANDSA D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,003 CFM)
SOURCE ULAT ONS. MECHANICAL FEE
�ISC/�q�q— AIR HANDLING UNIT(OVER 10,WBCFM)' CONSTRUCTIONTAX
Signeturo� iw l/ mtmct / -Dole EXHAUST 11000 OVIDUCT) HOUSING MITIGATION PEE
BAZAR US MATERIALS DISCLOSURE
Wilitheoppliamr.or�ture building occupam stow or hondlehamNous maarisl HEATING UNIT(TO 1W,00a)BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
HEATING UNIT(OVER 1 ,00s)BTU)
Cade,Section 25532(apl
0 Yes ON. VENTILATION FAN(SINGLE RESID) PAID
-Dam Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous
air contaminants as defined rea by the Bay AAir Quality Management TCAL:
Dlmdm4
E]Yea ❑Nn BOILER-COMP(OVER I 00,00a)00,00a)BTU)
I have read the hazardous materials requirements under Chapter 6q5 of the Cali- AIR CONDITIONER ISSUANCE DATE
hemi.Health&Safety Cold, ctions 2515 5,255�and 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ.Ff. /W� � (u _ q 9
building doesn en has amnant t'it y responsibility to notify me occupam o"
he require s n thein a fnC ifimm fQcupancy.
ng 0 4
wnero ut ze agent Date TOTAL: ISSUED BY:
OFFICE