B 0652 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
G� ��� L. �►� S 27 9
OW R'SNA E: PHO E: CONTRACTOR'S NAME: LIC NO:
NI
..&� L ` C CONTROLN
AftCHI'FE GINEEk. /V IC NO: ADDRESS: ❑ 9-3
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ ConsWtont Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
Rua dr� 4oz)zzl 2 0- e' ff �i
LICENSED COM'RACTOR'S DECLARATIONQ=Z ,
1 hereby affirm at I am licensed under provisions of chapter 9(commQTYELECTRIC PERMIT FEE
enaing JOB DESCRIPTION
{ 00 with Section 7000)of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL:
F p in full farce and effect. ! PERMIT ISSUANCE
W U ❑SFDWL [I KITCHEN REMODEL
Q,UU License Class Coma APPLIANCES-RESIDENTIAL J 7<DITION , ❑PLUMBING RE-PIPE
yZF .Dam Contractnr
F.0 to ITE CTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
O Z_Z /fyntlerst�ttq.r p ons s II be use am cards _ MODIFICATION
UP TO YOOAMPS ❑INTERIOR El CHIMNEY REPAIR
Lice eded Frofessiough 201-IOWAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IrgU AMPS ❑BATH REMODEL/REPAIR D DEMOLITION
rptpa�.,COwij a I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mr,am.(Sectiun 7031.5,Business Professions Code:Any eityorcounty SIGNS ELECTRICAL ❑OTHER
O,an which requires a permit to construct,alter.Improve,demolish,m repair any structure
prior to it,issuance,also requires the applicant for such permit o file asignedsta¢mem SPECIAL CIRCUIT/M ISC, -
�yp. that he is licensed pursuant to the provisions of the Contractor License Law(Chapter 9
ad'Fa' (commenting with 9atlnn 901H))ofDivisi¢nJof the Bnsivess and Professions Ccde)or TEMP.METER OR POLE INST. COMMERCIAL:
G d e W that he is exempt therefrom and the basis for The alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
.Section 103 IS by anya applicant Fara tsubars mea licam to a civil penalty of POWER DEVICES
y pP 00). ) PF ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars y employees
�� IMPROVEMENT
6 �I,as owner of the property,or my employees with wages estheirsole compensation, SWIMMING POOL ELECTRIC
,will do the work,and the structure is not intended mattered for sale(Sec. Business THER
3 and Professions Code:The Contmcmr's License Law docs not apply to an owner at OUTLETS-SWITCHES-FIXTURES
property who builds or improves throun,and who does such work himself or through I
his own employees,provided that such improvements ere not intended or offered for NEW R17SIDEWIAL ELECTk SQ F1'.
sale.If.however.the building or improvement is sold within one year of completion,no .FT,F 'A
owner-builder will have the burden of proving that he did not build or improve for par-
s
s owner
6 as ow r of the property,am exclusively contredin6 with licensed comracmre m TOTAL: - 12 199
construct the project(Sec.904q Business and Professions Code)The Contractor's Li- - J
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such prnjems with a contractors)licensed pursuant to the Caroni
Licemc Law. PERMIT ISSUANCE By
❑lam exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S MPENrjuU on DECLARATION BACK FLOW PROTECT.DEVICE 7
I hereby affirm under penalty of perjury one of the following declams Ca r O FL3 0
Olhave and will far
eCeni 3700 of Consent to sclm,to, forWorkers Camper. DRAINS-PLOOR.BOOK AREA,
cation,as provided for by Section JT00 of the Labor Cade,fur me performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APIC,
My Workers Compensation Insurance eerier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 4i
COMPENSATION INSURANCE• GREASF/INUUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(This section need not Fc completed if the permit is forone hundred dollars(S IOU)
GREASETRAP
m less) - PLAN ECK PEE
Ie,any that:.me pert.m.a,,.the wank
ricarc hich mpiaispee W.r issued'Ismail SEWER-SANITAkY-STORM F:A.200 FT.
not employ any person in any manner so as m become suhjem m the Workers'Compen- E E r/1
Z, sation Uses of Califomia.Date WATER HEATER W/VENT/ELECTR V
Q Applicant R G FEE
IA NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation powisiona of the Labor Code,you..it FEE
W - forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FT: ID
z I hereby affirm That them is aconstmetion lending agency for the performance of Date - eiptM
U The work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name f
O G Lender's Address TOTAL: O
yI certify that 1 have read this application and state that the above information is BUIL G FEE
correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE Wit
V building conswction,and hereby authorize represematives of this city mentor upon the SEISMIC FEE
above-mentioned propeny,for inspection purposes. PERMIT ISSUANCE
(WO agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgments,costs and expenses which may in any way aveme against said City ALTER ORADD TO MEC11
in consequence of the groming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL C . PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) _
SOURCE REGULATIONS. MECHANICAL FEE
ATR HANDLING UNIT(OVER 10.000 CFM) CONS'FROM ION TAX
Signature¢fApplicaIT A Z s or Date's EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
HAZA DOUS MATERIALS DISCLOSURE
Willy the Clicant ror m Muni:pal a e,Chapter 9.12,
ad the
hmerd and Safety HEATING UNIT(TO IIp,(IW BTU)
as defined io the Capenino Municipal Gide,Chapt.9.12,and the f{earth and 9afety-
Code,Section 25532(a$' HEATING UNIT(OVER 100.(M BTU)
❑Yes VENTILATION PAN(SINGLE RESID) PAID
Will th¢applicant or future building occupant use equnto l art dcviccs which Duro Receipt a
emit hazardous air contaminants as def red by the Bay Area Air Quality Management BOILER-COMP(3HP OR IW.WO BTU)
TOTAL
- DisvictY BOILER-COME(OVER 100,00)BTI)
❑Yes I&I.—
I have read me harard¢av materials requirements under Chapin,6.95¢f,he Cali- AIR CONDITIONER ISSUANCE DATE
tomia}lealm&Safety Crile,Sections 25505,255]3 end 25534.1 understvnd than if rhe Nrvc RESIDEN PIAL MECH. SQ.IT
building does not commonly have a tenant,that lli yrearansibil'ny to notify theoccupant
of the¢quiremems which most he met Pn drawn of a Ceniticam of Occupancy.
Owner o...thonzed agent Dale TOTAL. ISSUED BY'.
OFFICE