S 0961 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - - BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT w.LIMNING-MBcunNICAI. S 0961
tlU11.DING PROJECT IDENTIPICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
( i 3 ASd l
OWN AME: PH E: CONTRA R'SN ME: L
NIC - CONTROL#
AR HITECT/EN INFER: LIC NO: Il) ,$5: �/ ❑ -
lpJ Z
CONTACT: PHONEj: - BUILDING PERMIT INFO
Z3 ❑'Consultant Fees Paid 6y AppliC9nt(Initial) BLDG ELECT PLUM MECH
® l ❑ ❑ ze ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
I hereby a0irn that I ton licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O5C, ith Sectian]n80)of Doo n3oOr Business and Professions C de,andmylerce is TIAL,
F�OQ w PERMIT ISSUANCE 0.'wF in full force end B t G+Ss'. ! FDWL 11 KITCHEN REMODEL
aUZU Licen TSD � APPLIANCES-RESIDENTIAL ❑ADDITION ❑SPLUMBING TRUCTURAL,rF6L Date Contractor
F,prq ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT ❑STRUCfURAL�
2024 londers red my plans shall her used as public records MODIFICATION
Oz�-10 UP T0200AMP5 El INTERIOR El CHIMNEY REPAIR
C=�.Y.I1 Licensed Professional XII-1000AMPS IMPROVEMENT E]SWIMMING POOLS
a G9 _alOWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REMODE EP IR El DEMOLITION
Q 6
1 hereby affirm that I am exempt from the Coal...ma's License Law for the
aq5 U fallowing reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHEk
u+a W F which requires a permit to comtmn,alter,improve,demolish,or repair any structure
,("JPO priormits issuance,also requires the applicam for such pe,aiuo file sm,imistitement SPECIAL CIRCUITNISC.
ythat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
W rrGC (commencing with Section 7000)of Division 3 oflhe Business and Professions Code)or TEMP METER OR POLE INST.' COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
iLLCI W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TUNANT ❑FOOD SERVICE
ynotmore than five hundred dollars($500). IMPROVEMENT
L]1.as owner ofthe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
'F' Q will do the work,and the structure is not intended moffered l'orxale(See JM4,Business ❑OTHER
Gaud Professions Code:The Cimmemis License Law drew not apply 10 an owner of OUTLETS—SWITCHES—FIXTURES
r property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECPR SQ ET
sale.If,however the building or improvement is sold within one year ofcomplenon,the SQ. RARER $SQ.Ef,
owner-builder will have the burden of proving that he did not build or improve for par-
pose of sale.).
[21,as owner or the pmpeny,am exclusively contracting with licensed coators
ntcIn TOTAL:
consumer the Project(Sec.70I44.Business and Ikofosslors Code:)The Contraemis Li-
cure.Law does not apply m as owner of property who builds or Impasses thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with o conlmcloo x)licensed pursuant to the Comai
Liceme Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing d rakers Co
•Dlhave and will for byneCion370e of the Lam Code,forthe Worker's Comp the DRAINS—FLOOR.RIX]F,AREA,GOND. STORIES TYPE CONSTRUCTION
saline as provided for ni Section 3]00 0[the Labor Code,for the performance of the
work which this permit is timed. FIXTURES—PER TRAP
have and will maintain Worker's ante of
w Insurance,h his respired by Section
3700 of the Labor Crude,for the performance of the work l'nr which this permit is issued. GAS—EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN '.
My WorkerCom mati Insurance carrier and Policy n y n nn�f
Carrier: Policy Nn: 0ygl (]II I GAS—,EA.SYSTEM-OVER4(LA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Taisedion need not be mi
completed ifthe pert is former hundred dollars GREASETRAP
or lest) . PLANCHECK PEE
I certify thein the performance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any man.,an em become subject to the Walkers'Campen- ENERGY FEE
zZ ..tion Laws of Califomla.Date WATER HEATER WNENTIELECURWW
0 Applicants GRADING FEF.
y NOTICE TO APPLICANT:If,after making this Cer ifiente of Exemption,you should WATER SYSTEMffREATING
become subject to the Workees Compensation provisions of the Labor Code,you must SOILS FEE
Wforthwith comply withsoh provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PATO Date
1 hereby w affirm there i is sued(Se.construction0 lending agency for the performance of
ti the work for which this Permit Is issued(Seo.3fHJ.Clv,CJ
O ,F, Lenders Name OTAL'
WW1 Leader's Address TOTAL: /
IU 1 certify that I have read this application and state that red above attenuation relating is BUILDING FEE
F (�/J building
I agree to complyand herM1 all ummed representatives
ntativ s of and store laws relating m QTY. MECHANICAL PERMIT FEE
L.1 � building cnnsWdion,and hereby authorize representatives of this city menler upon the SEISMIC FEE
men
ohove- tioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to nave,indemnify and keep homeless the City of Capuchin ugnstaiELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way accae against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit VP
NO FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT Alk HANDLING UNIT(TO 10.001CFM)
SOURCE REGULATIONS. - MECHANICAh FEE
AIR HANDLING UNIT(OVER 10,003 CFM) ` 1eiONSTRUCf10N TAX
Signature of ApplarmContracmr Date EXHAUST HOOD(WMUCT) Ut
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicam or fur..building occupant smictr handle Incurious material HEATING UNIT QO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)' HEATING UNIT(OVER I00.00f)BTT)
❑Yes ❑No VENTILATION PAN(SINGLE kESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3HP OR 1(10,8(10 BTU)
'emi(hamrdous air terminations as defined by the Bay Area Air Quality Management TOTAL:
District'
❑Yes 7N BOILER—COMP(OVER 108000 BTU)
1 have read the hazardous materials requirements CONDITIONERgoirements under Chapter 6.95 of the Call- �y/ ISSUANC-D
forma Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.Ef. t ^ 2
heIdingd :not cuoently haves tenant that it is my responsibility to notify the occupant
mf Lha re reme pd suunco of a Crard to t Use. cy.
ner or authorized agent u/te TOTAL: ISSUED BY: 0—D �A
OFFICE