S 0679 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY'OF CUPERTINO BUILDING.ELECTRICAL. VF.RMIT NO.
BUIIAING DIVISION APPLICATION/PERMIT 1'LU11111NG-MF.CIIA11111 S 0679
- IIWLUING PROD F.GTIUEFO'IF'IGTION
BUILDING DRESS: SANITARY NO, APPLICATION SUBMITTAL DALE
WNER'S E:N 1 1L3_F.7� .�/ C T� B �. I.IC N/C CON'1'ROLN
ARCHITECT/ENGINEER: LIICC/NO: ✓Rk`J ADD E ('f/rN_T�I[/
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG- ELECT PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
DaZ JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
ilRR 1 NTIAL:
WOO AKKBnfD3nfthcBndP f CcJmy cm
PERMIT ISSUANCE.
FLL� nfull force and eRe ❑SFDWL ❑KITCHEN REMODEL.
�U�F�]] LicenwCss
C.C. APPLIANCES-RESIDEN'I'IAI. ❑ADDITION ❑PLUMBING RE-PIPEPRE-PIPEF�j 41 Damracmr
N`0. ARCHITECTS DECL RATION ❑MULTI-UNIT ❑STRUCTURAL.
~ Z lunderstand myplaas shall bmost ed meant,as public reca , PANELS MODIFICATION
ZOZ (] UPTO200AMPS I ❑INTERIOR ❑CHIMNEY R17PAIR
rot:[i ns
Liceed Professional 301-1000AMPS IMPROVEMENT OSWIMMING POOLS
<N •.1 OWNER-BUILDER DECLARATION ❑BATH REMO :I/R PA 2 ❑ iM TIO S
F O w..1 OVER LBW AMPS
6 1 hereby affirm that 1 um exempt fano the Contractors License Law for the
K 1 V following mason.(Section 7831.5,Bmias&and Promadinns Code:Any city or cuumy SIGNS ELECTRICAL ❑fyI'HBR
LL 3 LL F' which requires a permit m consumer,alter,improve,demolish,or repair any swear, F
prior to its isomencaalso amuire,Iheapplicunt fusion permit o life asignelmammem SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions of the Contmno/s License Law(Chapter 9
�p(D (commencing with Section 70M)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE I OMM R IAD
that he is exempt therefrom and the huis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tXR 4th.
Section 7031.5 by any applicant for a permit%objects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
rr���r not mre othan five hundred dollars($SIM). their sole compensation, SWIMMING POOL ELECTRIC EN
IMPROVEMT
m ❑ Las owner m the proaz
perty,ormy employees with wages
will acidic work,and dostractem is not intcmkd or offered for sale(Sec.]044.Business
W ❑OTHER
Ial and Professions Code:The Comorro'a License Low dos not apply a an owner of OUTLETS-SWITCHES-FI
progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RF_SIDENTIAL ELECTR SQ.FT.FLOOR AREA S/SQ.FT.
sale.If,however,the building or improvement is sold within one year of completion,the
ser-builder will have the burden of placing that he did not build or improve for pur-
pose of sale.). TOTAL:
❑h as owner of the property,am exclusively contracting with licensed emanation to
answer the project(Sec.76M,Business and Profession.Code:)The Cmdust n'sLi-
ns
Li-
camLaw does not apply to an owner of pmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts or
cts far such projects with a contracts)licensed pursuantto the Cor actors
License Low. PERMIT ISSUANCE
I am exempt under Sac. .B&P C for mix reason
ALTER-DRAIN&VENT-WATER(EA) VgLpAT10N
Owner nate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby will
mai under penalty mperjury one of the following Wdmr's Co
❑Thaw andnnside for by
neCion37M of CantatamCode,for
eie Workers Compel- DRAINS-FLOOR.ROLE.AREA,COND. gTORIFS TYPE CONSTNUCI'ION
cation,r provided for by Section 3]rN1 of use Labor Crxic,for ore perfnrmunce mine
rk for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compenmtion Insurance,an menced by Section
J7011 of the La rCode.fordo rfowance of the work furwhichrhispen itislsmad. GAS-EA.SYSTEM-I INC.4 OUTLET (]CC.GNOUI' APN
My Wu in ori punto anierPolicy c GAS-FA.SYSTI3M-OVFR4(EA)
Carver. No,Policy
-
CERTIITCATEOFEXEMPION FROM WORKERS' GREASEENDUSTRL WASTE INTERCEPTOR
CGMPENSAI'[ON INSURANCE BUILDING DIVISION FEES
(This sectimm�eed not becompleted inns pemdt is force hundred dollars(SIM) GREASETRAP
m less.) PLANCHECK FEE
I certify that in the perfowanceofthe work for which this pewit is issued,l shall SEWER-SANITARY-STORM EA,2M Fr.
not employ any person in any manner so as it)become subject m the Workeri Compen- ENERGY FEE
O `,Z satian laws of California.Date WATER HEATER WNENT/ELECfR GRADING FEE
Applicant
h NOTICE TO APPLICANT:If,after making this Ceti of Exemption,you should WATER SYSTEMiTREA'1'INO 0
I" SOILS FEEbecome subject tothe Workers Compensation provisions of the Labor Code,you must
ai forthwith comply with such provisions or this Notion&hail be deemed revoked WATIiR SERVICE
trJ
FjO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
l hereby aRrm that is a construction lending agency for the performance of Dam <ttiptN
H the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
C)U Lenda'&Name
TOTAL.
Landers Address
G 1 candy tan
hat 1 have read this application d smm that the those information is BUILDING FEE
W comm.l name it)comply with At city and county ordinances and state laws relating in QTY, MECHANICAL PERMIT FEE SEISMIC FEE
U building venswaion,and hereby unthnrim representatives ofrhi&city to enter upon the
aMwe-maminned property for inspection Impose'. PERMIT ISSUANCE ELECTRIC 'E
(We)agree to saw,indemnify and kap hamlus rhe City of C,smmo against _
babilities,judgmenu.costs and expenses which may in any way intense against said City ALTER OR ADD TO MECH. pl. B FEE
in consequence of the starring of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,MBCFM) MECHANICAL E \\J
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER IO,tc CFM) CO NTAJ((L
SipawreofApplietud Canaan, Dare EXHAUST HOOD(W/DUCT) HO GMIT QA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanrmme orhandle hmardous material HEATING UNIT(TO Iffy"BTU)
as declined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1000K)B I J)
Code,Section 25532(a)7
❑Yes FIN. VENTILATION PAN(SINGLE RESIDE PAID Uma Receipt#
Will the applicant orfuture building occupant use equipment or devices which BOILER-COME, OR 100.000 BTU) '
)• emit instructions air contaminants as defined by the Bay ARU Air Quality Management 'TOTAL:
DistdaT /
Oyes ON.
B
OILERU)
have read the hwnrdous nmteriuB rs mems under Chapter b.YS of the Cali.
ISSUANCE DATE
finite Health&Safety Cods.Sections 25. , 33 and B5M.I undersand that if theSQ.Pr.
huildingd tcu any eumnm ismym nsibilirymnotifythemmulnr
u hie ust 'ormiss fu C,nifrRam�(kcu
O et or amhorized ge /�O Datc TOTAL' ISSUED 13 Y: v • •- �O
OFFICE