S 0042 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY t
CITY OG'CUPFRTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING•nlF.exANICAI. �yy Z-- "n---�^ t (-
RUILDING ' O i, IDENTIFICATION !/
BUILDING ADDRESS: Q SANITARY NO. APPLICATION SUBMITTAL DATE
/ 077Y C� ar�1'n
OWNER. NAME: I. A A PHDNE:Zf�'/ CON I NACPOIVS AME: LIC NO:
G I Jut NIC CUNTROh p
ARCHI'I-ECf/ENN1NF.F.I: LIC NO. ADDRESS: ❑
CONTACT: - PHONE. BUILDING PERMITINFO
WaZ
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT 17EE t
1 hereby affirm that I em licensed under provisions of Chaprer 9(commencing JOB DESCRIPTION
O00 with Seelic.7"ln(Division 3afthe Bminessond Professions Cade,and my license is RESIDENTIAL:
!+1 O O PERMIT ISSUANCE.
F In full furca and client 2 ❑9PDWL ❑KITCHEN kEMO1lE1.
aUV License Lic.p APPLIANCES-MINDEN'I'IAL ❑ADDITION ❑PLUMBING RE-PIPE
I-zW Dare Caa'mdor
'/tQ6 S DECLARATION ❑MUL'TI-UNIT ❑STRUCTURAL
ARCHITECT
b.pm PANELS MODIFICATION
z p n Z I unJcrsnnJ my plane ebull M awed as public rccoNs
Oz—O UPTO100AMPS ❑INTERIOR CHIMNEY REPAIR
F.oe.�W Licensed Pmfessirnal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
¢a'
J OWNER-HUILDER DECLARATION
a s�' OVER IIIDDAMPS ❑BATH RF.MODEL/REPAIR EIDEMOLH'ION
Q I hereby.(Sero that I oro exempt Business and Pr Gammen,',e:Any c Law for theEl
U following reason(Station]onstrut,aer. and Professions h,oe:Any city or county SIGNS L'L[CTRICAL OTHER
W 3)y¢ which requires..permit re flm,'the ahee improve,demolish, fi repair any structure
�nmJ priore sfiveuatmculsnrc to
he hmtppliwntfor wchperminaicenslc e Law
Chapter) SPPAIAI.CIRCUI'fIMISC.
y� i' that he is limnseJ pursuant'.the provisions of the Conaacmr's License law(Chapter9
u1�GC) (cnmmencingu'ith Section 7001im Division 3ofthe Business and Professions Code)or TEMP.METER OR POLE( COMMERCIAL:
c.q m q that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
iC LL� Section 9031.5 by any applicant for a perish subjects the oppllcunt m a civil penalty of POWER DEVICES ❑'11iNANT ❑P0011 SI?ItVICP,
w..ti not more than five hundred dollars(85101.
OTHER IMPROVEMENT
�?O ❑Lasuwnerohbe proper&..myemployeawith wired astbeirsole aATBu ation, SWIMMING POOL F.LECr Ih
SW will do the wnas mal Cmlc c he Cont is not s License aw dews not apply uI94,Business ❑OTHER
[x] and Pmfessians Gxlc:The Cnmmnor'x License Law does not apply Io an owner of DUTLIi'I'S-SWITCHES- JRIiS
L 3 property who builds or impnwes'hereon,and who does such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELF.CI'R O FT.
sole.ll however,the ImildingmIntprnvmnna is sold within oneycar ofcompletion the 5 .FI' RpYF.A 5/SQ.FT.
