S 0153 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONWERM ITPI.UMBING•MECHANICAL S 0153
tlOWDING PROJI:(,T IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMI NAL DATE
1089 (P V-„N
OWNE SHAME: I'I10NE: CONTRACTOR'S NAME LIC NO:
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ARCf11TECT/ENCINEER: -J LIC NO: G DRESS: I ❑
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CONTACT: PHONE: I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG BUT= PLUMB Ec
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE
1 hereby affirm thin 1 an licensed under provisions of Chapter 9 Terminate, ]OB DESCRIPTION
"Z th Satimn](gl1B o(Division 7of the Busineu and Pro(essinns Cade,and mylicemeis RESIDENTIAL;
g20p wt PERMIT ISSUANCE.
W• in full force and effect. ' �-f�,6 ❑SFDWL OKITCHENREMODEL
ag�U((.� Liccns CI4s -� Lica_1L0--�-1Q— APPLIANCES-RESIDEN'T'IAL El ADDITION El PLUMBING RE-PIPIT
..Z Yl Datc os'Z Contractor
VSQ4 T10' ❑muUT-UNIT ❑STRUCTURAL.
P.Dy ARCHITECTS DECLARATION PANEIS
Z O vv�2 Z 1 understand my plans shall he used as public recordsMODIFICATIONOZ;JQ UP1'0200AMPS ❑INTERIOR []CHIMNEY REPAIR
a4 WJ Licenud Profe.wironel 201-INSAMPS IMPROVEMENT (]SWIMMING POOLS
OC
,4 .2 OWNER-BUILDER DECLARATION OVER IORIIAMPS El BATH REMODF.IIR TAIR ❑DEMOLD'[ON
W, 1 hereby affirm that 1 am exempt from the Cnmmcmr's License Law for the
x406 U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICALCIOTHL'R
F OI'" which requires a Pentad m construct,alter,impmve,demolish,or repair any mmcmrc
Prior to its iasuavco,olsamquims the applicant tar such Permit to lila a signedatmenema SPBCIALCIRCUIUMISC.
SS pre., that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
WL4 o (commencing with Sermon 700(pa(Division 3 of the faminessand Professions Calmar ]EMP.METER OR POLE INST. COMMERCIAL:
4 ey that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
W
Section]031.5 by any applicant for a permit subjects the input icant to a civil Penalty of POWER DEVICES
r" not more than five hundred dollars D5W), ❑TENANT F1 FOOD SfiRVICF.
^Q I]Lasowner ofthe dhemary,ort myndinuaceumiducagcsasale(Sce.c04UBusiness SWIMMING POOL BLECI'RIC IMPROOTHER CMENT
will dmhework,andthenaxureisnotintended T.awdofar
ot apply 1.an amar of ❑OTHER
and Professions Cnde:The Contmcaso Licence law duos not work
hi m an rtvner of OUTLETS-SWITCHES-1'I%TU
RjkV
property who hnilds or improves(M1crcon,and who does such work himself nr Through
his own employees,provided that such impaannent.s me not intended to offered I.. NEW RESIDENTIAL.ELECT R
sale If,however.the building or impavemem is sold within one year of completion,the SQ.FT.F1 OR E 5/SQ.FT.
mer-builder will have the bureau of paving that he did not build or impmve(or par-
Msseofmic.). AIN ]
1,as owner an T the Properly.ant exclusively contracting with licensed contmcmc,I, T act dl"n
amsuucl the project(Sec.9M4,Business and Professions Cede:)The Cortuacmrs 1.1-
can.
