S 0720 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PENONL nIGnI
CITY OF CUPERTINOBUILDING FTIT NO, 0 7 L^0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL TIT
BUILDING PROJECT IDF.NTIFICS1 ION
BUILDING ADDRI-SS. ;SANITARY NO. APPLICATION suBMr OPAL DATE
Or /� —! 7
OWNER'S NAMIi: PHONE: C ACTOR'S NAM' LIC NO: CONTROL#
ARCHITECf/ENGINEER: LIC NO: ADDR S:
D 97 a. �II
CONTACT. PHONE: BUILDING PERMIT INTO
���N , ❑ Consultant Fees Paid by Applicant(Initial) BLDG FLF.CT PLUMB Nit
M ❑ ❑ � ❑
LICIENSED CONTRACfON'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby olirm that I em licensed ander pmvisinns of Chapter 9(commencing JOB DESCRIPTION
OaiL with Sectlon](xNq ofDivixinn3ofthe Barimix,md Pmfcasions Code.andmy license is RFSID NTIAI:
1100 PERMIT ISSUANC[
F in full force and effect. ❑SFDWI. ❑KITCHIiN RIiMODEI.
�UV License Class Lac.# APPLIANCES-RESIDENTIAL ❑ADDITION I�161MNG RE-PIPE
F-Z Y1 Date Cnlnmctor
N 6 d
ARCHITECTS DECLARATION ❑MULTIANIT ❑STRDCfUkAI.
1„ y PANELS MODIFICATION
ZOra�Z l tndetatnd my plans shall be ns cdaapublisamords UI"IO2do AMPS
[]INTERIOR ❑CHIMNEY REPAIR
i,cilil W Li.axod Pmftosimed 201-IWAMPSIMPROVEMENT 0SWIMMING POOLS
56 V ;
OWNER-BUIr.D1iR DECLARATION
a Q I hereby affirm that I am exempt Tram the Conwmnr's Limn.Law far the OVI'k ItN111 AMPS ❑BATH RIiMODEURIiPAIR DEMOLITION
5y�O VU fallowing reason.(Semon]031.5,Business and Pmfesxions Cade:Any city m county SIGNS ELECTRICAL ❑OTHER
YI"�W hwhich rubber a permit nI construct,utter,improve.demolaxh,m repair any uwcuum
pF�0n #ditto its assuanee.k.requarexthe applicant I...ch perrohm file aligned statement SPECIAL CTRCUI'T/MISC.
2„!(yzi that he is licensed pursuant the provisions omm
f the Cnctor's License Law(Chapter 9 ales
W�0<C (Oof(commencing with Smli.n700Division]of the Business and Proesarons Code)of TEMP.MI I FR OR POI.E?INST'. COMMERCIAL:
Q.y e e' that he is exempt Ihemfmm and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION Fl DEMOLITION
L� Section 71131.5 by any applicant for u permil mhjmts the applicant It,it civil penaltyof POWIiR DEVICES ❑TENANT ❑FOOD SERVICE
ht mart than five hundred dollars(SSW).
FZ6 1,as owner of the norm Ioecs with woes as their sole cont oration. SWIMMING POOL ELFCfRIC OTHER IiMENT
0El pmpe Y Yman Y 6 ,l ❑OTHER
ill duthework,and the he CommanmsLicens n Law
notasale(Sec.to an owner
cof
a m and Professions Code:The Cnmmcmts License Imw does not apply to an owner of OUT-ITIS-SWITCHES-FIX'T'URES
property who mulds or improves thereon,and who dors such work himself or through
his own employees.Provided that such improvements are not intended or offered for NFW RESIDENTIAL BLECTR SQ IT SQ,FT.FLUOR AREA $ISQ,M.
