S 0147 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O Q
BUILDING PROJECT IDENTIFICATION S 4
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
NEWS OU AMy� � lOIIPHONE all CO kACTOR'S NAME: � CN0 N/C CONTROL#
o ARCHITECT/ENNGG.INEER: LIC NO. _ ADDRESS', iTLI ❑
CONTACT: - PHONE: - BUILDING PERMIT INFO
1 6 w�(�/�� e) �,v t II_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG [LL T PLUMB MUCH
V✓t 61-CIEENSED CONTRACTOR'S DECLARATION`V T QTY, ELECTRIC PERMIT FEE ❑
I hereby affirm that[.In Ilaenaed under provisions of Chapter 9(commencing JOB DESCRIPTION
ROCZ with Section V000)of0ivium 3ofthe Business and Professions Coda,and license is
(.,00 y PERMIT ISSUANCE RESIDENTIAL,
in full force and effect,
1UI" License Cl s ` Zo Lic.# 0SFDWL D KITCHEN REMODEL,
FZ W Dam Cnnlmclor APPLIANCES-RESIDENTIAL [I ADDITION [D PLUMBING RE-PIPE
Z Cr.G L ARCHITECT'S DECLA ION PANELS D MULTI-UNIT D STRUCTURAL.
y K 1 understand my plans shall be used as public retards MODIFICATION
OZ4AUPT02MAMPS DINTCRIOR El CHIMNEY REPAIR
Licensed Professional '
�$d 2,j
OWNER-BUILDER FaDECLARATION 201,1000AMPS IMPROVEMENTEl SWIMMING P001,5
C'RC1 Q 1 hereby affirm that 1 um exempt from the Contractors License Law for the OVER IOfq AMPS D BATH REMODCh($EP ❑D• 0 I
X 3 6 F following reason.(Section 7031.5,Business and Professions Code:Any city ar canary SIGNS ELECTRICAL D OTHER ��►1
{°l R WyQ which requires a permit to construct.alter,improve,demolish,or repair any somemrc
prior at it issuance,also requires the applicant for such permit o fie a signed statement SPECIALCIRCUIT/MISC.
C� that he is licensed pursuant in the provisions of the Contracmr's License Law(Charm,9
N CO (commencing with Section]000)of Division 3 ofthe Business and Professions Cale).1 TEMP.METER OR POLE INST. COMMERCIAL:
is
6 p,m eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
W"m
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES El nFQDD SERVICE
P.'not more than flea hundred dollars($500).
M< U Lasownefofthe propeny,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will tlothe work,and Ne structure is not amended nr offered forxale(Sec.9044,Business D OTHER
3 and Professmm,Coda:The Contractor's License Law drres not apply 1.m owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If,however.the building or improvement is sold within one year ofcompleacia,the SQ.bT (j$AgPi $/SQ.TE
ter-builder will have the burden of proving that he did not build or improve for pur- r, A IIID
pose of salon.
❑I,as t the I pthe propeny,am excessively contracting with licensed cnmctorx In TGTAL QI 80
' wnswen the pmjem(Sec.9044,Business and Pmfesslons Code:)no Contractor's Li- - /d
cense Law does not apply to an owner of property who builds or impmves forced;and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contramogs)licensed purmanno the Contracmr's C�/Yvv11 �w
License Law. PERMIT ISSUANCE Vr LUt "th
_ F11 am exempt under Sec. ,B&P C for this reason ��N/'
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
` WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declarations:
❑I have and will maintain aCenifcarenf Consenitoself-insure for Workers Compen- DRAINS-FLOOR,ROOB AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3900 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS 'OCC GROUP APN
My Wor r' mens ni,! Insure{pP1ce•!y�--���y—¢r and Policyya
Carrier: o _ EA1 Policy No.2A " GAS-EA.SYSTEM-OVER 4(EA)
CE TIFICATEOF EX PDON FROM WORKERS' '
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
'(This section need not he completed lithe permit is for one hundred dollars($I Off BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK FEE
Irene,that in the perfarmance of the work far which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Wnrken'Cnmpen- SEWER-SANITARY-STORM EA.20)FE ENERGY FF,F. -
0 �.. anion laws of California.Date WATER HEATERWNENT/F,LECfR
z Apelican[ t GRADING FEE
r y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMGREATING
ahecome subject m the Worker's Compensation provisions of the Latin Code,you must SOILS FEE '
{IJ
Q forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT, PAID
U 0 Thereby affirm that there is a eonstmc[ion lending agency for the performance of Date Receipt
LL H the work for which this permit A issued(Sec.3099.Civ.C.)
0 Lenders Name - TOTAL:
{U Lender's Address TOTAL:
Rs I certify that 1 have read this application end stain that the above information is BUILDING FEE
cA correct 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby authorize mpmscmatives of this city to enter upon the I SEISMIC FEE
- abnve-menlime for inspection purposes. PERMIT ISSUANCE
( gree m s e,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
luddliti ,judgmen ,ens aadrapc.,cvwmay ny way accrue against said City ALTERORADDTOMECH.
in can, u ce the tin oflhis pe in. PLUMBING FEE
APPLI N . T DS AN WE PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM) MECHANICAL.FEE
CONSTRUCTION
' U O
AIR HANDLING UNIT(OVER 10,1100 CFM7, CONSTRUCTION TAX
Signa reofA,plic.HAZARDO US MATERIALS DISCLOSURE Mule EXHAUST HOOD UMMUCT) HOUSING MITIGATION FEE
HAZARDOUS
Willy the Cupertino
future building e,Chant same 9.12,handle HeaNnandSaf ty HEATING UNIT(TO IlU,1N)II BTU)
as defined by the Cupertino Municipal Code,Chaptei 9.12,and the Health and Safety
'Coda,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes , - , E]No PAID •�
VENTILATION PAN(SINGLE RESID) Date Reecipt#
Will the
isim,applicant orfutoto building by the muse Are.
At,Qualitnt or y
deviceswhich
BOILER-COME OHP OR 1(NIOW BTU)
emit District?
oua air mntaminanta as defined by the Bay Area Air Quality Munagemenl T AL:
Disrim"
❑,Yes [3 No BOILER-COMP(OVER I(q,O(1I)BTU)
l I have road the hamrdous materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER - ISSUANCE DATE
+. fomia Health&Safety Code,Seen.,25505,25533 and 25534,1 undersmad that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not mmemly haves tenam,[bat it is my responsibility m upan
unify the occut
ofthe requirements which must he met prior to issuance of a Cenificate,of Occupancy.
Owner or authorized agent - Date TOTAL] ISSUED BY:
OFFICE