S 1515 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD.IaNC,-ELECTRIC.%I. �j PE 1ITNO
BUILDING DIVISION APPLICATI IIT PLUMBING-MECHAN'ICA6 xJ 1515
BUILDING PROJECT IDENTIFICATI
BUILDING ADDIH SS: QQ � SANITARY NO. APPLICATIONSUBMITTALDA:
Q✓;1 S Te�leTw1S eEa. �-V O am.DIN z--k. ,
[` i..lc C
.,QWNNER��S NAME: PHONh. ' C( ' RACE SNAME. 1LIC NO: NIC CONTROLp �J
ARCHITE�C'f/ENGINUNrIL. Slung EERLIDO ADDRESS: ��SJ�tON ❑
_ME Nu+J Ga lwu c5't.9 s 8� AL
AL
CONTACT: PHONE' BUILDING PERMIT INFO
WwI� VCQ�r45 �8 ❑ Consultant Fees Paid by Applicant(Initial) %BLDG ELECT PLUMB MECH
a+'4731 lITT-JR lLy
LICENSED CONTRACTORS DECLARATION QTy, ELECTRIC PERMIT 'FEE
1 hereby affirm that 1 am Ilcensed under prnvisium of Charier 9 tcommedcing JOB DESCRIPTION
CMZ with Section 70l of Division 3 of the Business and Pmfessimm Cpl dray he,..,, RESIDENTIAL;
yOO (e.an PERMIT ISSUANCE
Y F in PoII forte and ellen. 3 ( �T ❑SFDWL ❑KITCHEN REMODEL
¢VV License Clm. Lie..» - APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Z ae Dine Cantmctm
n<y ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT OSTRUCTURAL
cards
O y Z 1ders
unand my plam,hull he used m public reMODIFICATION
Z�C ' UPT0200 AMPS 2 ., �0 []INTERIOR ❑CHIMNEY REPAIR
�F-W Licensed Pro&xmnal - 201dIXX1AMPg IMPROVEMENT []SWIMMING POOLS
Yf; OWNERBUILDER DECLARATION OVER I(glOAMPS El REMODEUREPAIR ❑DEMOLITION
Y Q I hereby offan that 1 ore exempt from the Contractor's License Law for the
O L V following reason.(Station 7031.5.Business and Professions Co:WAny city or county2. SIGNS ELECTRICAL O ❑OTHER
1 O vG which requires a permit to contract alter,improve,demolish,or repair any structuref
J
moor its l,xurac.also requires the applicant for such remain a signed statement SPECIAL CIRCUIT/MISC.
oermit rile
y} that he is licensed pursuant lathe previsions of the Contractor's License W
row(Chaper9
(commencing with Section 7000)of Division3of the Business and Professions Cartel or TEMP.METERORPOLE T.
i e C that he Is exempt therefrom and the basis for the alleged exemption.Any viola an of W BLDGIADDITION ❑DEMOLITION
y y Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES TENANT ❑FOOD SERVICE
not more than Eve hundred dollars(S50% IMPROVEMENT
FSS71.as owner Of the property,or my employees with wages as their sole compensation. SWIM INC POOL ELECTRIC
p. will do the work,and the structure is not intended oroBercd for sale(Sec.IDa4,B usiness []OTHER
3 m and Professions Code:The Contractors License Law does not apply to an owner of 68 OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELEC'R
sale.If,however.the building or improvement is sold within one year of completioo.the SQ.FT.FLOOR AREA Si FT.
owner-builder will have the burden of praying that he did not build or improve for pur-
pose of sole.). \Go
-11,as owner of the property,am exclusively contracting with licensed commission,to T
ametrom the project(See.7044,Business antl Profeuamrx Coda)The Conuactor's Li. Q . .
