S 0192 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO , BUILDING-ELECTRICAL. PE IT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 0192
Z
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: b SANITARY NO. APPLICATION SUBMITTAL GAT I
a G e l
OWNER'S NAME: PHONE: CONTRW 'S NAME. LIC NO:
_ LV� 14A NIC
CONTROLM
ARC 1TECTMNGINEER'. LIC NO: - ADDRESS: ! ❑
y +�
CONTACT: PHONE. •Y7/) BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 em licensetl ander pmvisinm of Chapter 9(commencing
JOBIDESCRIPTION
Cz with Section 7")of Division 3 ofrhe Business and Professions Codnandmylmenseis PERMIT ISSUANCE RESIDPNTIAL;
in full force and`e1J �� py�y�f
{p e '� OSFDWL E)KITCHEN REMODEL.U License Class LIC.N gppLIANCES—RESIDENTIAL OADDITION ❑PLUMBING RE-PIPE
aa Dnte��n�E CSDECL
E.pO ARCHITECTS DECLARATIONPANELS El MULTI-UNIT []STRUCTURAL
z o ui Z I understand my plans shall be used as public records - MODIFICATION
Oz�p UP TO 200AMPS 11 INTERIOR El CHIMNEY REPAIR
`F',l� `WI Licensed Professional 201-1000AMPS IMPROVEMENT [I SWIMMING POOLS
,^� ...41 OWNER-BUILDER DECLARATION OVER Iopc AMPS - O BATH REMODEI/REPAIR ❑DEMOLITION
r K W 6 1 masa .Diem that 1 am exempt from the i...CContractors License city
o for the
�j d 0 following reason.(Section]03L5,Business and Pndeasiuns Code:Any city or county SIGNS ELECTRICAL O OTHER _
which requires a permit m construct,alm9 improve,demolish,or repair any swcture
�0 prior to its issmnce,also requires lheuplicant for such peUbitm file.signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions ofthe Contruarsr's License Law(Chapter 9
ul q0 (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
Y y m pe that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION O DEMOLITION
till t�• Section 7031.5 by adyipplicam for ap.it smuceisthe applicant to.civil penalty of POWER DEVICES
rn nut more Than Eve hundred dollars($5fgp. ❑TENANT ❑FOODSERVICE.
IMPROVEMENT
SQ ❑ Lo the work,the proprty,mmyemployees with wages r ale(Sol,compensation, SWIMMING POOL ELECTRIC
[..� will dathewmk.and Cothe The
ore ntis roti Livens Lawdue,rofifierad at apply
Business ❑OTHER
W and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITC —FIXTURES
�' .. property who builds ar improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are not intended or offered for NB REST L ELECPR SQ ET.
sale.IL howevem the building or improvement is sold within one year n(complelme,the SQ.FpT�I.IFLOORARLiA $/SQ.ET.
mer-builder will have the burden of proving that he did not build or improve for pur- N<UKr Yi A 90
p se of sale.). V
TOTAL:
❑ 1,as owner of the property,am exclusively contracting with licensed contractors in
construct the project(Sec.70FL Business and Professions Crede:)The Conaacmes Li-
censeJUL Law does not apply to an owner of property who builds or improves thereon,and QTY. NO FEE
who contracts for such epursuant projects with a eontmclor(s)licensed pursuano the Commetims r�1 ,
License Law. PERMIT ISSUANC C��IUr lIUYtHIIN
O lam exempt under Sec. ,B&PCfanhisremnn V
Owner Dale ALTER—DRAIN&VENT IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby iti irm under Penalty of perjury one of the following declarations:
❑ Ihave and will maintain a Certificate ofConscia In self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE WNSTRUCTIOD
sation,as provided for by Section 37M of the Lubar Code,for the performance of the
work far which this Permit is issued. FIXTURES—PER TRAP
Phave and will maintain Workers Compensation Insurance,as required by Section
of the labo�rr Ceopde,fnnhhepperombecee of the work for which this pmit eris iswed. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUPMy ANN
Crtl :rk p�o�✓mwunf'iL//rtle,andP court b
aor cr. GAS—EA.SYSTEM-OVER 4(EG
b ITT XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE(INDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This action need mol hecomplemdlfihepermit ismamachinlreddollars($100) GREASETRAP
ma's.) PLANCHECK FP.P,
Icertifylhatin thepenormanceofthe work for which this permit isissoed,l shall SEWER—SANITARY—STORM EA.2M FT.
not employ any Reformat any manner xo main become suhjec To the Wadon,Compen- ENERGY FEE
aZ
station Laws of California.Date WATER HEATER WNENUELECTR GRADING EE
A,Hrr n
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should WATER SYSIEMiTl EATING
a �^ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
ry
forthwith comply with such provisions nr This permit shall he deemed revoked. WATER SERVICE
aQ forrm
r7. z CONSTRUCTION LBNDlNGng agent NEW RESIDENTIAL PLMB. SQ.FT PAID Date RecciptN
U Iforhereby whih,hithatthere isad(Seecontraction0 lending agency forthe pertormance of
ti the Leadeek for which this permit is issued(Sec 3(197,Civ.CJ _
fL H Lender's Name _ TOTAL:
V Lender's Address TOTAL:
a BUILDING P•
[yam 1 certify that I have read this application and style that the shove information is
U Vl burred lagree tnicomply
with all countyordinancesonundatmc laws utropme ue QTY. MECHANICAL PERMIT FEE
U Z$ building construction,and hereby amhorise representatives of this cirymemerupnthe SEISMLCF
rr above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to rove,indemnify and keep harmless the City of Cupertino against ELECTRIC
liabilities,judgments,casts and expenses which may in any way iecme against said City ALTER OR'ADDTO MECIT
in consequence of the granting of this permit.in FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CFM)
SOURCE RLGULATIONS. MECHANA PEE
IC
AIR HANDLING UNIT(OVER Ift"CFM) CONSTRIIC ONTAX
Sigoamrc of Applicanl/Contlaemr Dote EXHAUST HOOD(W/DUCT) HOUSING ML ATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupanl store or handle haataftais material HEATING UNIT(TO 100,001)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(u17 HEATING UNIT(OVER 100k000 BTU) -
❑Yes ON. - VENT]L.ATION FAN(SINGLE RESID) PAID
Date ReeeiptM
Will the aplicam or future building et use equipment or devices which
emit h.zmdous air mnmminants as defined by by the
hthe Bay Area Air Quality Management BOILER—COMP(3HP OR Initials)BTU) TOI'AI.
District? '
OYcs - ONo BOILER—COMP(OVER 100.000 BTU) -
I have re ad the harurduus materialsreqIts under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
uire
fnmia Health&Safety Cede,Sections 8505,25533 and 25534.1 undcrsmnd that Ethic NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the mretnent which must he met i nor m issuance of a Certifcam of Occupancy. V V
Ow'ne or acd agent Date TOTAL: ISSUED BY.
OFFICE