99100152 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'q 'q 100 IS2
CI TY OP CUPERTINO BUILDING-ELECTRICAL11 PERMITNO.
"BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PROIL+C•TIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMTITAL DATE
�D Z
WNER'SN ME: PHONE: CONTRACTOR'S NA E LIC NO:
O IJ 4 / NIC
CONTROL%
CH1IbCUhNUINhlrX: LIC NO: / DRESS: ❑
JCONTACT: PHONE: BUILDING PERMIT INFO
�S�q /Z�`�/- ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
0 El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OSection7g )ofDivision3oftheBusinessandHofinesior Code.' dmylicenxcis RESIDENTIAL:
PERMIT ISSUANCE� ll force and chem. CSFDWL C KITCHEN REMODEL.nse Class 6 APPLIANCES-RESIDENTIAL CADDITION ❑PLUMBING RE-PIPE
Ne Cunvedor
F ARCIRTF.CI'SDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
p Z 1 understand my plans shall be used as public meord MODIFICATION
oZ—O UPT02MAMPS C)INTERIOR E3 CHIMNEY REPAIR
W Licensed Professional 12014000AMPS IMPROVEMENT 0SWIMMING POOLS
yf' OWNER-BUILDER DECLARATION OVER IWOAMPS CBATH RF,MOD .M1 'P R GDF:?O`.ITION
C 1 hereby affirm that I am exempt from the Contractive,License Law for the _ Kb
�1 O ty U following reason.(Section 7031.5.Business and Professions Cdr':Any city tar county SIGNS ELECTRICAL C OTHER
1+13 t b- which requima a permit to constmel,alter,improve,demolish,or repair any structure
��0 prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC. QD O NX
py+gy that he is licensed poornttothe provisionsoftheConwctor'sLicense Law(Chapter9 COMMERCIAL,
u1�G� (commencing with Section 7000)of Division 3 ofrhe Business and Professions Code)or TEMP.METERORPOLEIN
14 q that he is exempt therefmm and the basis for are alleged examples.Any violation of C NEW BLDG/ADDITION C DEMOLITION
a�
Section 7.3 LS by any applicant for a pencil sobject,the applicant to a civil penalty of POWER DEVICES CTENANT 0FOOD SERVICE
y not more than five hundred dollars(S501)).
FC ❑I,as owntt of Ore pemeny.or my employees with wages ns Their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
$a will do the work,and the so cum is not Intended or offered for sale(Sec.71W,Business ❑OTHER
ISI" and Profesaiom Cade:no Conturaters License law docs not apply to an.1 of OUTLETS-SWITCHES-FIXTURES
IL 3 property who builds or improves thancon,and who does such work himself or through
his own employees,provided that such Improvement are not ismoded err offered fill NEW RESIDENTIAL ELECfR SQ PT.
sale.If,however'the building.,innmvement is sold within one year.feampletion,are
SQ.Fr.FLOOR AREA SISQ.Ff.
owner-builder will have the burden of proving that he did net build or improve for Pur-
pusc of salty TOTAL:
C 1,as r of the property,nn exclusively contracting with licensed contractors to
construct theeprnjcet(Sec.TW,Business and Pr..feasions Code:)The Contractor's Li-
xLaw does not applytoanowner ofproWnywho buildorimproves thersen,and QTY, PLUMBING PERMIT FEE
who contracts f.rsuch projects witha coatmemi s)licensed purs.antto the Contractor's
License Law. PERMIT ISSUANCE
1 am esompt under Sa. .B&P C fm this mason
e I ALTER-DRAIN&VENT-WATER(EA) VALUATION
TIO
WORKER'S COMPENSATION DECLARATION following
BACK FLOW Pli(IICCT.DEVICE A Q
1 hereby affirm under penalty of perjury one of Ne following Waker's declarations: 7
Fj (have and will forbinetion 300 of Com eau.Code,for the Workeeace of the DRAINS-FLOOR,ROOF.AREA.GOND. GTO IES TVPP.CONSTRUCTION
worn,as provided for mi Section 3781 of the LUMt Code,for the performance.f she
work for which Nis patent is issued. FIXTORFS-PER TRAP
❑ I have and will maintain Worker's C.ce ofiltiw Insurance,h requited by Section
J]W of the LeburCWe,for the perfannwce, nd' I work for which this permit is issued GAS-EA.SYSTEM-I INC.4OUTLETS OCC.CROUP g1^APA
My Work�y„� hggtprssu ec icr nd Policy numberKgae:z _
Gerrie: idyll CLk� N..: ([y�L,L• (Z GAS-EA.SYSTEMOVER 4(EA)
•RTIFICA]'80PE EM ON FROM RMS.
0
COMPEN ATI NINSURANCE GRFASFJINDUSTRL WASTIiINI'ERCEPfOR
(This section need not br comp a',if Ne permit is recross hundred dollars(Sla)) OUILUING DIVISION F[ES
or lase.) GREASETRAP PLANCHECK PEE
I treaty that intheperfomwme ofrhe work forwhich this permit is issued,i shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to become subject to the Workers Compels- ENERGY FEE
O z sation Laws of California.Date WATER HEATER W/VENTBLECLR GRADING FEE
z 0 Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ^ Immune subject to the Warker's Compensation provisions of the labor Calc,you must SOILS FEE
Uj I�r+ forthwith comply wish such provisions or this permit shall be deemed rovoked. ,WATER SERVICE
CONSTRUCTION NEW RESIDENTIAL PLMN. SQ.FT.
U0 Ihcrehy affirm thavhem cre is anmswdi.n lending agency forthe performre anof Q D •ipsN
[L the work for which this permit is issued(Sec.3097,Cie C) U WI
0 U Lender's Name - TOTAL:
ULendees Addmsa TGIAL:
da 1 certify that 1 have mad this application and sure that the above information is DING P
fr N correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FFEE
Ubuilding construction,and hereby authorize representatives ofthi,city to enter upon the SEISMICF*
above-mentioned property for inspection puryoses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep formless the City of C.padoo against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
I.consequence.1 be granting ur Thi, .it.
APPLICANT UNDERSTANDS AVID WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00s)CFM(
MECHANICAL FEE
SOURCE REGULATIONS.
151 414100!� 110/1y� AIR HANDLING UNIT(OVER 10,QWCFM) CONSTRIICLIONTAX
Signature of Ap,lwant Ccournur D'e_h EXHAUST GOOD(W/DUCT) HOUSING Sm rdGATION FI7E
HAZARDOUS MATERTALMISCLOSURE
Will the applicant or future building occupant store or handle hazalloux material I(EATING UNIT(TO I(R.N10 BTU) ,
as def nod by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Cade.Section 25532on? 14CATING UNIT(OVER IW,000 BTU)
❑Yes CNn VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or futum Wilding oecupers use equipment or devices which Date Receipt q
-
emit hamNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR IW.000 BTU)
Dinric17 TOT
❑Yes CNo
tlO1LER-COMPfOVER IW,110.BTU)
I have read the N
hamomaterials terials requin6 Gooier apAIR CONDITIONERter 6.95 of the Call. ISSUANCE DATE
Ramis Health&Safety Cdr',S [airs 25505,25533 mrd 25534.I umdersnnd that if rhe NEW RESIDENTIAL MECH. SQ.IT.
buildingdaes not cumenty have anent,that it is my respond, try m noliry the«x owl
ofrhe rtgWmments which must priortoissuamceofaCertirC ape kp y.
Owne,minthooradagent JJ [m TOTAL: ISSUEDB .
OFFICE