S 0647 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.,
'BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 06,47/I 7
BUILDING PROJECT IDENTIFICATION �J�}
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMI'1.1'AI.DATE
pc� L c7 C424 CO
OW E ' AME: PONE: C NTA ORS NAME: LIC NO:
/ G N/C CONTROL
is i l ITcCl/ENGINEEIL 1 LIC NO: ADDRESS: Z ❑
Saw {rcC
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under pmvislons of Chapter 9(commencing JOB DESCRIPTION
1O1�L0Z with Section 7000)of Division 3 ofthe Business and Profccsiona Code,and my license is RESIDENTIAL
F W is full force and t.�\ PERMIT ISSUANCE.
�UZV Lice Class ^`�`� Lic.tt OSFDWL ❑Klq'CHEN REMODEL
hQL Date Lot aacmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F?m RCHITECT'SDECLARATID PANELS ❑MULTI-UNIT El STRUCTURAL
Z Ov�Zy I undecaxnd my plans shall Sensors,public reco MODIFICATION
OZ:$ - UP TO 2011 AMPS
F. G Licensed Professional . ❑INTERIOR El CHIMNEY REPAIR
g - 201-IIXI0AMP5 IMPROVEMENT OSWIMMING POOLS
+� OWNER-exempt R DECLARATION Contractors
ON
I �0.'W� I hereby affirm that 1 oro exempt fiem the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODP. EPAIR 0 DF.MOLITIO
iWpiyy 0 6 U following reason.(Section 7031.5.Business and Pmfessiom Code:Any city ar county SIGNS ELECTRICAL []OTHER
a+a 0.E' which requires o permit to construct.alter,improve.demolish,or repair any structure
0q prior to its Issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
p+ that he isiieensed pursuant to the provisions of the Commences License Law(Chapter9
E.GaC (comenciagwith Section]IIIXBof Dlvlslon3ofdw Bminessand Professions Code)m TEMP.METER OR POLE INST. COMMERCIAL:
0.p,a e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION
mL1 DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES [.J TENANT _ ❑FOOD SERVICE
p: not more than five hundred dollars($500).. IMPROVEMENT
xxd D 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
FO will du the work,and the swcture is not intended or offered for sale(Sec.9(144,Business DOTTER
Yl and Professions Code:The Contractor's Licence Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE/
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELECTIR
sale.If.howevee thebuilding or improvement is sold within one year ofeomplelma..the SQ.FT FLOOR AREA $/SQ.ET.
owner-builderwill have the burden of proving that he did not build or improve for pur. PAID�y
pont of sale.). l P I D
❑I,as owner of the pmperty,am exclusively contracting with licensed contractors to TOTAL'
onamn the project(Sec.901 entire,,,and Professions GdeJ The Contactors Li- - - ��
cense Law does not apply to an owner of property who builds or improvesdaman,and QTY, PLUMBING PERMIT .E P26
�who contracts for such projects with a comrecmr(s)licensed pursuant to the Contmctoeis C�►
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C fcr this reason _ VC V
ALTER-DRAIN&VFW-WATER EA) F+U TION
Owner Date LP
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
_ hy
affirm under penalty of Perjury one of the following declarations
ve antl will maintain a Certificate of Consent to selPlnaum for Worker's Comper- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
which,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37M of Ne Labor Code,for the performance ofthe work for which this pemtil is issued. GAS-EA.SYSTEM-IINCAOUTLETS OCC.GROUP APN
MyW is an random In;ce carrier and Policy a here ' GAS—EA.SYSTEM-OVER 4(EA)
CamC C.CfeP�cr Ce Policy No.
CERTIFICATE OFIffXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE IM'ERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed time permit is future hundred dollars(SIW) GREASETRAP
or less)(This
FEE ,
I certify that in the perfnuarmae ofthe work for which this permit is issued,(shall SEWER—SANITARY—STORM EA.Nall FT.
rsnonpersons not employ any peon in any to become subject to the Workerk Compen. ENERGY FEE
Z. satiou Lawsof Califomin.Dale WATER HEATER WNENT/ELECTR
Applicant i GRADING FEE
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTEM/TRGTING
abecome subject to the Worker's Compensation provisions of the Labor Cede,you most SOILS FEE
W forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
tCONSTRUCTION LENDINGpGENCY NEW RESIDENTIAL PCMB. SQ.PI'. PAID Dale Receipt if
I hereby affirm that is s ed(Sec.30 lending7,Cm.agency for the performance of
F-n the work for which this permit is issued(Sec 3099,Civ.G)
F Lender's Name TOTAL:
L.J
Leaders Address TOTAL:
1
Z) I certify that 1 have read all
city and coup and state that the above information Is BUILDING FEE
Ta/1 correct.1 agree to comply with all city and county ordinances and state laws relating ns QTY. MECHANICAL PERMIT FEE -
V � building construction,and hereby authmlureproecmmivec of this pity to enter upon the SEISMIC PHH
above-mentioned pmpeny for impaction purposes. PERMIT ISSUANCE
(We)agroe to save,indemnify keep harmless the City of Cupertino against ELECTRIC FEE
end
liabilities,judgments,costs and expenses which may in my way warm,against said CityALTER ORADD TO MECH.
in consequence of the granting of lhis permit.in FF.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CPM) MECHANICAL FEE
' SOURC/E�R�EG�U/L
pv/ Cl�lly�r� AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX -
Signe/cores ApplicanYUCoontr✓acmCrr �j(,�• D EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I 00,0(g)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 1010,000 BTI!)
❑Yes No PAID
VENTILATION PAN(SINGLE RESID) Date ReeeiptH
�y('I��n- , licaot or future building occupant use equipment or devices which
. u /i BOILER-COMPCIHPOR 100,000BTU)
'mYlTuzrrdousroreontaminants as defined by the Bay Area Air Quality Management TOTAL:
Dist d?
Dyes ❑Nn BOILER-COMP(OVER I(10,(00 BTU)
I have read the haaardourmmeriale mqulmmcma under Chapter 6.95 fthe Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,25533 and 25534.I understood that if the NEW RESIDENTIAL MECH. SQ.ET.
building does or ave nano that it is my responsibility to notify thenccupam
of flJ'rqui t hi prirrmissu da e)W^ f0 upancy.
Owns aathoriied agent ` Date TOTAL ISSUED BY:
- — grg-
OFFICE _mss. _ Y A