S 0244 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPBUILDING-ELEcrIUCAL " ^IT NQ' O,i ^ A
VISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIJ G
BUILDING PROJECT IDENTIFICATION ff•i
BUIUXNGADDRESS: ' SANITARY NO. APPLICATION SUBMITTAL BAD
/
OWNER'S 74F. HONE: C RA (WS MF LICNO:
NIC C{—ON�TH{g/OLr�p
ARCHITC 1EG EER: LIC AD a ❑ T� T
CONTACT: O I N BUILDING PERMIT INFO
i� a ❑ Consultant Fees Paid by Applicant(Initial) BLDG LEcr PLUMB MECCH
LICENSED CONTRA OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 Mmby affirm that I oto licrnsd under provisions of Chapter 9(commencing JOB DESCRIPTION
qa2 with Section 9lXXq of Divisinn3o[the Business and Prnfessinns CtMa,.. myt,..se is RESIDENTIAL'
� in full force and effect. PERMIT ISSUANCE ❑SFDWI. ❑KITCHIiN REMODEL
QL.UI(_J License Class Lica APPLIANCLS-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
NUF Date Contractor—
< ❑MULTI-UNIT ❑MODIFICATIO
F.Dm ARCHITECTS DECLARATION ppNELg
Z p v�Z I wtdernwnd my plans shall named as public records UP TO 2(p AMPS MODIFICATION
REPAIR
0Z..O INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 2014000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER["AMPS [IBATH REMODEDREPAIR [3 DEMOLITION
1 hereby affirm that I am exempt from the Contractor's Laterite Law for the
X d U following reason(Sution 7031.5.Business and Pmfessinns Code:Any city or county SIGNS ELECTRIC ❑OTHER
W 3 R.F which requires a permit to construct,alter,improve,demnllsh,(ir repair any structure
e u'0 prior to ars issuance,also exports,the applicant firs,such rennin to file a signed statement SPECIALCIRI. .
$666vvv�'� that he is licensed pursuant to the provisions or the Contractors License Lov.,_pter9
�TJlaO (commencing with Section 71100)of Division 3 of be Business and Professions Cork) TEMP.METER OR �INST. COMMERCIAL;
P.y e y that he is exempt 0emfmm unit the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION Cl DEMOLITION
YXl 4N• Section7U31.56yanynpplicamfnrapernilsuNcnstheupplacantmacavil Penalty of POWER DEVICIS ENANT ❑FOOD SERVICE
not more an.five hundred dollars($500). IMPROVEMENT
�SS 0 pl,ns owner of the propcny,or my empinyecs with wages es Ncirsole compenmlion. SWIMMING POOL ELECTRIC
a will du the work,and the structure is not intendedmoffered for to(Sec.7894,Business OTHEiR
a32 and Professions Code:The Co ormfor's License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not amended or offered for NEW RESIDENTIAL.ELECTS SQ IT. {{{lll(((lII
sole.If. r,dam building.,improvement ixsold'within one year of completion. SQ.FI'.FLRRR,RAREA $)SQ.FT.
owner-builder will have the burden of proving that he did not build or Improve for put-
P.of aide).
❑ 1,as owner of the property,am exclusively contracting with Ilcenxed ennunctors to
construct he project(Sce.70 4,Business and Roration o,Code:)The Contfacmd Li-
came Law does not apply tounowner(if property who build or improves thereon.and QTY, PLUMBING PERMIT NZ
FEE
who comructs for such p b oro,with a continuum.)licensed Pursuant eco the Contractors
I.nccnsc Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER VALUATIONS
Owner Data
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.UEVICE
I hereby storm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conserv to self-insure for Worker.Compcm DRAINS-FLOOR.ROORAREA,COND. STO TYPE CONSTRUCTIO'.
sation,as provided for by Section 3700 ad the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PCR TRAP
1 have and will mainmiri Worker's Compensation Insurance,ua required by Section
370O.Ohe Labtu Cade.fords,performattca.fnheworkfirwhich issued.foreman is GAS-EA.SYSTEM-I INC.40UTLE OCC.GROUP - AI'N
My Workers Compensation Insurance turner and Policy number aro:
Comer. Policy N., GAS-EA.SYSTEM-OVER 4 OA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASILINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUIL G IS N FEES
('I3tias,Omn neednolhecompdenedifthepennin is fo ireclundredd.N.03100) GREASE TRAP
or less.] PLANCIIECK PER
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject the Worker.'Cmnpen- ENERGY HE,
,Z sation Laws of California.Data WATER BEATER WNENT/ELECTR GRADING FUE
O Applicant l
.~Na NOTICE TO APPLICANT If,alter making this Certificate of Exemption,you should WATER SYSTEMRREATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permitahall Is,deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL
PLM). SQ.ET PAID at Reccipta
UI I hereby arm constructionther,as a construction lending agency for the perfta
nmnce of
{L H the work for which this permit is issued(Sec.3097.Civ.C) TOTAL:
0 Lender's Name
W 'r(7fAL:
i,.&eAddress
s
fy. Iy I certify tm oI have read this application and stmt that the above information is BUILDING PEE
i-t to correct.l agree to comply with all city and county oNinatm®and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
(„) building canntructioo,end herehy authorize representmays.Ilhi.city to anter upon the
abovcanentioned property for inspection purposes. PF.RMI'I ISSUANCE ELECTRIC PEE
(We)agree m save,indemnify and keep handest the City of Cupertino against
liabilinica.ju an,, efd ezpenus which may in any wey accme against said City ALTER OR ADD TO MIiCfI. PLUMBING IEE
'n con: ue ce the 6runtin6 of Chia permit.
APP" ',N ' ERSTAN S AND WILL COMPLY WITH ALL )N POI T AIR HANDLING UNIT('10 10.1100 CFM) MECHANICAL FEE
SOUL CT I .f \TIONS. `1Ar
1 AIR HANDLING UNIT(OVER Io,(Np CFM) CONSTRUCTION TAX
Sign Do 17XHAUST HOOD OW/DUC) HOUSING MITIGATION FEE
ceHAZA c US ERI/E5 D SCLOSU
Wdlthcapplic mor matmoldingoccupanl .,ban hnzarloutm:neram HE UNIT(TO IIXt.000 ITU)
as defined by the Cu Municipal Cade.Chnrmr 9.1 a Health and Safety HEATING UNIT(OVER Ig1,0N10 BTtI)
Coda Section 25532(a)'!
❑Yes ❑No VENTILATION FAN(SINGLE RFSIDI PAID —am
Will the applicant or future Wilding respro t use equipment of devices which BOILER-COMP(3HP OR IIp.00111{TU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management VIA Distinct? BOILInR-COMP(OVER I00.00)BTU) jig
EI yes E:1 No
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER 1fgf^;
forms Health&Safety Code,Sections 255115,25533 and 25534.1 undetsmnd that if the NEW RESIDENTIAL MECH. SQ.IT. f 7 1,
10
building dates not currently have a tenant,that it is my resp rnsabidity to notify the occupant
of nM aryuimmems which most W men prior to issuance of a Cemficme of Occupancy.
Owner or authoriad agent Date TOTAL: :ISSUED BY:
OFFICE