S 0510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLF.CRICAL PE§1ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MHCHANICAL 0510
BUILDING PROJECp IDENTIFICATION
BUILDING4RESS AnA• i� % SANI'T'ARY NO. APPLICATION SUBBMM/ITTAL DATE
W R'S NAME: >_1�/s PHONE: CONTRACTOR'S NAME: LIC NO:
GNv NIC CONTROL#
+�ARCHITECTHENGINHER: LIC NO. ADDRESS: - ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Feet Paid by Appliesnt(initial) BLDG E rLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
I heathy aNrm that 1 am licensed under,.i,i.aa of Chapter 9(commencing J DESCRIPTION
WoowithSection]BBO)ofDivision 3oflheBusiness i dProfession,Cod...ndmylleen.cis
Fad1" full homeland effect PERMIT ISSUANCE RESIDENTIAL
QUy"j License Class Lic.a JOB
❑KITCHEN REMODEL
N6L Dam Contractor APPLIANCES-RESIDENTIAL 3 ❑ADDITION El PLUMBING RE-PIPIT
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ]STRUCTURAL
O Z n�' I understand my plans shall ed used as public records MODIFICATION
UPTO]TNI AMT'S
r�I".yMy1 Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
q j l,.l 201-10MAMPS IMPROVEMENT
W� <<II OWNER-BUILDER DE CLARATION ❑SWIMMING
y kW! 1 hereby.(firm That 1 nm exempt from the CasoursC's License Law for the OVER(IND AMPS RATE REMODEL/RfiPAIR DEMOLITION
l3 L V following reason.(Section]031.5.Business anJ Nvfessions Cale:Any city or annoy SIGNS ELECTRICAL ❑OTHER
al O which requires a permit to constmet,alter,improve,demolish,or repair any structure
y prior to its issuance,also requires The applicant for such Permian life a signed statement SPECIAL CIRCUIT/MIS❑.
Lim
�<2 Nat he is licensed pureuum to the provisions of the Contractors License Law(Chapter 9
�l]C (commencing with Section 7000)of Division 3 of the Business and End..ions Cole)or TEMP.MLTER OR POLE INST.
{L e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
i< 4th, Station]031.5 by any applicant for a permit subjects the applicant to a civil penalty or POWER DEVICES
ul>q not mare an live hundred dollars(S5n(). ❑TENANT ❑FOOD SERVICE
SO ❑ Las owner ofthe pmperty,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F wdldmhe work,and accuricme,is not intendcAorr
ou& l laterite(Sec.](W.Business THF.R
and Rnfessions Cede:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
a'a property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If,however the building or improvement is sold within one year ofcompletion,the S ORgyEA $ISQ.FT.
owner-builder will have me burden of proving that he did not huild or improve for purr- Yti/ /�_�
est 0f 681e.). C/� -I'H`.{P/
C I,as owner of the properly,um exclusively contracting with licensed contractors to TOTAL �/
construct me project(Sec,1044,Business and Professions Cale)The Contractor',Li-
ce es,Lawdoesnmepplymanownerofpropenywhobuildsorimprovesthereon.and QTY PLUMBING PERMIT FEE Uh �N�'EHfJNQ
who contracts for such projects with a conuactorts)licensed pursuant tothe Contractors
License Law. PERMIT ISSUANCE
C lamexemptunder See ,B&PCfmbismason
ALTER-DRAIN&VENT-WATER WA)
caner Date VALUA'T'ION
Y WORKERSCOMPE SATION DF:'LARATION BACK FLOW I'Rl]TECf.DEVICE
1 hereby efrnn under Penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate ofConsentm selfhome for Workers Co.,.. DRAINS-FLOOR,ROOF,AREA,CONT).
sation,as provided for by Section 3700 of the Labor Code,for the performance or the STORIES TYPE CONSTRUCTION
work far which This permit is ismd. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Computation Traumatic,as rquired by Section '
37M ofthe Labor Cole,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 CUTLES OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4 THAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES(This section need not he completed ifthc permit is(iron,hundred dollars(SIM)
or less.) GREASE TRAP PLANCHFCK IEE
(certifythatimbe pay manner
nce rso Newakfor me,wubject io permit is issued,'Contain- SEWER-
noa employ any person in any manner so az to berorrw subject to Na Workers'Contain- SANITARY-STORM GA.301 FT. ENERGY FEE
Z cation Laws of Califumia.Dam WATER HEATER WNENTIELECTR
Z O Applicant GRADING FEE
In NOTICE TO APPLICANT:If,after making this Cedificme of[xemption,you should WATER SYSTEM/IREATING
a [' become subject radio Workers Compensation previsions of the Labor Code,you must SOILS IEE
W G forthwith comply with such provisions or this permit shall be deemed revoked. r WATER SERVICE
aO
i7. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
L) O I herebywhiclectidu that there issued(constructione097,Cie.agency for the performance of Date Receipt#
LL the work for which suis permit is issued(Sec.7tH],Civ.C.)
0 [FTU-) Lender's Name TOTAL:
Lenders Address 'TOTAL:
�' Iy 1 unify that 1 have and this application and stem that the above information is BUILDING FEE
In building agree mcomply with all city and county ordinances and sate news relating a QTY. MECHANICAL PERMIT FEF.
V Z
above
enmeotioned oreend hereby emhonpurposes. fives of this cirymemer upon the SEISMIC PEE
eMvmmemiagrepapery Torremnify an keep a PERMIT ISSUANCE
(Wo)agree lesson,indemnify and keep harmless our the Clay of Cupertino against ELECTRIC FCC
in
lms, oin anJ exp:nvesmit, may our way accrue aguinU suit City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FF.Ii
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IENM CFM)
SOURCE F 1 TIONS. MECHANICAL PEE
�������� AIR HANDLING UNITIOVER II).000 CFM) CONSTRUCTION TAX
Sr tamSr cam ofAppbcaHAZARucmrJo,Dam EXHAUST 11000(W/DUCE) HOUSING MITIGATION FEE
fiAZAmchrr MATERIALS SURE
Will the applicant or future building occupant nmeerbandle Tottenham,material HEATING UNIT(TO 1a)J000 ITT U)
az dcfned by the Cupertino Municipal Cade,Chapmr 9.12,and the Health and Safety
Code,Section 2 532nd? HCATING UNIT(OVER 100.000 RTU)
C Yes [I N. VENTILATION PAN(SINGLE RESID) PAID
I4 Will the applicant or furore building occupant use equipment or devices which
Date Receiptp
1, emit Di'motzardous air contaminants as define]by the Boy Arca Air Quality Manugcetrenl BOILPR-❑OM1 3H10R H)0,000 BTU)
111 _ Dinrict? - 'I'OT'A L:
❑Yes CNn BOILER-COMP(OVER 100,000 BTU)
I have red the hmallous materials requimmcna under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
parts Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NF.W RESIDENTIAL MECH. SQ.Irl'.
building does not currently have a tenant Nat is is my responsibility to notify the vacation �
of the rruirummis which must hto e mal prior issuance of a Cenificam of Oseupow,
Owner or authimeeJ.gent Data TOTAI-: ISSUED BY:
OFFICE