S 0257 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LEC I RICAI, PERMITNO,
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION 0257
ILDING ADDRESS: 77t-
'S
ATION SUBMITTAL DATE
01
03 Jon
NAME: ONE: " ACTOR'S NAME: LIC NO:
N/C CONTRDI.#
\RCHITECT/ENGINEER: LIC NO: 7q- ❑ 9r- a
CONTACIE PHONE: - BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
A K
LICENSED CONI'RACTOR:S DECLARATION QTY. ELECTRI .PERMIT ',
1 herehy ulfirm visions Thal 1 am licensed under proof chapter 9(commencing r 106 DESCRIPTION
0,05 with Section700dof Divislon3ofthe Business and Professions Cnde,and Eny license is RESIDENTIAL:
WOO PERMIT ISSUANCE,
F W 'in full force ata effect 7/1 / ❑ DWL ❑KITCHEN REMODEL
ouu LicenseC s Lic. APPLIANCES-RESIDENTIAL DDITION [:1 PLUMBING RI9-PIPE
F W Date Gomnctor 9W41 .1645�5
m y ❑ LTTUNIT ❑STRUCTURAL.
ARC ITELT'S E ,AR N
z i.Ogn. unJ p a ,ands PANELS MODIFICATION
zcm UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR.
r.4t Licensedpff2lishourn- 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION ,�I
C r4 OVER 1000AMPS I�FTH RE P /R PAIR El DEMOLITION
d I hereby affirm on 1 em exempt fmnt the Contorts Cu :An,License Law for the O CH
O following rcuann.(Section](131 S,Business and Pn,fe,ainns C.do:Any city or county SIGNS ELECTRICAL. OTHER
PRO
witeloo,or..aIpermit l ....... i p demolish, p Y INclarc
� hprinter,t al q titpplppl If. mm n fl signed statement SPhCIAL CIRCUIT/MISC. 'll
�� th.th I' Jpun amt the p ith Cmam License la (CFupwr9 I L
FU
yrC�' (e amen mg 0,h Sect 900(0 fD 3 frit B ;nes undP f Gale)an TLMP.METSR OR POLE INST.
P,`yea that h exempt thercf d the Iasi f the alleged ex pf Any pat on of R).4G/ADDITION ❑DEMOLITION
^r,tin Set 7031 5 by any applicant for a permit Fj �I:the applicant to a civil penalty of POWER DEVICES97719 IM r GUYtH I II�OOD SERVICE
not more than five hundred dollars($500).
F Z>• OTHER C ❑Lo the work,the propmy,structure myemntendes wllhwrgesasaei(Ser. 044,Business SWIMMING POOL ELELTRI
will do thewodc,anile:TheContractors
License La do for sale(Sec.'1144,Business ❑OTHBR _
and Pndevsione Code:The Contrndor'a License Law does nm apply to an owner of OIITLETS-SWD'CH89-FIXTURES
property who hullds or improves theram,and who does with work himself or tltroagh
his awn employees,provided that such improvement,ate not intended er offered Ior NEW RESIDENTIAL,ELECTR SQ FT.
aide.ILhowever.hic addingorimprovemenlissoldwithin oney yrofcompletiomthc SQ PI'.FLOOR AREA $ISQ.Pf.
ter-builder will have the burden of proving that he did not build or ,improve fru pun-
k,of sale.).
❑ 1,as owner of the zo,do,am exclusively mmrveting with heartier]contractors 1. OT L
construct the project(Sec.7144,Business Emil Professions Cade:)The Contractor'a Li- { `
prose Law does not apply to an owner of property who builds or improves thereon,and QTY. _ - e PLUMBING PERMIT' PEE
who contracts for such protects with.contractor(,)licensed pursuant to the Connector's
License Law. PERMIT ISSUANCE �C"S�
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WR'I'ER CA) JrJ6 VALUA
Owner Dvte �
WORKER'S COMPENSATION pan. b DECLARATION BACK FLOW PROTECT.