.i- /1 /I[{/
c sc law does not apply to anownm of papery who builds or impaveaducaon.and QTY, PLUMBING PERMIT CITY OF
who contracts for such projects with a contmxods)licensed Pursuant Lucia,Commences �UrE J FIA
Liccnsa Law. PERMIT ISSUANCE ,,I U
rl I if.exempt under Sec. .B&P C for this reesom
ALTER-DRAIN&VENT-WATER BA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby allirnt under panahy of Perjury one of the following declarations:
❑I hoveavd will maintaina Cenilicateof Consenttoself-insure for Worker's Compen- DRAINS-R.00R.ROOF,AREA.GOND. STORIES TY PE CONSTRUCTION
cation,as provided far by Section 37M n(the Unto Calc,for the performance of the
work for which this permit is issued. TEKTURES-PIER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3701 of the Labor Code,for the performance at the work for which ftthhis lie nnil is issued.k GAS-EA.SYSTT:M-I INC.4 OUTLETS (ICC.GROUT' AI'N
My WoryarjC yrc��many rl un a syrm IT Policy NOY('a r� 1«'�``� I GAS-EA.SYSTEM-OVER 4 LEAL
Cartier L ►yti�Sa7
CIERTIFlCATE OPEXEMTTION FROM WORKERSOREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed if the parent is far tine hundred dollars S100) OREASETRAP
or Ica.) PLANCIIECK FEE
Icenifythm inlheperormanceofthe workforwhich thispecoot isissued,I shall SEWER-SANITARY-STORM EA.210 P..
not employ any Taman in any manner so as m become subject to the Workeri Compan. ENERGY FEE
Z7.o sodium Taws of California.Dam WAI ITR IIHATER WNENT/EIJECTR
Applicant GRADING PEE
i—i .Ni NOTICE TO APPLICANT:if,alter making this Certificate of Exemption,you shroud WATER SYStEM/IREA'1'ING
hesome subject m the Workces Compensation provisions of the Labor Code,you mum SOILS FEE
� .r forhwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE.
Q
CONSTRUCTION LENDING AGENCY NEW RESIDFNI'IAL PLMB, SQ.FE PAID
V Q Thereby affirm that here is•construction lending ageray for the performance of Data R ei IT
U. ra the work for which this permit is issued(Sec.3097.Civ.C.)
f"I bender's Name TOTAL:
O ULender's Address 'TOTAL:
LL 1 certify that 1 have read this application and state that The chose information is BUILDING FEE
y ennead agmcmcumply wish all city and caumy ordinances and state laws relining to QTY, MECHANICAL PERMIT FEE
U building conslmelion.and hereby authorize representatives afthiscity um enicrupom the SEISMIC FE-Elk
above-mentioned property for inspection pumpnsca: PIRRsH r ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC[ .F.
liabilities,judgments,costs and expemes which may in any way accme against said City AITER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APj1LICA4r UNDERSTANDS AND WILL CO PLY WIT I ALL[N-POINT ATR HANDLING UNIT(TO 10,00)CPMI
MECHANICAL i
SO IRCE I EGULATIDNS. 13 �� \
AIR HANDLING UNIT(OVER 10,000 CVM) CONSTRULTIO TAX
Sig are ofAMlicaut Commctar Dine EXHAUST HOOD(W/DUCD HOUSING MIT ATI FEE
HAZARDOUS MA ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material REAL ING ON]'I'fTO 00,0% BTU)
ax defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 25532fta)? HEATING UNIT(OVER 100.000 BTU)
❑Yes C]No VENTILATION PAN(SINGI.H RESID) PAID Date Rea- tin
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP UHP OR 100,000 BTU)
TAL:
Distrix?
El Yet, 0 N BOILER-COMP(OVER 100,000000 BTU) -
I have read the haaareausrumen.is mryirements unser Chuptcr 6.95 of The Cali. AIR'CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Sections 5505,M533 and SSW.L understand that if dw NEW RESIDRNTIAL MECH. SQ.FT.
building dues not cunemly have a tenant.Nm it is my aspmmibilirym notify the..,at
of the requirements which must bo are prior to issuance of a Certificate of Occuponcy.
Owner or amhrriecd agent Date TOTAL: ISSUED BY:
OFFICE