B 0175 APPLICANTTO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
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CITY OF CUPBRTINO 'BUILDING-ELECTRICAL, P17RMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PROJECT IDENTIFICATION
175
BUILDINGADDRFSS: SANITARY NO. AI'PLICAGON SUBMITTAL DDATE
OfNERS NAME: p ( E: N RACE R'S NA LIC NO:
NIC CONTROLM
PVvswrslk
1 CHITEPA
CI' INE : LIC NO:y ADDRESS: ED
CONTACT'. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby Plant,that 1 ani licensed under provisions of Chopter 9(commencing JOB DESCRIPTION
Paz with Section 7001)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL,
00 PERMIT ISSUANCE
C F m full force end effpt� --�1 ❑SFDWL ❑KITCHEN REMODEL.
aUU Liccna'CJys Liak V .APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F z W Dale—FOg= Cnntrnct
mQ4 ❑MULTI-UNIT ❑STRUCTURAL
FDm
ARCHITECTS UF. 1 TION PANELS
z0 z Iunderstand myplansshall beueedaspublic rccaid, MODIFICATION
oz- UPT02W AMi'S El INTERIOR El CHIMNEY REPAIR
r„'zi.
1—Licensed Professional 201-101DAMPS IMPROVEMENT CSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER mill Amps C BATH REMODELREPAIR E3 DEMOLITION
pW Q 1 hereby affirm that 1 am exempt from the Contmctals License Law for the
X30.U4. requires fallowing rerson.(Section 7031-5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W W WONe which requiresa permit m contact,alter,improve,demolish,(it repair any structure
RJ prim to its issuance,also requite,the applicant fur such permit to rile asigned statement SPECIAL CIRCUITIMISC.
Beet he is liceri pursuant o the provisions of the Criminate,License Law(Chapter 9 COMMERCIAL:
W EGD (commencing with Section 7000)of Division 3 of the lousiness and Professions Centel or TEMP.METER OR POLE INST.
460�1 that he is exempt therefrom and the basis far the alleged esemption,Any violation of C NEW BLDGIADDETION L1 DEMOLITION
W.'ny Section 7031.5 by anyapplicent fare Noralsubjects matipplicied to a civil penalty of POWER DEVICES [I TENANT CFOOD SERVICE
gp6not mom than five hundred dollars WOOL IMPROVEMENT
CLasiwwarof thepropedy,or my employees with wages as their sole compereatinn, SWIMMING POOL ELECTRIC
C2L r'C.�
will Jmhe work,and the structurt is not intended oroffeM for sale(Sec.7044,Business ❑OTHER
/r� �w and Pnffessions Code:The Commcmr's License Law does am apply to an owner of 0117LETS-SWITCHES-FIXTURES
3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL EL17CI'R sill.
sale,If,however,the building m urapmvement is sold within one year of compIdium the SQ.FT.FLOOR AREA LSQ.III.
er-builder will have the burden of proving that he did not build or improve for per-
prnt of sale).
❑I,as owner of the property,am exclusively contractingwith licensed contractors to - IOTA
conawet the project(Sec.7014,Business and Professions C(ds)The Conuactoes Li. -
cense Law does not apply toanowner ofpmNnywho builds orPurposes themon,end QTY, PLUMBING PERMIT E.
who comtaos for such projects with a am,mamr(s)licensed pursuum m the ctumosmors
License Law. I PERMIT ISSUANCE
I am axemptunder see.- .B&1'C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLAMATION I BACK FLOW PROTECT.DEVICE
1 hereby aRimt under penalty of perjury one of the following declarations.
I have and will maintain a Certificate of Consent to self-insure for Worket's Camper- DRAINS-FLOOR,RUDE,AREA,COND. STORIES TYPE CONSTRUCTION
smion,as provided for by Section 37W of Ne Labor CMe,for the performance of the
n forwhichthispermitis homed. FIXTURES-PER TRAP
w have and will maintain Worker's Compensation Insumnce,as required by Section
3 of the LaborCde,for the performance of the work for which
��this
/p�ennit is isvneed.. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCLGROUP APN
My Worka'C,_}IFn1yutr�lnstttgpLG[a(uePolcy it P I ll"'d L[��� • GAS-EA.SYSTEM-OVER4 HA)
Garner. l_2t�_3�- I Yi^I l__l_>_
CERTIFICATE OF EXEMPTION FROM WORKERSGREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ETES
(This section need not be completed if the permit is Porous hundred dollars(S 10) GREASETRAP In R
or less)
Icertifythat intciacdormenceaRhe workfarwhichthispermit isisprd,l shall SEWER-SANITARY-STORM EA. FT. ^
not employ any person in any manner so as to become subject the Workers'Compen. - j_G.A
Z sedan laws of Cali fomiu.Data WATER HEATER WNENT/ELECTR
O Appluoun 1 fn NOTICE TO APPLICANT:If,after makingtis Cenillenteof Exemtion,you should WATER SYSTENITREAI'INO r' I r-1. /. cA
F^ 2 became subject to the Worker's Compensation Provisions of the labor Code,you must
fortacithons -
W hwith mply vpuch provisinr this pbe deemed revo
eranitahall deeked WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. S4 FE PAID
UO Ihereby affirm that there ism carbonation lending agency for the performanceof ,Dat ReceipBk
Hw H the work for which this permit is issued(Sec.3097,Civ C.) "'--" TOTAL:
Q U Lender's Name
lenders Address TOTAL:
�" Iy 1 certify that 1 have read this application and,tote that the.trove information P
is BUILDING EE
,,,lemrecL l agree to comply with all city and county oainancesand sme laws Petition,to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize mpmsensmives of this city to enter upon the SEISMIC Pconstruction,
obtve-mentioned property far inspection purposes. PERMIT ISSUANCE
(We)agree Its suvt,indemnify and keep harmless the City of Cupertino against ELECTRIC MI
liabilities,judgments,atustnd expenses which army idea,way accme against said City ALTER OR ADD TO MECH. PLUMBING
in
consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0010 CFM) MF.CHANICAI.
SOL P.GULATIONS. //''�S(''�
� la�l�]( AIR HANDLING UNIT(OVER ID,g10 CFM) CONSTRUCTION TA
am o Applicant/ onmacmr Date V MIAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HA'LARDOUS MATERIALS DISCLOSURE 0
Will the applicant or future building occupant meteor handle lue,moou,material HEATING UNIT(TO 100.001 BTU?
as defined by the Cupenioo Municipal Code,Chapter 9.12,and the Health and Safely
CMe.Save..2553200? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑NoPAID
VENTILATION TAN(SINGLE RESID) Dote Recent 0
Will the applicant or future building occupant use equipment or devices which IlOIL1iR-GGMP(3HPQR iW,gp BTU?
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TO L:
Distrito? BOILER-COMP(OVER 100,1100 BTU) -
El Yes [-I No
1 have read the haznNouv materials requirements under Chapmr 6.95 of the Cali AIR CONDITIONER ISSUANCE LATE
Health&Sandy Code.Sections 25505,25533 tad 25534.1 undetatand that if the NF.W RESIDENTIAL MECH. SQ.FT.
building does net currently have a tenant.that it is my responsibility to entity the occupant
of the requirements which must be rep prior m papoose of a Cenifcara of Occupancy. ^ Q
Owner or authorimd agent Data TOTAL O ISSUED BY: 'LI
OFFICE