99110138 i APP!�ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q q Q
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDLNGADDRESS: SANITARY NO. APPLICAT ON SUBMITTAL DATE
il�
OW_ HISS ME: PH Ii: C(INTRAMOR'S NAME: LIC NO: / 1
NX CONTROLg
AHC ITEC'VENGINEE : LICN ADDREit ❑
1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ C.mailtant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
3 0AAA ❑ ❑ ❑ [�
LICENSED CONTRACTOR'S DECLARATION ry ELECTRIC PERMIT FEE
I hereby aRrn Kiat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Fctwith Section'IWfI)ofgivisinn 3ofthe Business and l4tfessions Ctde,and my license is LIMIT ISSUANCE. RESIDENTIAL'
Fc
ret full force send cllay. _ SALa�rY u1
EQ.UO Licens lass_�-_'�V-n^1Lic,a A N4 ❑SFDWL L1 KITCHEN REMODEL
NGU Dino Conttaz-����IlS APPL NCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
RCHGECI'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
Zp 1 understand my plan,droll be used ax public.,,ad, MODIFICATION
MODIFICATION
h-0
CZ UP10200A C1 INTERIOR 11 CHIMNEY REPAIR
r4tWLicensed Professional 201-1000AMPS IMPROVEMENT 11SWIMMING POOLS
W OWNER-BUILDER DECLARATION
OVER["AMPS ❑BATH REM UREPAIR El DEMOLITION
C 6 1 hereby affirm that 1 am exempt from the Commerce,License Law for the
C 6
YW$ eJ Ibllowing reason.(Section 71131.5,Business and Prum,sima Code:Any city nn countySIGNS ELECTRICAL ❑OTE IER IN 4pN�'�e'
f LL O y which requires a porion to consumer,ether.improve.demolish,nr repair any ettucturc is
pd.,to its issuance.also requires the applicant forsuch .it flea signed sm¢men SPECIAL CIRCUIT/MISC.
that ho is licemcd pursuannnthe provisionsofthe Cotamcom's Choose Lew(Chapmr9
1+1 00 (rmmmencimg with Section 7100q)of Division 3ofthe business and Profession,Code)or 'I'EMP.METER OR POLE INSP. COMMERCIAL:
d ae�' that he is exempt therefrom and the basis for the alleged exemption.Any'"aamn of [I NEW BLDG/ADDITION [I DEMOLITION
Section)031,5 by anyapplissom fora permit subjects doripplisma ma civil pe..try of POWER DEVICES
m m t more than five hundred dollars($503). ❑TENANT ❑FOOD SERVICE
F' Q [71,as owner of the propeny,nr my entpinyms with wages as nc�ir hole cmnpensminn, SWIMMING POOLELF.CTRIC it IMPROVEMENT
will Jo the work,unit no ntuure is not intended m uffcred for sale(Sm.7W4,business ❑OTHER
m
W 3 ro and Professions Cade:The Co ajons,on's Liana law dries not apply to an mvner of OUTLETS-5 W 11'Cf{ES_FI%TURES
propeny who builds or improves thereon,and who does such work himself or through
his own employms,provided that such improvements are not intended or offered for NEW RESIDEM'IAL ELECfR S
sale.IL however,the huildingor improvemem issNd wilhirmis)c..of completion,the Q:PT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of pmving that he did not build or improve for par-
pcie of sale).
