S 0009 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, - PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHArvICA
BUILDING PROJECT IDENTIFICATION
.RUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
2,w l Lund Lane. , Cu erfi'a o GA 9 so i1V 3"—
WNER'S NAlli si`V' �O Cy
L+. ��� CONTRACTOR'S NAME: LIC NO: NIC COSNTROL
ARCHITECT/ENGINEER: ICN . ADDRESS: El1
�. CONTACTPHONE: BUILDING PERMIT INFO
Lee , M u h �4 o S) 2 q3-U33 ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ El ❑
QTY ELECTRIC PERMIT FEE
I hereby affirm that I em licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
ODZO with Section 700dof Division 3ofine B.Imenmil Professions Ced,,ind an,license i.
FF++ m full foreeand effect. PERMIT ISSUANCE RESIDENTIAL,
�UzU License Class - Lic.F ❑SFDWL C KITCHEN REMODEL
H60. Date Contractor APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL.
Zo2`ry ❑A I understand my plans shall he used as public records MODIFICATION
UP TO 200AMPS
F E: Lsutsed Professional C INTERIOR C CHIMNEY REPAIR
^� 201-1000 AMPS IMPROVEMENT
OWNER-BUILDERm Ce Craim ON CDEMOLSWIMMING POOLS
6 I hereby a(Bmt that I am exempt from the Commttnr's License Law for the OVER 1(110 AMPS BATH REMODEUREPAIR ❑DEMOLITION
d U following reason(Section]03 L5,Busine.as and Professions Cnde:Any city ar county SIGNS ELECTRICAL C OTHER
y -
0 F which requires a permit to construct,aher,improve,demolish,or repair any stmclure
E"
Prior its issuardi all-requires thoapplicant for such Permit to filen signedmmemem SPECIAL CIRCUIT/MISC.that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
q0 (commencing with Section 70001 of Division 3 of the Business and Professions Cartel or TEMP,METER OR POLE INST. COMMERCIAL
d y M y that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
ficCl y Section 90315 by any applicant for a permit subjects the appliennno u civil pooltyof POWERDEVICES
not more than five hundred dollars 050% ❑TENANT ❑FOOD SERVICE
❑I,as owner ofine property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
o will do the work,and the stmcmre is not intended mothered for sale(Sec.]044,Business ❑OTHER
W0. eo and Professions Code.The Conhacmr's License Law,does not apply to an owner of OUTLETS—SWITCHES—FIXTURES -
.. property who builds or improves Iacocca,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS It ICY
sale,If,however the building or improvement is sold within one D an""rpletiomme SQ.FT.ILOORAREA $/SQ.pT.
owner-builder will have the burden of moving that he did not build or improve for pur-
pose m sale).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the pr ject(Sec.70ai Business and Professions CedeU The Contractors Ll- -
naeLawdoesnotapplytoanownerofproperlywhobuildsorimprovesforamen,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a continental)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
C 1 am exempt under See. ,B&P C for this reason
ALDER—DRAIN&VENT—WATER(EA)
weer Date O VALUOATION,
WORKER'S COMPENSATION DECLARATION 1004 �k
f BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty re pejuryaneofthe following dorker Corr
❑on,as and will for byneCion 37re of the stat Labor
Code,
the Worker's Compen- DRAINS—FL OOF,AREA,GOND. STORIES TYPE CONSTRUCTION
smion,as provided for by Section 3]00 of the Labor Code,far the performance of the
work for which this permit is issued. FIXTUR ER P
❑I have and will maintain Worker's Compensation Insurance,as required by Section 37M of the Labor Code,for the Performance of the work for which this permit is issued. GAS—EA.SYSTENU I'IN O LETS OCC.GROU APN
My Worker's Compensation Insurance trailer and Policy number are:
Carrier: Policy No.: GAS—EA.SYSTEM-OVER A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL STET PTOR
(This section need oath completed if mepermit is far one hundreddollars 11 GDIVISIONFEE;S($100) GREASE TRAP
or less") - PLANCHE K
Iwrtify that in theperformanee of the work forwhlch this permit ie issued,lahall SEWER—SANITARY—STOR .200 FT.
not employ any person in any manner xo es to became suhjce[to the Workers Comma- - ENERGY FEE
z '.tion Laws of California.Date
O
Applicator I WATER HEATER WNENT/ELECTR
7 PP GRADING P
q NOTICE TO APPLICANT:e,after making this provisions
or of Exemption,you shoal,, WATER SYSTENITREATING
F become subject ro the Workele Campemmion pmvtsmns of the Labor Cade,you must _ SOILS FEE
forthwith comply with such povisinns or this permit shall IN deemed revoked. WATER'SERVICE
0
;;).z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ FT. PAID
I hereby affirm that there Is a construction lending agency for the performance of Date
the walk for which this permit Is issued(See.3097,Civ.C.)
•`� Lender's Name O TOTAL
I :U 'ndu's Addms. TOTAL
Rwi 1 really that 1 have read this application and style that the above honorarium is BUILDIN ^�
rr rA cnrrecr l agree mevmply wire all city.ad county instance, ad state laws coming to QTY, MECHANICAL PERMIT FEE
L) building construction,and hereby immure representatives of this city to enter upon the SEISMI EE -
above-mentioned property for inspection purposes -
(We)agree m save,indemnify and keep harmless Ne City of Cupertino against PERMIT ISSUANCE EhECTRI FEE
liabilities,judgments.costs and expenses which may in any way aceme against said City ALTER OR ADDTO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,01%)CFM) CONSTRUCTION TAX
Signature of ApplicanUContmnor Date EXHAUST HOOD(W/DUCT) HOUSING MITIf)�'I EE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantoofumre miliir,,anopounwaear havdlehaamdousmmerial HEATING UNIT(TO IMAM BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(o)f HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. PAID S `� V
VENTILATION PAN(SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which Date t
em it hazardous air conmminer,as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,010 BTU) -
District, TOTAL:
❑Yes . ❑No BOILER—COMP(OVER 100,000BTU)
I have read the hazaodnus mmerisisAIR CONDITIONER -
rogmremenbunder Chvpta6.95 the Cali- IS A DATE
fnmia Health&Safety Code,Sections 23505,25533 and 255,4.I understandccand that if the NEW RESIDENTIAL MECH. SQ.FT. /2
building does not cunemly have a mnad.thm it is my responsibility 0 notify the orcapam l _
.fit.requirements which must he met on,an issuance to Comficale of Occupvncy.
Owin,mauthonaedagent Date - TOTAL: ISSUED BY: (b19
OFFICE /