S 0408 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PFJM1ITN0. O O
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING—MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
LN . 'CUf F,RTI r J a ¢,�Z S•q'�
R'S NAME: PHONE: NTRACTO 'S NA E: LICN
_ ` ' N/C CONTROL#
JARCHITELI'/ENGINEER: LIC NO: 1 , D FS: 165 ❑
CONTACT: PHONE: . BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
o�Z with Section of Division3oftheBusinessandProfessionsCode,andmyliesmeis
W00 PERMIT ISSUANCE RESIDENTIAL:
F W F to full force and effect. 0 SFDWL 0 KITCHEN REMODEL,
�UU License Class Liu#
In6L Dale Contractor APPLIANCES—RESIDENTIAL 0ADDITION OPLUMBINGRE-PIPE
Fpy ARCHITECT'S DECLARATION PANELS OMUL.TI-UNIT -]STRUCTURAL
z O z 1 understand my plans shall be used as public records - MODIFICATION
Oz O UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
,� sal License)Rofessinnel 201-["AMPS IMPROVEMENT 0SWIMMING POOLS
.aai. •.I1 OWNER-BUILDER DECLARATION OVER MY)AMPS 2%XH REMODEUREPAIR O DEMOLITION
W Q I hereby.(firm that I am exempt fromm the Contractor's License Law for the /�OT
WO y U following reason.(Sectio,9031.5.rt.Business and vee dualmns Code:Any city or county et.r. SIGNS ELECTRICAL ❑OTHBR
O F which requires a permit m cmmwet,alter.improve,Demolish,or repair .nny structure - _
prior m its issuance,also requires the applicant for such permit m files signedsmmment SPECIAL CIRCUIT/MISC.'
2 y
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W C� (commencingwith Section 70011)of Division 3ofthe Business and Professions Coact COMMERCIAL''^'i TEMP.METER OR POLE INST.
dyk�c p{ that he is exempt zany applicant
li and the haste for the alleged exemption.Any violation of - _ ❑TNEWEN BLDG/ADDITION ❑DEMOLITION
W� Section thn56y hundred
doll rfor a s($50nnit subjects the applicant macivil penalty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICE
not more than five hundred ty,or
y employees
O Lo the work.the protieny,ur myemntended wiN sed theirsele compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will dothework,and the is Contisnotintended orawdu forsale(Sec.]done cosinesf ❑OTHER
3 and Professions ills o The C es them's License Law does work i s if owner of OUTLETS—SWITCHES—PI ES
his o
property who bails,or improves thereon,and who Jaen such work himself or through
his own employees,provided that such improvementsld w ere not iyear ofc or offered for NEW RESIDENTIAL ELE FE
mle.ILhowevegthhave thi burden fp mens issoldhe ithinone ild rf completion,the - SQ.FT. SISQ.Ff.
owner-huilJer will have the harden of proving that be did not build or improve for sur-
p�emfaaie, _ AUG 25 �,5
�[I,as ownee Mr the property,um exclusively contraming with licensed contractors to AL:
s ndout the project(Sea.7044,Business and Professions Coda:)The Contractor's Li-
verse Law does not apply to an owner of property who builds or improves(bureau,and QTY. PLUMBING PERMIT �r FEE / L
whoemarects forsueh projects with acnmmcmr(s)licerwripursmnuo Ne Contowtous CITY ur LUPEHTI1YA(
IC
License Law. ' PERMIT ISSUANCE
O l am exempt under Seo. ' ,B&P C for this it
wner
ALTER—DRAIN&VENT—WATER(EA7 VALUATION
ODam_
WORKEWSCOMPENSATIO VC RATION BACK FLOW PROTECT.DEVICE
46 1 he y affirm under penalty of perjury oa o[the following declamtinns:
O l have and will maintain aCenificatcofCousem mself-insure for Workers Compen- DRAINS—FLOOR,ROOF,AREA,GOND.
satins,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
weak for which this permit is issued. FIXTURES—PER TRAP
0 1 have and will mainums Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUT LETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am,
Cartier: Put icy No.: GAS—'EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed lithe permit is forms,hundred dollars($1(p) BUILDING DIVISION PBBS
or less) - GREASE TRAP pLANCHECK FEE
(certify that inthe Performance Ne work for which this thePerini(Workers
ed,Ishr- SEWER—SANITARY—STORM EA.2001T.
not employ any person in any manner so as m.,corm,,object m the Workers'Compen- ENERGY FEE
Z action Laws of California.Date WATER HEATER WNENT/ELECI'R
7� O Applicant ) - GRADING FEE
q y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
abecome subject to the Workers Compensation proskmre of the Labor Code,you must SOILS FEE
[kI forthwith comply with such previsions or this permit shall be deemed revoked. Wpq'ER SERVICE
] z CONSTRUCTION LENDING AGENCYagency NEW RESIDENTIAL PLM#. SQ.FT. PAID
U O work
affirm Nat share iso ed(Section lending agency for the Performance of Dam R tips it
Ninsel, or which this permit is issued(Sec.3fN].Civ.CJ as
Q Lender's Name TOTAL:
Lender's Andress TOTAL: \
1 certify that I have reuJ this application and stem Net the above infnrmmion is BUILDING PEE
.�. Z) correct l agree to comply with all city and county ordinances and stammws relating to QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby authorize representatives ofthis city to toleration the SEISMICFEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FF.
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the granting ofthis permit. PLUMBING FF r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CPM) -
SOURC/SRR U;, S.�' , / AIR HANDLING UNIT(OVER IQWOCESO CONSTRMECHANICT '+
CONSTRUCTION TAX
Sig sur of AppllcnnUCommemr' m EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS D ' OSU I HOUSING MITIGATION mi
Will the applicant or future building occupant store or handle hammy smaterial HEATING UNIT(TO Ini BTU)
as defined by be Cupertino Municipal Cede,Chapter 9.12,and he Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,1x1)BTU)
❑Yes ON. PAID
' VENTILATION FAN(SINGLERHSID) Dam Receipt
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3HP OR IIXl,gq RTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTALDistrict?
OYes Olson BOILER—COMP(OVER IW,WOBTU)
I have read Ne bacandous materials requirements under Chapter 6.95 of the Cad- AIR CONDITIONER ISSUANCE DATE
fotnia Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.PC
huilding does not Currently have a moan(that it is my responsibility to notify the tempests
of the mqutram,ms which must be met prior to Issuance of a Cenificate of Occupancy.
Owner in authorized agent DateTOTAL: ISSUEDBY:�
OFFICE