29072 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2O
9
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 0 SANITARY No APPLICATION SUBMITTAL DATI
t G
OWNER' ME: 1 PHONE' CONTR A F.: q6
NIC CONTROLp
kRCHITIi /ENGIN R: NO ADDRESS ❑
C��ACfr PHONE: BUILDING PERMIT INFO
CC "' ^ �� ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH
L NSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE
I herehy offir that
I in licensed under provisions rf chapter v(cmmmencing JOB DESCRIPTION
Z with Seddon m00)nf Division 3cfhe Bu.mess and Protein...Cede
.std my license is RESIDENTIAL:
FW_ ' full force and PERMIT ISSUANCE
ym F„ '" ` ❑SFDWL O KITCHEN REMODEL
QUU License Class Lic.p APPLIANCES-RESIDENTIAL DADDITION EI PLUMBING RE-PIPE
bo, a Date eenDECL
ARCHITECTS UECLA N ❑MULTI-UNIT El STRUCTURAL
I..,D ii PANI3IS
O Z n Z l undcrstanr mall y plans,bbe used it"addic rccmrds MODIFICATION
UP DO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
rot:Mj Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIXp AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
y 6 I hereby affirm thm 1 am exempt from the Contractor's License Law fnr the
x C.U Minivan,Kwon.(Section 7031.5,Business and Profi Ona Code:Any city or snooty SIGNS ELECTRICAL ❑OTHER
'3 p-Q which requires u permit to construct,alter,improve,demolish,or repair troy sweture
FLLOJ prior m its issuance,also requires the applicant for such Permian file a signed statement SPECIAL CIRCUIT/M ISC.
f to mm he is licensed Pursuant to the provisions of the Cantmctors License Law,(Chapter 9
WC po (com iencin wit Section of Division 3 of the Business and Professions Code COMMERCIAL:
g w ) )or TEMP.METER OR POLT:INST.
d p,o yr that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLXl' li
Section 7031.5 by anyappl;amt for a permh subjects the applicant)a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
tot more mon five hundred dollars(55 W).
^Z Y IMPROVIiM1iN'1'
E�aO ❑I,as owner of the property,or my cmpinyecswim wages as thcirmle compensvtion. SWIMMING POOL ELECTRIC
will do the work,and he urruni is nm imended oroRered for sale(Sec.70c4.Business ❑OTHER
a 3 m and Pfnfessinns Cade:The Conusctors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds Or improves tbcreon,and who docs such work himself Or through
his own employees,provided thm such impnrvemems ore not;"tended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale,If.however,the building or improvemem k,old within nneycnr of cnmplelin r,the SQ.7..FLOOR AREA S/SQ.FL
owner-builder will have the burden of proving that he did no build or improve for pun
poseofealed. JPI4 I p
[11,res owner of the propeay,am exclusively contracting with licensed contractors to TOTAL: z h
consumer the prnjen(Sec.10W,Business and Professions Codc:)The Conlmcloes El-
cause Law does not apply toanowner ofpropenywho builds oritnprovesthereon.and QTY PLUMBING PERMIT FEE MAR 12
who contracts for such projom.s with a contranm mr(s)licensed purstmIn the C"ntmn"r's ,16
q^
License Law. PERMIT ISSUANCE /x,
E]1 am exempt under Sec. .B&P C for this reason C�/Y
Owner Dme ALTER-DRAINA VENT-WA (FA) VVAA�LUA N//p,•�
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO"TELT.DEVICE '/ /�� - (J 0
1 hcrchy infirm under penalty of perjury one of the following decimations: l/
I have and will maintain aCeailicate of Consenfloself-insure for Workers Compere DRAINS-FLOOR,ROUF,AREA,COND. STORIES TYPCCONSTRUCHON
ration,as provided far by Section JAN)of the IrMa Code,for the performance of the
wok fm which his permit is issued. - FIXTURES-PER TRAP
I have and will maimai Wmkerz Cocacaainsntinn Insurance,as requiter by Section
My orks,' rC of the performanceofthework ch emit is isytW. CAS-A.SYST[M�OVIROON
Am�S OCC GROUP APN
My Wokcr'.0 rmA Polic �/VY,/LQfU('�
Carrier Policy No.