sale.If,however,the building or improvement is sold within one year of completion,the
ownenhuilder will have the burden of proving that he did not build or improve for pta,
pose o(xaley TOTAL:
1,as owner of the property,am exclusively connecting with licensed contractors to
couswcl the project(See.7044,Business and Professions Cade:)The Conwetots 1.1-
mans,Low does not apply to an owner of property who buildx m improves tomen,and QTY. PLUMBING PERMIT FEE
who coronets for such pmjcets with a amwcmr(s)licensed pursuanuo the Cummmors
License law. I PERMIT ISSUANCE CEI VED
❑ Into exempt under Sec. ,B&PCforhisreuon
AIJER-DRAIN&VFSNT-WATER(EA) DEC 0 8 VAIII�ION
Owner Date 199
WORKERS COMPENSATION DECLARATION 13ACK FI.OW PROTECC DEVICE
• 1 hereby affirm under penally of perjury one of the following declarations:
❑ Ihave,andwill maintain.CertaficomafCnnsem to self-imam far Workers Coogan- DRAINS-FLOOR,NOON AREA,GOND. STORIES TYI ?CONSTRUCT ION
smion,us provided far by Section PW of the Lab nr Code,It the performance of Om D Y•
work far which this pewit is rimed. FI STORKS-PHR TRAP
awill maintain Workers CompemmaonInsurance.ea Inquired by Section
37W at the Labor Cafe,forthe performance afthe work for which dink,wrobis issued. GAS-EA.SYSTEM-1 INCAOUTLBfS OCC.GROUP MIN
My Warkk pas do cc erand Policy nal ^' GAS-BA.SYSTEM-OVER 4(I:A)
Cartier', o'n �Pulicy No.:
fes/-----
CERTIFI F:OP ILC FIT ION FROM WORKERS' GRFASI%INDUSTRL WAST[i INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION I:EFS
(11issectionnmma becomplGedlfthclrertnit isforamhundred dollars(51(X8 GREASETRAP
or less) PLANCEIIiCK THE
I certify that in the perfowance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person In any manner so as In become subject subject to the Worker:Comfier- ENERGY FEE
z ,Z saran Laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE
O Applicant l .
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
become subject to the Workers Compensation pmvisi,m of the Labor Cede,you must SOILS FCIi
forthwith comply with such provisions or)us permit shall he deemed revoked. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. Dam Reccip
UEDIherehy effiwshat there isunmuwctinn lending agency for the performance of
f'+ the work for which this permit is issued(Sec.3097.Civ.CJ
O U Lender's Noma IT L:
Lcndle,Address 1(Y1 I
I certify that I have read this application and state that the above infomlation is BUILDING PF.F.
t7o conen.I agree mcomply with all city and county orJinanres and store Iowa rclwing to QTY. MECHANICAL.PFRMIT FEE
U a building construction.and hereby amhorite mpmounnives of Nis city to enter upon the SEISMIC FEE
a move-mens toned propnny for inspection purposes. F,7
(We)
(We)agree to save,indemni ly and keep hamdess the City al Cmicnann against ELECTRIC FEE
Imbilities,judgments,costs and expert E hichanomany wayaccmeagain,tom,l Cky ALTHR OR ADD TO MIiCH. PLUMB LNG PEE
in cunscyuencc of the gmming off s era%%qqq`Y�L t
APPLICANT UIDF STAND. A / COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 11,1X1)CFM) MECHANICAL FEE
S CE L, ONS.
124—C AIN HANDLE NO UNI'1'(OVER IO,(NNI CFM) CONSTRUCTION TAX
Sigmnur of Ap 'unt/Corractor / Date EXHAUST HOOD(W/DUMI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,fulum building occupant xmre or handle himaduraincral HHA'I'ING UNIT(TO I0I,000 B TU)
m defined by the Cupmimo Municipal Code,Chapter 9.12,and the Health and Safety UHAT.ING UNIT(OVER 100,(N)l 1t'I UI
Code,Section 25532e1?
❑Yes ❑No VENT]LATION FAN(SING LE RES I O) PAID
Dam Receipt#
Will the applicant or future building occupant use equipment of devices w'hleh BOILCR-COMP(JHP OR I W,)(XI BTU)
mat huaanlous oar contaminamts.x defined by the Bay Arc.Air Quality Management TOTAL'
Nuclei? BOILER-COMP(OVER 100,000 BTU)
E]Y., 0 N
I have mad the ham leas m tel als lequimmmm um r CMpmr 6.95 of the Cali AIR CONOITIONCR ISSUANCE DATE
forma I le.lih&Safety Cal,Sections 255(15,25533 aIW 25534.I understand that if the NEW RESIDEWIAL MECH. SQ.FT. / ) _ y, — 4
building does am cmrendy have.,mint,ohm it is any responsibility to ratify the orccupard
of the r+;uimtllents which most be mel prior to ima ane,of.Cmifsnte of Occmpancy,
Owneroramhodmdagenl Date 'TOTAL: ISSUED BY: A
OFFICE