S 1700 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBIALDING-ELECTRIGAL PESIT NO. 0 O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
iliP11LDING ADDRESS:' - - SANITARY NO. APPLICATION SUBMI'FIAI.DATE
NIiR'S AMF.'. PHONE: N'I,RACT R'SNAME: LIC NO: �
NIC EDNTRDL k
(� ARCHITECT/ENGINEER: LIC NO: ,W(E,SS: ❑
CONTACT: PUONIC q BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGHLFCT PLUMB MECH
El ED 1:1
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afr that 1 am licensed under provisions of Chapter 9(a,mmeneir, JOB DESCRIPTION
Oa'Z With smaon 7wo)ofl3ivision3 onhe Bushes,and Pm fncnion,Code,andon,aon,a is RESIDENTIAL'
Fy O O PERM['P ISSUANCft
FW„ in full force antic q ❑SFDWL ❑KITCHEN REMODEL
aZ U Ciccone loss Lieb-L39OJ'3� APPLIANCES-RESIDENTIAL in d Tal Date Conwemr 0 ADD TION ❑PLUMBING RE-PIPE
E "ai
'I ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAI,
ZO-ZIunde....undo,dansshall be used or publicrceoo, RODIFIcNTPON
OZ4" UP TO 200 AMPS ❑INTERIOR MNEYREPAIR
P:En. W Licensed Promotional 201-1000AMPS IMPROVEMENT SWIMMINGPOOLS
94;�j OWNER-BUILDER DECLARATION OVER lfxxlAMl's ❑BATT{REMODEIIREPAIR ❑DIiMDLITIDN
d 1 heathy fi ism that I con exempt from the Cmnrnanr'e Lareme Law for Cao
0.V following mason,(Section 91131 SCalls: „ coO
,Business and Profession,Ce:Any city . only SIGNS ELECTRICAL ❑ THER
W 3 a y which rcyuims a permit ro arcs,met,olmC improve,demolish,or ma
repair any Slare
Fq�fOfnnd prior to it,issuance,also real theapplicam broach permit to rile a xigncd statement SPECIALCIRCUI'1'/MISC.
2 r�yn4 that he i,liu:nsed punuaauo the provisions of the Contractor's License Law(Chaper9
00 (commenting who swuan9otxB of Divi,h,n3n1'roe Ba,mers one Pro[ossion,code>„r TEMR METEROR POLEINSL COMMERCIAL'
0. m tG this he is exempt therefrom and the hrsis for the alleged examprion.Any violvrian of [-]NEW BLDG/ADDITION ❑DEMOLITION
0. Section 9031.5 by any applicant for a permit subjects the ap,Iiemt to a civil penalty of POWER DEVICES
ter”
noncore than fire hundreddollarx($500). ❑'IENANI' ❑FOODSERVICE
Ep" dI,vs owner of thopmpeny,or my etnplayeos with wager ux their sole annpnncminn, SWIMMING PO RIC IMPROVEMENT
2 O will Code work,and the-rtmewre is not immrdetlorerrered forsale(Sce.9014,Business El OTHER
fail m and Professions Cn1e:The Cnmmdor,Licume Law doer
not apply to an owner of OUTLETS-SWI' TILS TURES
0. ,,,,party who huilds ar improves thereon,and who doe,such work himself er through
his own employees,provided that such improvements are not marinaded or offered for NEW RESIDENTIAI.P .,GI' S
sale,If.meovec the building or lmprovvarim,scold within one year of cvmpleion,the SQ.FT.FLOOR AREA VSQ.FT.
,wer-builder will have harden eF,mving Chm he not build or initiative pur- pp
eofsaleJ. P M
❑ Luc owner of the,ornery,am exclusively contracting with licensed contractors to T TAL:
instruct dm project(5ec 9044.Business and Profession,Coar"The Con.meer'r.I-
conic Law does not apply to on ownerof,m,erty who builds or impmvns thereon,and QTY. PLUMBING PERMIT FEE �({Y 26 �'®
who wntmcts torsucb projects with o contmctods)licensed pursuantth
m e Conmmmr's nn
License law, PERMIT ISSUANCE
❑ Iran vacant,under Sec. ,B&PCfonhicmamn CHY ur
ALTER-DRAIN&VENT-WATER CA) {/VAAy�LU/ATTI�IOON
Owner Dole ., 2 {/'�
WORKER'S COMPENSA'T'ION DECLARATION HACK FLOW PROTECT.DEVICE
1 hembyalarm under entry to perjuryone ofthe following decker'sCi V
❑ lurvetmdwill adfor Consent Lab nsode,forc her Worker'sne of the ,RAINS-FLOOR,ROOT,AREA,COND.