❑ I,as owner of the propeny,tan exclusively contracting with licensed contractors to TOTAL:
instruct the project(Sea 701 .Business and Professions Code)The Conlmcmr's L,-
cruse Law does not apply to an owner of propcoy who builds or improves thormon,and QTY, PLUMBING PERMIT FE
who contracts for such projects wit a contractors)licensed pursuant to the Comrectn S
License Law. PER "ISSUANCE
0 l am exengaonden Sec. ,B&P C for this reason
AI.T'ER- AIN&VENT-WATER IEA) VALUATION
owner rime
WORKH HIS COMPENSATION DECLARATION BACK FLOW OTECT.DEVICE
41 1 hereby affirm under penalty of perjury one of the following dealamtions: \ O
I have and will maintain a Cenilieam of Consent to self-insum for Worker's Compen- DRAINS-FLOG ROOF.AREA,COND' STORIES TYPECONSTRUCI'ION
sation as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER T
anti will maintain Worker's Compensation Insurance,as required by Section
71k)of toe Large Code,for the performance of the work for whichthis permi I' I,ytml. GAS-ISA.SYS i'EM-II 4OUTL61S DEC.GROUP APN
MyW .tprTp so moncrandl'nlicynu r `+
Curries Tes-o-1 No.: GAS-EA.SYSTEM-OVER .A)
T dC E . ION F FROM WORKERS' - -O
COMPENSA HON INSURANCE GREASFANDUS'fRL WASTE I NRCEPTOR
('this section need not be completed if the permit N for one hundred dollars($100) BUILDING DIVISION IBES
nr leas.) GRl'v15L TRAP PLANCHECK HE
I comity that in the Performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-S"FORM EA2f
nor employ uny on parsin any nmvnur o,as tri become suhjecnn .the Workers'CmnEwn- ENERGY FEE
OZ union Laws of Cabrer ire.Date WATER HEATER W/VENT/BI,ECTR
Z Applicata - GRADING FEE
p) NOTICE TO APPLICANE If,after making this Certificate of Exemption,you should WATER SYSTEMRREATING
a become subject m the Workers Ci mpcnsaanm pro it,os s of the Lubar Cale,you must SOILS FEE
forthwith comply with such Provisionsonhlspernit shall hedomedrevoked. WATER SERVICE
Q
� zCONSTRUCTION L ENDING AGENCY NEW RISIDENTIALPLMII. $Q.FT. PAID
U O 1herehy affirm that hem is a construction lending agency for the perfomrunce of Date RaeiptM
Frho work for which this Permit is issued(Sec.3097,Civ,C.) --
O U Isndcr's Name �r,s //,\TOTAL: .11
a Lcndds Address TOTAL:
Liz 1 comity that 1 have read this application and state that the above information is BUILDING 4fil 1
rr UJ coned.[agree to comply with all city and county ordinances and statew
las relating m QTY. . MECHANICAL.PERMIT FEE V
U z building conswetion,and hereby amhorim representrnivesofth'ro city memerupon the
itove-mentioned propertySEISMICy for inspection purposes. PERMIT ISSUANCE
(N'e)agree muve,indemnify and keep halesNe s City of Cupcninn against ELECTRIC E
habil lots,jul,ficac,cnm..and.,trom which may i n any way secret,ugaina said City AIT FIR OR ADD'TO MF.CH,
in amsequence of the granting of this permit. PLUMPING IR
APPI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,"CFM)
Sf I " REGUfATlffff����NS. ` MECHANI FEE
� ..Lr I� CC AIR HANDLING UNIT LOVER IO,rMIO CPM) CONS'TRUCfION TAX
Signature
HAZARDOUS
Data EXHAUST`\ EXHAUST HOOD(WMUC ) HOUSING MITIGATION FEE
HAt or future
MATERIALS DISCLOSUREhandl
Will there,Cr rAine,Mune ipal o oecupant x9.12.bundle hazardous material HEATING UNIT(TO IW.fgp PTU)
a de,Sec io rbc Cupertino Mnnicipul Cala Chapter 9.12.and rhe Hwlth nnA Safety
Code,Section 25532[e)P DEALING UNIT(OVER I0II,000 BTU)
E]yes V/tvo VENTILATION PAN(SINGLE RESIDE PAID
Will theanorafulure building litd
Date Raelpt x
emit hazardou .11 connminnts es defncd by the Bay Ar..Air Quality Management BOILER-COMP(3HP OR BTU)
TOTAL:
Uimna^
E]Ycs BOILER-COME'(OVER 100,000 BTU)
I have readthe hazanleis materials is ander Chapter 6.95 of the Cali AIR CONDITIONER
t5,2553 cn p ISSUANCE DA
f nen oro f ties
n Safety Code.Sabena 25505,25533 and 25534,1 understood than if the NEW RESIDENTIAL SUCH.
ml n of trendy haves mnanWhm it is my respons'billym notify the acupam
hich mull M met pnor to issuance of aBcatc o[Occ my
Ow un�a����Date�Datee TOTAL: ISSUED BY:
OFFICE