CERTIFICATE EXEMPTION FROM WORKERS'
COMP E
SATION INSURANCE GRASPIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This seetimoced not be completed Blue pcmti,is for..hundred dollan(S I put GREASETRAP
or less.) PLANCHECK PEE.
I certify that in the perfornunceof the work for which this p,mut is issued.I shall SEWER-SANITARY-STORM EA.2W IT.
not employ any parson in any owner so as to bccnnte subject to the Wnrk,o'Cotnpcn. ENERGY FEE
OZ cation Lins,of California.Date WATER HEATER W/VENT/ELECI'R GRADING FEE
Z 2 Applicant
N NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/I'ItfATING
fix ; become subject m the Wnrkcrs Compensation provisions of he Labor Code,you must SOILS FEE
CL1 r. forthwith comply with such providons or dro,nmit shall be deemed recover. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAI,PLAID, SQ.FT. YAIU
U z Date RcaiplM
L)QIbcrcM1y affirm that is aconswmmn lending agency for the performance of
the work for which his perms is issued(Sec.1091,Civ.C)
0 F" Lenders Name - TOTAL:
W IU Lenders AJdresa TOTAL:
�+ BUILDING FEE
ff.... 1 ttrtify that I have mud this application misstate thin he uhove informmion is
4N coarct.lattice tommply within city and county ordinances and ,are laws relatingm QTY. MECHANICAL PERMIT FEE
U Zbuilding contraction.and hcrchy authorise representatives ofthisen,to enteruptm the SIi15MIC FEE
above-mcmionel propeny for ins puryoscs. PERMI'IASSUANCE
(We)agree tin r 'e,indemni nd keep harmless the City of Cupertino against ELECTRIC FEF.
liabilities,judgments ss and en nines hick mmyin anyway accrue against said City ALTER OR ADD TO MECH.
in consequence oft vmmg of ll s PLUMBING PBC
APPLICAN'I'UN F STANDS D 111 CO P WTH LL ON-P( N'r AIR HANDLING UN,.lrO 10,d,BCFM)
SOURCE R1iGU1 T O S MECHANICAL FEC
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTION TAX
Signature of Appli nVCont curSURE Dam EXHAUST HOOD(W(DUCO HOUSING MITIGATION FEE
HAZA DOUS ATERIA,conLS cantor
Will the ytheCupernI'M. ihu1Coda.capanl,9.12,handle Health
nd Safe,, HEATING UNIT(TO IIX1,(MA BTU) �a
as defined by the Cupertin Manic al Cede.Chapter 9.12,and the Health and Svfcty
Code,Section 25532(a)p HEATING UNIT(OVER 100,000 BTU)
❑Yea ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt x
Will d the air con r or future a burring by the B use equipment or devices which
't banrJnur air conmminnnts:u Acf sed h the Ba Area Air Quality Manxttentent BOILC:R-COMP(JHP OR 10(1.OW BTU)
' Y Y TD'I AI:
)isnim^
❑Yes 7 N BOII.I!R-COMP(OVER 100,000 BTU)
AIR CONDITIONER
1have readthe h ode Ss t...2larequit533 sic under Chaptmore dt at if h- ISSUANCE DAT
fomia Health&Safety comedy
have
Santonin 25505.25533 sp 25536.1 unncrsand that if the NEW RESIDENTIAL MSCI{. SQ.FT.
building Jtws nm cumemly have a taunt,hot it is my responsiril Ity at nrnify me twcupam
of the ou,no nwnts which mint M;tnet prior,,iioaocc of a Cunlfcwm of Occupunup f� A
Owner or euthndud agent Dale TOTAL I ISSUED BY:
OFFICE