eotion,as,rovidul for hySwlinn 3908 of the Lab Code,for rbe,erformmoce of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIX'I'URHS-PER TRAP
❑ I have and will maimah,Workers Cam,unsarioa Inrumnce,ar inquired by Section
37Woflhe Labor Code,to,,the pe,f,,mor,coftbe work for which Chic pemdt is issued GAS-PA.SYSTEM-I INCA LITTLE IS OCC.GROUP APN
MY
Wurkej..Com enxat nn lns"a .omicron']Policy n�ro..Ie
Cam'ec e]//b�F/O l- Policybf Jh �3� GAS-EA.SYSTEM-OVER 4GA)
hICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR -
(lak,ectionneed not becnardatel if the permit k Col rs
ae hundred della ($100) BU
lFRING DIVISION
nrlessJ GREASETRAP PLANCHUCK PEE
I cenifythm
noire perf,,rtnaace of Uewrakfmwhichthk,ennit is i e,ucd,lshall SEWER-SANITARY-STORM P.A.200 IT
not employ any perwn in any manner so es to become sabjecno the Workers Count.- ENERGY FEE
z ,7., Cation Laws of Califmnia.Date WATER HEATER WNENTCLECTR
Apphidat t GRADING FEE
y
ti
NOTICE 10 APPLICANH:If,after making this Cenifcare of Exemption,you should WATER SYSTEM/TREATING
E•^ ^'t
become,object to the Workers Canymnretion provisions of the Caters Code,yon most SOILS PEE
forthwith arm,ly veth.cueh provisions or this pemdt shall ler doetne l marked. WATER SERVICE
Q
CONSTRUCTION C, CY NEW RESIDENTIAL PENCE. SQ.PI'. PAID
Wz Ilorohy affirm this thea ixa conswninn lending ugdmy fnrthu perfonnonce of Data Boreal to
the work Co,which this permit is istiztbit(Star 3097,Civ.C.)
Q U Lender',,Name TOTAL:
W Lender,Addrec, TOTAL: „
1 certify that I have read this n,plicvtion and state this the above information is BUILDING FEE
�i h carrecL l agree to comply with all city and county ordinances and nam laws miming le QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby auto i,mprewcurlivesnr this city themes upon the SEISMIC FFB
N above-mentioned p,.,ccy for no,edi,,a neuroses.
(We)agrto save,indemnity and keep leanness the City of Cupertino against PERMIT ISSUANCE BLECTRIC PEE
ee
iaialities,judgment,.carts and expense,whiehmay no any way aname ago lisr said City ALI ER OR ADD TO MECH.
in...m,uence of the granting offin,permit PLUMBING FEE
APPLICANTUNDERS'LANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 I0,000CPM)
SOURCE REGULATIONS. MECHANICAL PCF.
_-ra/ 9,Y AIR IIANDIANGUNI T(OVER 10,000CFM) CONSTRUCTION TAX
Signature ofApplieant/Contra (Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARD SMATERIALS DISCLOSURE
Will ticapplicant orfuutm building oced,antstom or handle meallou,material HI?A'fINC.UNIT(TO INC000 BTU)
as defined by the Capeaino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BI U) -
❑Yes E]No PAID
VEN'I'ILA'I'[ON CAN(SINGLE RESIU) Date Recei,t it
Will ate applicant in future building y the n use A equipment or devices which
emit hazardous sir contaminants as defined by We any Area Air Quality Manugmnenr BOIIJ:R-COMP(311P OR 100.008 BTU)
'I'O'1'AI_
District?
❑Yes El No BOILER-COMP(OVER 100,000 B'IU)
I have marl the hazardous materials rcyuitetnems untla Chapter 6.95 of the Coli- AIR CONDI'I'IONER ISSUANCE DATE
fomes Health&Sofoty Code,Saurian,25505,25533 and 25534.1 undemanal this if the NEW RESIDEN'HAl,MECH. SQ.fi U
building docs not currently Cusco mount,that it Is my responsibility to notify the occupant
of the requirements which const bo met prior m issuance of a Cenil ateof(,,upon y.
Owner or authorized agent Dara TOTAL: ISSUE IJ BY.
OFFICE