cense Law Ones n ti c,ply ni ossom of progeny who builds or improves thereon.and MBING PERMIT FEE :
who contracts for such projects with a contractor(,)licensed pursuant to the Contractor's
License Law. PERM ISS CE
O 1 am exempt under Sec. ,B&P C for this reason
ALTER-DR ENT-WATER(EAI VALUATION
Owner Det,
WORKER'S COMPENSATION DECLARATION BAC O DEVICE �{`�
I hereby affirm under Penalty of perjury one of the following dMarations: �' �+
I have and will maintain a Certificate of Consent to self-insure for Workers Comped- 2 All FLOOR,ROOF,AREA,COND. STORIES TYPE CON IOI
nation,an provided for by Section 37M of the labor Code,for the performance of the q
work for which this permit is issued. FIXTURE TRAP tJ
Zj 1 have and will maintain Worker's Compensaiod Insurance,as manned by Section
37W of the Labor Code.for the performance of the work for which this pennlns issued GAS 4e .S TEM-I INC.4 OUTLETS OCC.GROUP APN
My War kk J����CC nn�,dS tinq Insurgaae scat�pp d Policy man
bbaa{{a�r� 'I
Comer T[ Ffukl.. I-Aza'FBblrty Nn: ;SJ LZ'Z Or{— GAS-EA.S EM- VER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEAS1,4yST WASTE INTERCEPTOR
(Thissection need not hecompleretllflite permitisfor mnandndrctl tlollars(SI00) .fi�.Tf,A3`5',L`'BIIII.DIN,ODMSION PEES i"^� _�ry..
or less) GREASE TRAP pLANCHECK FEE
I manly that in the performance of the work for which Ibis permit is issued.I shall SEWER-SANITARY- MEA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Compem 0 O ENERGY FEE (
O Z union Laws of California.Date Z WATER HEATER W/VENT/ELECTR
Z Applicant 16, 1 65 0 GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenificne of Exemplar.you should WATER SYSTEM/TREATING
4 > become subject to the Workers Compensation provisions of the Labor Code.you must SOILS FEE
Isla forthwith comply with such provisions or this peonathall be deemed revoked WATER SERVICE g/
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Da Receipt»
V C I hereby all that here is a construction lending agency for the Performance of
f" the work for which this permit is issued(Sm.3097,Co.C.)
Lender's Name. TOTAL:
U Lenders Address O f
p" I ccnify that I have read this application and state that the above information is BUILDING F
F N conect.I agree to comply with all city and county ordiamass and state laws relating to QTY, MECHANICAL PERMIT
V Z building construction.and hereby authonze representatives of this city to enter upon the BEISMIG
'-' above-mentioned property for inspection Panamint. PERMIT ISSUANCE :q � � ELECTRI BE S
(We.)agree to save,indemnify and keep harmless the City of Cupertino against
Imbilities,judgmerm.costs and expenses which may in any way name against said City ALTER OR ADD TO MECH,
22
in asequence of the granting of this permit PLUMBING E
Lilt IV 2
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,"CFM)
SOURCE REGULATIONS, ANICA FEE
2 AIR HANDLING UNIT(OVER 10.000 CFM) D COf45�T�RUCTIONX
Signature of ApplicaOUCoduactor Data 'L EXHAUST HOOD(WIDULT) 1 j I t L,
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITI�iAT10N FEE
Wlllthe applicant a
or future building cupre um scoor handle hazndous material HEATING UNIT(TO I OO."BTU)
as defined by the Cupertino Municipal CWe,Chapter 9.12.and the Heaton and Safety
Code.Section 25532(a)7 y HEATING UNIT(OVER 100,WO BTU) / LJ
[I Yes FlNo f
VENTILATION FAN(SINGLE RESID) PAID Date ti pt x
Will the applicant or future building by the B use ea Air Qu or devices which BOILER-COMP(3HP OR 100i BT
emit hazndous air comaminbms us Defined by the Bay Arca Air Quality Management
District'? —
OILER-COMP(OVER 101),00i
❑1'es ❑No B
I have read the h4nNous muanols requirements undo Chapter695 arm.Call- AIR CONDITIONER - ICSU E c
,
om
a Health&Safety Calc Sections 25505.25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ,Fri. Ly'
building dine,not currently have a tent.that it h my responsibility to notify the occupoot
of the rolm"ment,which must I met no, issuance of a Ceniticne of Okcsa,rl'.
-5--nal or smhoriad'gcm Due TO L'. v ISSUED BY:
OFFICE