29906 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELRCrR1CAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IHBNTIFICAI'ION
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
iIC RlpE,6l/trabd GT.
f1 NE SNAME: PIIONC:�-�0�� CONTRACTORSNAME: LIC NO:
NIC CON'TNOLR
RCUITECTIENGINLER: LIC N(O', �C`�`1Q ADDRESS; _ ❑
ONTACT: , Q PHONE: BUILDING PERMIT INFO
&` *036 '7QD nsQSdC ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that L am licensed under provisions nr Chrism,9(commencing JOB DESCRIPTION
O=Zwith Sxtimn9W(B of Divisinn3oflhe Businccs.nnJ Prnrenainna Cade.and my license iv RESIDENTIAL
LL O O PI:RMI'1'ISSUANCE
FW infullforccandeffect. ❑SFDWL ❑KITCHEN REMODEL
<—U Licvnnc Claes I,ic.k APPLIANCES—RF,SIDENI'IAL ❑AUDITION ❑PLUMBING RE-PIPE
yZw Dac Cnnmomr
ARCIiI'1'IiCT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p I udersta
nnd my plans shall be used re public records PANELS MODIFICATION
OZ—� UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FNFW Licensed Profesnicnad 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
YY�—,I OVER 1p0AMPS C1BATH REMODEUREPAIR ❑DEMOLITION
Q I hereby action that I am exempt from the Contractor's License Law for the
KOi U following reason.(Section 7031.5.Business and Professions Calc:Any city ser county SIGNS ELECTRICAL ❑OTHER
4]3 LL which requires a perms to construct,ulmr,improve,demolish,or repair any structure
FLL01 prior to issuance,also requires theappliater for such permiuo file a signed statement SPECIAL CIRCUI'DMISC.
HHy•.l that M1elsliermadpursmnt,the pmvlslo...ufthe Convncluln License Lvw(Chupmr9
0q lammmm�cingwith Section 7(mb)of Divhion 3 of the Business and Ibo1cvdmu.Calc)ur TEMR MEHHEOR POLE INST COMMERCIAL
a. mthat he inexempt therefrom and the basis for the alleged exeinption.Any illation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W„N Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of MOWER DEVICES ❑ §PANT ❑FOOD SERVICE
t mom than five hundred dnllvrn(591g0.
F Z Y IMPROVEMENT
=6 Q 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work.and the stmcture is not lntmaed or offered for.dejSec.7614,Business HER
Ed�m and Professions Code:The Commuters License Law does not apply,to an owner of OUTLETS—SWITCHES—TEXTURES
6 3^ property who builds or improves themmn,and who does such work himself or through
his own employees,provided tha such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ IT.
sale.If.however the building or improvemmmt is sold within onth
e yeerufcompleion. e SQ.FT.FLOOR AREA ASG FT.
owner-builder will have the burden n1'proving that he did not build or improve for per- Po/ftp'
pow ol �••/ (J�—[J/�
O'1'AL:
71 L air rof the prolcol am exdnsively contracting with licensed contractors to 'i'
mmwcl the protea(Sea 70,14.Btsinev,and Pmfib,ions Crile:)The Conwcmr's Li-
reroc law does not apply to on owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a control licensed pursuant o the Commences
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for this mason
Owner Dam
ALTER—DRAIN&VENT—WATERBEA) VALUATION
OO^ 1
Wm under
SCOMPENgary on DECLARATION BACK FLOW PROTECT DEVICE v
I hereby affirm under penalty of perjury one of the following declarations::
Ihuv<unJ will maintuinu CenillemeofConscnuoselGinsure for Worker's Cnmpen- DRAINS—FLOOR.ROOF,AREA,COND. STORIES 'TYPE CONSTRUCHW
nation,as tao,ad d for by tieaion 991X1 of the Labor Code,for the performance of the
work In,wrlch this permit's instar FIXTURES—PER'rRAP
❑ 1 have and will mountain Worker's Cmnmpcnsarion Insurance,us required by Scotian
3700 fthe Labor Cafe,fnnhe perfemernmet the work for which thin Permit is invited. GAS—EA.SYSTEM-I INC.4 OUTI,In8 (OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS—EA.SYSTEMOVER 4 JEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR17ASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FE'
t (This section most not becomplcled ifthe Permit is formic hundred cousin(SIM) GRP.ASEI'RAP
or)ess) PLANCHECK FEE
L cenify that in the perLmmmuce,of the work for which this action is is.sued.I shall SEWER—SANITARY—STORM EA.2(1017.
not employ any Person in any manner so as to became subject to the Workers Compen- ENERGY FEE
Z satin..Lows of Culifoome.Dae WAI'17R HHAIER W/VENT/EL17CHR
zC) Applicant LEADING FEE
h NOTICE TO APPLICANT:IC oiler making this Cenificure of 1?xcmplimn,you should WNEER SYS'IEMITRPATING
F become mijectto the Workers Compensation Provi,iuns mine Labor Code,you matt SOILS HE
� ? forthwith comply with such pookans ,,his permit shall be decocted rooked. WATER SERVICE,
a �
7Z CONSTRUCHUNLENDINGAGENCY NEW RL•SIDENTIALPLNIB. SQ.f7. PAID Data Rectiat#
Ll Ihcreby affirm that inaumxumw
construction lending agency for the perfonce of
the work for which this permit is issued(Sec.YN7,Civ.C.) 'TOTAL:
C" U Lcurcr's Name TOTAL
WLcndcrs Address :
a I certify that 1 have adn thigrsicainn and smtc that the above information is BUILDING FEE
h
correct.las=to comply with all cityand county ordinances and sem laws relining to QTY MECHANICAL PERMIT FEE
V 0.
buildho,summation,and hereby stall rim representatives of this city to toner upon the SIiISMIC FEE
above-mentioned property for invpecrinn purpo.wu. PERMIT ISSUANCE
(We)agree m save,indemnify and mle
keep harmless he City of Cupertino against
ELECTRIC FEE
Iiahilitics,judgments,coasamW cxEerse,which may inane wayaccme apinstsaid City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CPM) GONSTNUCfION TAX
Signature ofppplicant/Contracmr Dam 17XHAUST HOOD(W/DU(7 ) HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or for c building occupamnmre or handle huevrdnusmumrial HEATLNG UNIT(TO 100.8)(1 BTU)
as Jebrod by The Cupertino Municipal Code,Chapter 9.12,and the Ileulth and Safety
Gude.Section 255321st)? HHA'IING UNIT(OVER 100,000 BE
❑Yen ❑No VENILATION FAN(SINGLE RESIDE PAID Date Receiptg
Will the applicanr or future building occupant use equipment or devices which
Fruit hmnrdou.n air contaminants an Jenned by the Bay Area Air Quality Management BOILER—COME(3HP OR 100.000 BTU) TOTAL:
Dial BOILER—COME(OVER 100,000 BTU)
(D Yes C]No
Ihave read the M1aeardous materials reyuirementn under ChaPtcr 495 of Tbc Culi- AIR CONDITIONER ISSl1A CIiD E
Tbmia health&Safety Code,Sectiorvv 25505,25533 and 25534.1 understand that if'he NEW RESIDENTIAL MECIL SQ.ET.
building does nor currently hive o natant,that it is my re ponsibllhy to notify the occupant
of The requirement which must M met prior to issuance.of Cedifeam o1Occupancy.
Owner or moronzed agent Data I TOTAL I ISSUED IlY:
OFFICE