owner-builder will have.The burden of proving that be did not build or improve for par- *4Y28
_ V
pose of role,. A� 8
❑I,as rwner of the property,uexclusivelexclusivelyy contracting with IicenreA contranore to TO
nslrud the project(Sec de
7194.Business and Profession,Co :)The Contractor's Li- - - - v
mace law does not apply m an owmerofproperty who builds or imen
tatert'hen,and QTY. PLUMBING PERMIT F �Y Ur �
who armmcpeace,.,
ts form,li awith a enntracmr(s)licensed pursuant.,he Contractors L✓Jrit-
Liceme Law. 1 PERMIT ISSUANCE k>•lNp
I am exempt under Sec. ,Il&1'C for this rcuson
ALTER-DRAIN&VENT'-NATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the following declaration:
Fl I have and will maintain a Cenificao,of Conserv to self-insure far Workers Camper- DRAINS-FLOOR,ROOF.AREA.COND. STORIES 'TYPE CONSTRUCT ION
action,us provided for by Section 37!X1 of the Luton Cade,for the performance of the
work for which'his permit is issued FIX'I'U1414S-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Station
37W of the litho Cole,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP AI'N
My Workers Cron ansmlan Insurance wrier and Policy number are:
Cortico Policy No.: GAS-EA.SYS'I IIM-OV FR 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASOINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIV ISI(lN FEES
ffhissrdannculnnt bcmmnrmvd irthepernJlis mannahundeeddollnrs(SIDO) CNE P
or less) PLANCIIECK FEF
I certify that in the performance of'he work forwhich this permit is issued,l shad WE
ITARY-S'TORMF.A.)WIT.
not a iploy any person in any manner so as m become subject n the Workers'Compen- ENERGY FEE
O Z .,conn Laws of California.Dane !R HEA'1'BR WNENTIELECTIt GRADING hili
Z Q Applicant
NOTICE TO APPLICANT:If,after ranking This Cenifiade of Exemption,you shuuld WATER SYSTEMTREA'1'ING SOILS PEE
abemnre,abject m aha Worker,Compensation prodoons of the Labor Code,you mum'
❑.l foMwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
rte CONSTRUCTIONsacLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
V pThereby off mnhanhcre isnmauction lending agency for mho perfonmmnee of Date Receipt IT
the work for which 0is permit is issued(Sec.309],Co.C.)
u' V Lender's Name TOTAL:
O Lender's Address
6Wi I certify that I have read'hls application and slot,(IT- theabove Information Is BUILDING FEE
h mares'.I agrecm comply with all city endcounty milinancaund into,laws relmingm QTY. MECHANICAL PERMIT PEE
U Z building mostntnion,and hereby autharin representativesafthis city nen¢rupmthe SEISMIC FEE
ahove-ramtioncd property Ike inspection purpose,, PERM if ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Cupertino against ELE(:ERIC PER
liabilities,judgments,motional expenses which may in any way accrue against said City AITER OR ADD TO MECH.
PLUMBING FEEinarusequenceof' mingoft ' Permit
APPLICANT HSTAND N1)WILL COMPLY WITH AI.E.NON-'OINT AIR HANDLING UNIT'ff010.(IOOCFM)
MECHANICALFRE
SOURCE ATIONS. �1D AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
of Applicant[ n'racnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA'r10N FEE
HAZARDOUS MA'IERIAI S DISCLOSURE
Will Im.inlicamor future building oer,cm,store nr handle hamrdous armentil HEATING UNIT(TO 101,00)BTU)
as O fined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sandy
Code,Section 25532(a)'! HEATING INTI(OVER Elgld)tlll BTU) -
❑Yes ❑No TIPAID
VCNLATION FAN(SINGLE RF.SIDI Dare Receipt X
Will the appleava or fplurc building occupant use equipment or devices which
cout havallous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME'(3HP OR 100.0110 BIL) TOTAL,
.District? BOILER-COME'(OVER 1 00,00(1(ITU)
❑Yes [:J No
I have read the be>vJoos reannermt,reamoraass under Chapter 6,95 of'he Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health as Safety Code,Sections 25505.25533 om125534.I uaderennd'hat if the NEW RESIDENTIAL MECH. SQ.FT. _
building does not currently have a Icnuntthat'it is my responsibility to notify the maupmt
of the requirements which most be me'prior m issuance of a Certificate of Occupancy.
Owner or nifiva red agent Date TOTAL: ISSUED BY:
OFFICE