S 2602 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - 0 fes►
CITY OF
(iI1PERTINO
BUILDING F.I,NCFRICAI. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT CA
PLurvIBINc.MECHANICALTIEFIC
BUILDINGPI10AXTIDENTINICATION'-".f �i„•�••Y
BUILDING ADDRESS. LST 3p \ r SANITARY NO. APPhICA'riON SIJBMITTAI.DATE
r '— I U /y' _ 9
V- 2-S
1((( OWNER'S NB}1� r I10NE: CON'BACTORS NAME: LIC NO: NIC CONTROL#
ARCH'1'. VV INPER. LIC NO: ADDRESS: ❑ ( 3 /
/11,
WW cT: PHONE: t,,; ,'i ,:''BUILDING;PERMIT INFO . ”
,? ❑ Consultant Fees Paid by AppliCeni(Initial) BLDG _ - ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION EyEry 1'- FLECTRICPERMIT+ II t11' FEE Lr�,'/ rOJ/
1 hereby affirm hat 1 am licensed under provisions of Chapter 9(commencing __ - �I t +' + JOB DESCRIPTION
Q=Z wih Secton]fXX)ofDtvsio Nlm Buslnessa amdrrylltdadal
WOO 7 PERMIT ISSUANCE
F-�C in full force an effect. s FDWL ❑KITCHEN REMODEL
<_u L¢ense Lic.# APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
vFi<i Dme�Contradon - ❑MULTLUNIT ❑STRUCTURAL
RCHITECTS DECLAR 1
F p y PAN13L5 MODIFICATION
z O y Z I understand my plans shall he used as public never s
OZ..0 UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
E•+,41"'-,L,a...111 Licensed Proftesimad 201=100IAMPS IMPROVEMENT SWIMMING POOLS
C C C Q I hereh affirm OWNER-BUILDER am exemDER from he C un nons License Law for Ina OVER 1000AMPS [I BATH REMODIiI/REPAIR DEMOLITION
6 3Eu�F following reason.(Section]onstr Business and Professions Code:Any city or rouurY SIGNS IiLECTRICAI. [I OTHER
m which requires a permit m rnnswm,abet,improve,demolisM1.Or repair any structure
�u'OQ prior to its issuance,also requires the applicant for such permit n file a signed statement SPEC1 AL CIRCUIT/MISC.
'bar he is licensed pursuant o the provisons of the Comeactnrs license Law,- -, er9
�y0pfen mmencing with Section 7")Of Division 3 ofine Business and Professions Code)., THMP.METHR(RPOLIIINST COMMERCIAL
q is:c y that he is exempt therefrom ant the basis for the alleged exemption.Any violation of C3NEW BLDGIADDITION ❑DEMOLITION
Wim
Section 7031.5 by any applicamfor a Permit subjects the applicant to a civil penalty of POWER DEVICE 35 ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(4500).
IMPROVEMENT
_< O Las owner Ofhepeshim or my employees w uffidewages astheir sole
0,14,E sinesation, SWIMMING W)Oh ELECTRIC
pW on will drlhewons ande stumurednc s License awdos not appre.to air Business '[I OTHER
j�m arta Professions Code The Contmaors License Law docs not,pPIY to rot owner of OU91ET5-SWITCIIES-I'IX'NRFS
a"3.. property who builds or improves(hereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered fur NEW RESIDENTIAL ELEC IZ SQ FT.
sale.Il howevcn the building Orimpmvemem is sold within Oncyeaofmmpletion,the SQ.Ff.FLOOR AREA $/SQ,FT.