1 hereby affirm under penalty of perjury one of elf following deduratWorkers Co
*Dlhavc and will maintain uCertificam of Consennnself-Insurcfor Workers Compen- DRAIN$-FLOOR,ROOF, E GOND. STORIES TYPE CONSTRUCTION
'anion,m provided for by Section 3'100 of the Labor Code,for the performance at Ilse
work for which this permit is issued. FIXTURES-PI3R TRAP
❑I have and will moment Worker's Compensation Insurance,as"Lima by Section -
37W of the Lahor Code,for the performance of The work for wit ich this permit is issued. GAS-EA.SYSTEM-I INC.40t1'r V.. s OCC.GROG APN
M Worker,Compensator Insurance cvrrler.nd Policy membrane:' r
«ten; policy Na.: GAS-EA.SYSTEM-OVER 4(EA) ii \Vn
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF,ASFIiNUUSTRL WAS'1'li INI'SRCEPTC
COMPENSATION INSURANCE g IL AD DIVISION FEES,
(This seeder need not les emnpleted flhe perch is prince hundred dollars($Its)) GREASETRAP
car le"') PLANCH -•E
I capirylhal in the performance ofihe work for which this permit is issued,Isholl SEWER-SANITARY-STORM EA.200 Pr.
col employ any pernrn in any manner so vs to Femme subject m the Workers'Gtmpon- ENERG '
QZ scion Laws of California.Date WATER HEATER WNEN'1'7FLECTR
Applicant `
F7
NOT ICH TO APPLICANT:If,According This Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS Pliii
a
became subject to the Workers Compensation provisions of the Labor Code,you nmst
forthwith errantly with such pmviainmen his pennitshall he dcantodoes.ked. WATER SERVICE .
aQ
UO
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB, SQ.IL PAID Dam Receipt#
1 hereby affirm thermic i is a convection lending agency for the performance of
U the work for which this Permit is issued(Sec 3097.Civ.CJ
Lender's Nemo 'r01'AL:
�.E W Lender's Address l'E
y 1 really Nat 1 have read this application and state that the above infozmction is BUILD G FEE
y rV1 correct lugme to comply with all eity.nd county'maintains and sm.lawsrclanng 1. QTY. MECHANICAL PERMIT FEE
) Z building construction,unhandy authorize representatives.fthia city to enlerupon the SEISM FEE
ideve-mentioned progeny for impeclion purposes. PERMIT ISSUANCE
(We)agree to cavo,indemnify and keep hunches,the City of Cupertino against ELECT C FE5
liabilities,judgmems,cos sand expenses which may in any way accrue against said City' ALTERORADDTOMECH,
,no ia
s,jadgioudf tvensex PLIMIRNGFE
AP 'A ILL PLYWTH�LI O -POINT AIR HANDLING UNIT(TO IO,fN10 CVM) MECHANICAL FEE
AIR HANDLING ON[F(OVER 10,000 CFM) CONSTRUCTION TAX
SignaureoP pplianUCont for Date - EXHAUST HOOD(W/DUCT) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will lheappllcont or future building tampon,store.,handle hazardouwmaleriul HEATING UNIT OPO 100,0011 BTU)
as defined by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Spot..25532(,)? I ILM INC,UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLR RESID) PAID
Will thea applicant or future building l use equipment or devices which Ume k pt#
pp gby thenBOILER-COMP(3HP,GR 100,0(10 BTU)
mil hamNous air contaminants as defined by the Bey Area Air Quality Management TOTAL:
Dislncl^ pOILER-COME(OVER 100,000 BTU)
I]Yes FT N0,
•
I have re ad the hamNoua nouranalx requitement,Lade,Chapter 6.95 of the Cali- AIR CONDI'I'IONER ISSUANCE DATE
fomia Health&Safety Coda,Sections 25505,25533 and 25534.1 anderad d that if the NEW RESIDENTIAL SUPER SQ.FT,
building does not currently have a tenant,that it is my responsibility to notify the occupant •.
of the agriccmem which must be not Inorto is,Wanprof a Ccnificnmof Occupancy.
Owner or authorized agent Dam T ISSUE,BY:
OFFICE