00050107 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY In
CITY OF CUPE RTINO BUILDING-ELECTRICAL 1 PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOO1
BUILDING PROJECT IDENTIFICATION
BUIL/G AI]pRES SANITARY APPLICATION
r SUBMITTAL DATE
SP
OWNER'S NAME: fto /
C/rtTeUY 7q � / NIC CONTROL,
ARCHITECT/ENGINEER: LIC NO. 6 ctiYuv` —s
❑
CONTACT. PHONE: BUILDING PERMIT INFO
L (•� - �,i_07 ` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
{J f/7l L ❑ ❑ 1:10
LICENSED CONTRA R'S DECLARATION QTYI ELECTRIC PERMIT FEE
I hereby affirm that 1 am m
licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 7000).f Division 3 of the amines,and Poor...ion,C and my license i. RESIDENTIAL:
I+IOp ,^r �O.IIe{a° PERMIT ISSUANCE
WonF. mfull forte and eB«'C. a�f.�a IIs ❑SFDWL ❑KITCHEN REMODEL
aVU License Class Lie.a APPLIANCES AL. ❑ADDITION ❑PLUMBING RE-PIPE
N Z u1 Data Conus trot
5y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z p r Z 1 understand my plans shall W used as public records MODIFICATION
OZ—Q UP TO 200 AMPS ❑INTERIOR C3 CHIMNEY REPAIR
Licensor Professional 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IM)AMPS [I BATH REMODEUREPAIR [I DEMOLITION
049, 1 hereby affirm that I am exempt from he Contractors License Law for the
iiGGS5,� d V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTNER
ur}+la,F` Which requires a Permit to construct,alter.improve,demolish,or repair any swcture
��� prior to its issuance,also requires the applicant for such Permian rile a signed statement SPECI AL CIRCUIT/M ISO C f
f } that he is licensed pursuant to the provisions of die Contractor's License Law(Chapter 9
W s MMC (commencing with Section 7000)of Division 3 ofihe Business and Profesiooa CedeAm TEMP.MET ER OR POLE INST'. COMMERCIAL'
d a o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�h Seelion71131.S by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than Five hundred dollars 10).$50
Z} IMPROVEMENT
pa 01,usawnerof the proper,or my employees with wugesis their sole compensation, SWIMMING POOI,ELECTRIC
M_C will du the work,and Ne structure is not intended orofiered for care(See.703a,Business OTHER
a,=R and Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves therem.and who does such work himself of through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however.the building orimprovement is sold within one year of completion,no
FT.FTIDRARER $/SQ.IT.
awner-builder will have the burden of proving Nat he did not build or improve for put. 790
pose of sale.).
❑I,as owner of the properly,am exclusively contracting with licemed rnnlfagnra m TOTAL:
construct the pmj«t(Sec.743a4.Business and Pmfeashma Code,The Convectors Li-
nse Law does not apply to an a."of p rpmY who builds or improves Ncrom.and QTY, PLUMBING PERMIT FEE
who sonans for such projects with a comme,o ds)licensed u
purmano the Contractor's w
License Law. PERMIT ISSUANCE t
❑ 1 an,exempt under Sec. .B&P C for Nis mason
Owner Date ALI ER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing Jwlamtirns:
I have and will muintuin a Certificate of Consent to self-insure far Worker's Compen- DRAINS-FLOOR,ROOK AREA,GOND. STORIES TYPE CONSTRUCTION
satin,as provided for by Section 3700 of the Lmor Code,lot the performance of the
licarrat
issu
d.
have unit oillsmainminsWorker's Compensation Insurance,as required by Section FlXTURES-PIiR TRAP -
37Wof the Labor Code,for the performance of rhe walk for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AVN
M Carrier
n I �f aria and Polis u J
Cam'ee. u !La `s • Palicy No.Y j'�/��,y,'�yq(��.►Q}/�- GAS-EA.Sys'fEMOVER4(FA)
CERTIFICATEOFEXEMPI'ION FRO REIES' - l�
COMPENSATION INSURANCE GREAMY NDUSTRL.WASTE INTERCEPTOR
BUILDING DIVISION FIi1S
(nis section reed not be completed lf Ne permit is forone hundred dollars($100) GREASETRAP
or less.) PLANCHECK ME
Loy any Net is inhice my
of the bicomeork for which this permit is issued,I'Comha11 SEWER-SANI'T'ARY-STORM EA.200 PT.
not employ any parotin in any manner ro as m became subject to the Wurkers'Compcn- ENERGY FEE
O z cation Laws of California,Date WATER HEATER WNENT/ELECTR T:E
O Applicant GRADING F
q y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/FREATING
abecomesubect to Nr WorersCarmen mtto.provisions ofthe LuWr Code,you most SOILS FEE
f0a forthwith comply vithmeh powisionsor Nis prtmitahallW clamed evakor. WATER SERVICE
G
CONSTRUCTION LENDING AGENCY NEW RGgIDEN'TIAL PLMB. SQ.IT. PAID
U O user R«eipi a
1 hereby alum that there is sued(Sec.30 lending agency far Ne perfommnce of
the work for which this pcmtit is issued(Sec.3fN7,Co.CJ
Lenders Name 'TOTAL:
Lenders Address TOTAL:
1 verify Nat 1 have read thirty and our and state Nat the above laws
relating is
BUILDING FEE
Wo cored I agree m comply with all city one county ordinances and such,laws renting toe QTY. MECHANICAL PERMIT FEE
U Z building conswdion,and hrrcFy umhoriaer<prem
aeetives of on,city to enmrupmthe SEISMIC FEE
above-mentioned properly for inspection purposes PERMIT ISSUANCE
We)agree to save,indemnify and keep hamiless the City of Capacities,against ELECTRIC FEE
Iiabilidesjudgments,cosu and expenses which may in any way aceme against said City ALTER OR ADDTO MECH.
in com¢quence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.000 CPM) MECHANICAL FEE
SOURC :c IATIONS.A 10.000— ���`�
�/`/J}'� AIR HANDLING UNIT(OVER IILU CFM) CONSTRUCTION TAX
Si�of ApplicantlConvecmr X Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hersrdous material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Solely
Code,Scene.2553200? HEATING UNIT(OVER 100,000 BTU)
E]Yes VENTILATION PAN(SINGLE RESID) PAID
Date Receipt If
Will the applicant or forum Wilding occupant use equipment or devices which
emit humorous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HVOR IgI,(00 BTU)
Tti TA L:
Disuictl C�,f! NOILEft-COMP(OVER 100.000 OTU)
Yen L�„u
I have real me M1araorous romancers u under Chapter 6.95 of the Cal i- AIR CONDITIONER ISSUANCE DATE
5,25
fomia Health&Safety Cole.
e.lions25505,235JJoral25530.1uorersuml Natif Nr NEW RESIDENTIAL MECH. SO FT.
buildingJ es�^curently a alenant Nat it is mYrenpnneihiliry mnotilY the occupant / CJ
afNitr .whian tptimaisxa .f.Ce Ii`fa�
Ownelroraobnm,rdagem � Date TOTAL: ISSUED BY: , C
OFFICE