99090016 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 41
CITY OF CUPERTINO BUILDING-ELECTRICAL. MIGHT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
5:
BUILDINGADDRESSANITARY NO. APPLICATION SUBMITTAL DATE
-
v E z a,vr LOPC
OWNERAME: (� CONT LCfOR'S NAME: ' jpLICNO:
II` / /f✓ORSN E: NIC CONTROLM
A CHITECTBNGIN[ER: LICNOi AD RES /
Lf! -T.
C.4
CONTACT: PHONE: BUILDING PERMIT INFO
CEJ DP001le�e - 93 ❑ Consultant Fees Paid by Applicant(Initial) BO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
1 hereby affirm that I on licensed under provisions of Chapin
9(commencing — _ JOB DESCRIPTION
y00 with Section7")ofDivision 3rf(he Business and Pmfessions Code.and my license is RFCIDHNTIA
FO0O PERMITISSUANCE
in full force and effect.
y.WF ❑SFDWL [I KITCHEN REMODEL
aUU Licenu Class Lica APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
NoI'dd Dalt Comracmr
py ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
ZO�K I understand my plans shelf beusedas public records MODIFICATION
OZ O UPT0200AMPS Ilf ❑INTERIOR ❑CHIMNEYREPAIR
h.0—,F.ttr�II Licensed Professional 2014"AMPS IMPROVEMENT SWIMMING POOLS
a od ; OWNER-BUILDER DECLARATION OVER IIID AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
CC 6 I hereby affirm that I am exempt from the Contractors License Law for the
t1 O y U following reason.(Section 2031.5.Business and Pmfessions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3 W y which requires a permit to common.alter,improve,demolish,or repair any structureihOo if tents issuance,also immicethe applicant forsuch permino Bless signed stutemem SPECIALCIRCUIT/MISC.
pS' pN. that he is licensed pursuant to the provisions of the Contracmrx License Law(Chapter 9 CIA L
t+1�00 (commencing with Section 7")of Division 3 of the Business and Professions Cala or TEMP.MIT ER OR POLE INSTr EB
a q C that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of 'W BLDG/ADDITION ❑DEMOLITION
Is%1 so Section"1031.5 by any applicant fora permit subjects the applimum.civil penalty of POWER DEVICES ANT FOOD SERVICE
of marc Non five hundred dollars(S5 W1.
FZP IMPROVEMENT
❑Lahe owner work,and
property, remyemsheadeswithwsed f rrale(solem. UM,B siren, SWIMMING POOL.ELECTRIC
' 0
will dmhesomn,andthe se Couisnminrenense La c does reale(Sec.to . Business []OTHER
Y1 and Professions Cale:The Contractors License Law Jas not studywork
Hi m if owner of OUTLETS-SWITCHES_FIXTURES
4i 3.. ],is.property who boilss or improves thereon,and who does such work himself a through
his own employeese provided trim such mens is sold w are out intended on offered for NEW RF.SIDF:NTIAL ELECfR SQ fT.
rale.IL howeveq the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA -SISQ.PT.
owner-builder will have the burden of proving that he did not build or improve for faro,
i (rose of sale J.
❑I,as owner of the property,am exclusively convecting with licensed contractors to TOTAL:
construct the project(Sec.40,1,1,Business and Pmfessions Code:)The Contractor's Li-
sense Law does not apply to an not net of
i-senseLawdoesnotapplytoanownerof property who builds or improves thereon,add QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant o the Converter's
License law. PERMIT ISSUANCE
❑I um 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 N v
1 herehy i lirm under penalty of perjury one of the following deelarrommi: V
❑I have am will maintain a Cendicnte of Comem to self-insure for Workers Compeer- DRAINS-FLOOR,ROOF,AR EA.GOND. gTORI TYPE CONSTRUCTION
s tion .provided for by Section 3700 mf the LuMt Code,for the performance of the
vera which this pemul is issued. FIXTURES-PER TRAP
I have and will mWnmim Worker's Compensation]as....cc.as required by Section
3700ofma Ulan Cole,fonhe perferbonce.f the work for whichthis permit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS
qup p=eOCC.GROUP APN
MYaV14�er/ rap balinn numltygepie airy NoPoiicy9Q0zTW GAS-EA.SYSTEM-OVER 4(EA)
((gtii/tD
CERTIFICATE OFIEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR „iJ\` \\ _ BUILDING DIVISION FEES
(This section need not be completed ifthe pemtit is on nnehundred dollars($100) GREASE TRAP
or tess.) IL-- t PLANCHECK FEE
I certify that in the performanceofthe work for which this permit is issued,l shall SEWER-SANITARY-STORME6CA YyL n\� EN GY FEE
non employ any person in any manner so as m become subject m the Workers'Camper- •' _
Oz station Laws of California.Dale WATER HEATER W/VEN`7MX(7RA Iry FEE
Z Applicant ,• `�
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM,TREA PING
become subject rte the Worker's Compensation provisions of the Lala,Code,you man •TS ILS FEE
{1J r fonbwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE s^
Q s
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SCisT. s PAID pate Receipt%
V Q IhereM1y aRimnhauherc isaconstmaion lending ngexy for the performurceof
LL F-t the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V Lender's Name
W Lcockes Address AL.
y BUILDING FEE
I certify(het I hove read this application urs stare(hat the rbove info..........is
W correct.l agree to comply with all city and county ordinances and spate laws relating to QTY. MECHANICAL PERM FEE SEISMIC FEE
Ll Z building convection,and hereby authorize represetnanives ofthis city no enter upon the
above-mentioned property fill inspection purposes. PERMIT ISSUANCE a, ELECTRIC FEE
(We)agree to save,indemnify and keep hamiles the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
PLUMBING FEEin consequence of the granting of Nis permit.
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) 49. Pe
SOURCE ILA NS. MECHANICAL FEF;
AIR HANDLING UNIT(OVER IQOWCFM) CONSTRUCTION TAX
SFKafurc of Applican s J Date EXHAUST HOOD(WMUC) HOUSING MITIGATION FEE
HA' RED SMA 'as DISCLOSURE
Willthwppiica,orfu rebuilding acupom note orhundle hozard...material HEXHNGUNIT(TO I04"BTU)
as defined by the CupA .pal Cade,Chapter 9.12,and the HeaIN and Safety
Code.Section 25532(.14 � W(SINGLE
I(OVER 100,M)BTU)
❑Yes �Nm PAID
VENTILATION PAN(SINGLE NESID) pale Receipna
Will the applicant or future building..,as,use equipment ter devices which P(1Hp OR toff BTU)emit hazardos oil rm..tmi..anls as deduced by the Bay Arca Air Quality hlanzgcovert TOTAL: 0. L
Dinrko P(OVER 100,000 BTU)❑YesNo i have red Ne hazardous materials amusem ant under Chapter fi 95 of the Cali- ONER 7 d ISSUANCE DATEforma Health&Safety Code,Sections 25505, 5533 and 25534.L understand tot if the NTIAL MECH. SQ.FT.
building d«s not currently have a tenant.aha ismy responsibility to notify the campunt n��
oftbe octalof be me,p' to issuance of a Cenifi cnf Occu /
Owner or umhorized.gem Uae TOTAL • ISSUEDBY:
OFFICE