owner-builder will have the burden of proving that he did not build or improve for put-
,,a Of sale.). / 7
I,as owner of the property,am exclusively emoraning with licensed commctors as / (� TOTAL:
came
La the project(Sec.]ata,Business arta Professions Code:)The Coctmcton,and
-I
cense Law does not apply man owner of prnpety who builds or improves thereon.end QTY. PLUMBING PERMIT FEE,' 3 `3 to
who contracts for such projects with a co enscmrts)licensed pursuant to the Contractor's
License Lear PERMIT ISSUANCE
1 m exempt under Sec. .B d 1'C far his reason
ALTER-URAIN h VIiNT-WATER(F.A) VALUATION
lerncaner Date Y3
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE7 7 V
I hereby anion under penaltyperjury one of perjuone of the following declarations:
❑I have and will maintain a Certificate of Cament to self-insure for Warlues Compen- DRAINS-FLOOR.ROOF,AS EA.COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of he Labor Code,for the performance Of the
work(of which this Ext is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance.in requited by Section
3700 of he Labor Code,felt the Performance of he work for which this permit is issued. GAS-EA.SYSTEM I INC.4 OUTLETS OCC,GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy Na.: GAS-EA.SYSTEM OVER a(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE%INDUSTRL WASTE.INTERCEPTOR < f BIIR.DING DIVISION PETS
(Thos section need not be completed if he permit is fornne hundrtddollars(4100) GRFASI3 TRAP
or less) PLANCHECK LTE
Icerufythm in the pedionnance.ftheamak,for whichlbispermit isismdid.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subject m the Worker' pc
Comn. ENERGY FEE
.QZ sation Laws of California.Date WATER HEALER WNENTIELECfR GRADING FEE
Z Q Ap,himlf ' -
NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you should WATER SYSTEM/ TREATING SOILS FEE
s4 become subject m he Workers Compensation provisions of the Labor Cafe,you must '
forthwith comply with such provisions or this permit shall b,deemed revoked WATER SERVICE
d Q
UO CONSTRUCTION LENDING AGENCY
agency NEW RESIDENTIAL PLM#. SQ.FT. PAID Date Receipt#
1hereby affi rte that there issconstruction
(See.30lensing agency for the performance of
the work for wnicM1 this permit is issued(Sec.3(19],Co.CJ
u' (~ Lenders Name TOTAL:
L) Lenders Address TOTAL:
W BUILDIN' EE
1 candy hm 1 have read this application and stats hm the aboveinformation is t,
ZE correct i agree to comply with all city and county ordinances and state laws relating no QTY" MECHANICALPERMITI ' FF.E
building construction and hereby amhonve representatives ofth'sety to enter tpon the t ,t SEISMICFEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC F.
babilitime,judgmems,costs and expenses which may in any way acerae against said City ALTERORADDTOMF.CII,
in ceruse e e of the Scanting Of this permit. PLU 1 ,F.
APPLY�NT UNDERSTANDS A WILL COMPLY WITH AL NON Pf AIR IIANOLING UNIT I'1'O IIkIXte CPM)
Sri
0 EGU"ATIONS. A AL LTE
AIR HANDLING UNIT(OVER 10,001 CFM) CO RUCTION TAX 'LAMC 1 d e �
co
Sig vium OfApplicaMContrm Date 17
HAZARDOUS MATERIALS DISCLOSURE XI3AUST IIOODIW/DUCT) SING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEN1'I NO UNTI'('1'0100.00I BTU)
as defined by the Cupertino Municipal'Code,Chapter 9.12,and he Health and Safety
fide,Section 25532ad, 1]EA'I'INO UNIT(OV ER 100,100 BTO)
❑Yea o VIPSTI LATION FAN IS INGLE RESID) PAID "'-
Date Receipt#
Will he applicant oribolding occupant use equipment or devices which BOILER-COMP(3111'OR 1011.(NIU B'LU)
emit haaardous air eontaminums as detinet by the Bay Are,Air Quality Management TAL'
{ ) Dlntrigp
❑Yes BOILER-COMP(OVER i trojeX11+'rU)
AIR CONDIIIONER
1 e rearl the bozo s mmcrivls reyuiremenb ander Chapter fi 95 of the Call- ISSUANCE DATE
fomia h&SafetyC e,S tans25505,25533ora 5534.1understandthatifthe N13WRESIDENHALMECII. SQ.EcL �'
In
S non cu by nten' Nmit is my n nsihlllq nmily the ercvupam
oft ea rmr,fi filen m nrmissu ce fu of cupuncy.
Owneroranh maul Date TOTAL: ISSUED BY,
OFFICE