S 0174 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIIJ)INC-F.LECI'RICA], PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUM RFUEC IDENTIFICATION
S 0174
BUILDING PROJNC'F IDENTIFICATION V U
BUILOINGADDRESS: CV e-�I( a SANITARY NO. APPLE TIONSUB DATE
D Y82 6 :fb zo .
R'S NAM13rHONE: RA(
NIC CONTROL OW A6ErIeA
r
%RCHITHC'ENGINEER: rNo RADDR ❑
10 730,9
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CONTACT:` PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELE PI.1MB n EC
C �U
"a )f,1
Di LARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(enmmencing JOB DESCRIPTION
WOz with Section 7")of0ivision 3 ofthe Business Doul Pmfesdans Cede,and my licence is PERMIT ISSIJANC17 RES]DEN I IAL:
Prwr in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�UV License a LIC.XJAM APPLIANCES—RESIDENTIAL El ADDITION [I PLUMBING RETIPH
FzW Dam Convector ,,
N64 " f t I r( ❑MULTLUNIT ❑STRUCRJRAI.
RCHITF.LTS DECIARA010N
E.::;y N PANELS MODIFICATION
zonZ lundeawnd my plans shall he usnl ns Public recordr
pz 0W UP TO 2(XdAM t ❑INTERIOR El CHIMNEY REPAIR
I p4i-Yl Licensed Professional 201-10h IMPROVEMENT SWIMMING POOIS
Y2,•,•1 OWNER-BUILDER DECLARATIONOVER IgXI 'S ❑BATH REMODEIIREPAIR DEMOLITION
yy 4' 6 reason,
hereby affirm that I am exempt from the Contractor's License Law for the
U following (Section 7031.5.Business and Professions Cade Any city or county SIGNS ELECT+ Al. ❑OTHER
3 t which requires a Permit tu construct,ulcer,improve,demolish or repair any suuaure
�,�y prior to its issuance,also examines the applicant for such Permit to file a signed statement SPECIAL R i�X
Y that he is licensed puomm,rothe provisions of the Comactoev License Law(Chapter 9
Ny Op (commencing with Section 7000)of Division 3 of the Business said Professions Colic)or TEMP. . EROR MOLE INST. COMMERCIAL:
that he is Ca t therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iG ISN, Section 7031.5 by any applicant for u permit subjects the applicant to a civil Penalty of POWER DEVICES OTENANT ❑FOODSERVICE
not more than five hundred dollars($500) IMPROVEMENT
n,C1 ❑ I.as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
CCwilldothe work,mothesum
ucrei.snot immd
�cdoroffered for.le(Sce.70,14,Business []OTHER
se and Professions Code:The Comrectoex License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
4 3 prolixity who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art nm intended or offered for NEW RESIDENTIAL ELECfR SQ ET.
sole.IL howevegthe building or improvement is sold within one yemaf completion,the SQ.FT.FLOOR AREA 3/SQ.FT.
owner.builder will have the burden of proving that he did not Build or improve for put- /fes p
pose n(. Wle.). TOTAL:SFE
W 1
I,as owner of the properly,am exclusively Contracting with lieensed Contractors 1. r_
Consthe pmjat(Sec.70kt,Business and Professions C.0 The Commcto
rtmwthe..,
rs Li- QPp
se Low does not apply,.eco ons m reo
er of property who buildimproves then,and QTY PLUMBING PERMIT n�
who contracts for such projects with u Contractors)licensed pursuant to the Contractors
License Low. - PERMIT ISSUANCE
❑ 1 am exempt under Site .B&P C far his reason _
Owner Dam ALTER—DRAIN&VENT—WATER(EA) CH ATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROITCI'.DEVICE
I hereby off rte under penalty(if 0
Perjury one of the following declarations:
❑ Ihuve anJ will maintain aCenifca,.of Consent msdf-insure for Workers Cnmryn- DRAINS—FLOOR,ROOF,AREA,COND. STORMS TYPE CONSTRUCTION
ration,as Provided for by Section 3700 of the Labor Code.(m the Performanm of the
..,it for winch this permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3]00o(the Labor Grade,for the PeAnrmanceufthe work forwhich this permit ix isauM, CAS—IiA.SYS'fEM-0INC.40l1TLhTS DEC.GROUP APN
My Wearri , sCo pc aNpp fns nc ecu .,it icy r�(r�L�ysZ GAS—EA.SYSTEM-OVER 4(P.A)
Hey CERTIFlCA OF EXEh ION FROM WORKERS' !! J GREASE/INDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FE
(This section need not he completed if Ne permit is for one hundred dollars H$100) GREASETRAP
or less.) PI.ANCHECK FEE Jt
Toy tiny that in the any manner oas(iwork for which this the it Wosissued.)shill gEWI!R—tiANITARY—STORM 13A.2(XI FT.
nm employ any person in any manner sec as m hecnme subject m the Workers'Cooper. ENERGY PD•li
O ,� .tion Lows of California.Dam WATER HUATER WNEWIELF.CFR
Z Applicant t GRADING FEE
ti NOTICE:TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMIGREATING SOILS FEE
a , Become subject to the Workers Compensation Provisions of the Lane,Code,you must
fSJ forthwith comply with such provisions or this Permit shall he d¢mel minted. WATER SERVICE
Q
7z CONhem isa'IONLItNDlNGAGENCY NEW RESIDENI'IALPLMB. SQ,FT. PAID Dane Receipt At
L) O I far which rh that there is s ed(Set.on lending agency tonne performance of
r the work for which this pemtit is issued(Sec.31197,Co.C.)
Lenders Name 'f0'I'AL:
wTenders AJdmss TOTAL:
ky 1 Certify that 1 have read this application and sure that the above infommoion is BUILDING FEE
N mrtect.l agrcerommply with all city and mumy ordinances and sure laws rdming us QTY. MECHANICAL PERMIT FEE
V 7 building Construction,and hereby coalition mpwameatives of this City to enter the SEISMIC FEE
aMrvcmentiancd properly for inspection Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdess the City of Cupertino against ELECTRIC FEE
Iialadhieajudgmend,costs and expenses which may in any way secure against said City ALTER OR AUD'I'O MECH,
in consequence of the granting of this permit. PLUMBING IPE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON- DINT AIRHANDLINGUNH'(TO 10,I100CF]SH
SOU EREGULATIO 5,
MIiCHANICAI.FEE
/� T/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa�sunUContacmr Date / EXHAUST HOOD(W/DUC'O HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant nrhome building cecupum store ar handle hueallousmuteriul HEATING UNIT(TO 100,0X)BTU)
as defiaed by the Cupertino Municipal Code,Chapter 9.12,and On Health and Salbry
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
[IYes [3 No VIINTIIAI[ON FAN(SINGLE!RESI D) PAID Doc ReccipN
op T
Will she applicant or future building occupant use equipment or devices which
emit hazardous air Contaminants as dented by the Bay Amu Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
T( 1'A
District? BOILER—COMP(OV HR 100.000 BTU)
❑Yes [:I No
I have read the hazurdoux nmmrials maturcumnts under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cafe.Section 25505,25533 and 29534.I understood not done NEW RESIDENTIAL MECIL SQ.lei'.
building docs not Currently have a mutual,that II is my responslRlllry to notify the occupant
of the rruirement which most be mer poor to issuance of a Certificate of Ocerpao y,
Owner nr auNonzed agent Data TOTAL: ISSUED BY
OFFICE