S 1017 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY DPS CUPIdRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/I'ERMIT 1'I.IG FRO11 G-S4:CIIANIFIC S 1017
BUILDING PROJECT IDEMTIFICATIOry- V
SANITARY N0. APPLICATION SURMI ITA).DATE
BUILDING ADDRESS:
-� OWNNEIV NA E: \ PHONE: CONTRACI'OR:S NAME LIC NO:
NIC CON'rROLx
ARCH) .CTIENGI :;R: EJC NO: ADDRESS: ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) nLuc ELECT PLUMB M13C.n
LICENSED CONTRACTOR'S DECLARATION QTV ELECTRIC PERMIT, FEE
I hereby amrm that I am licensed amide,pronisinn,of ennpmr 9(em,a arcing _ JOE DESCRIPTION
mwz with Se<,ian 98001nf Division3nfthe Business and Pmfessions C�Ne,end my license is RESIDENTIAL;
WOO PERMIT ISSUANCE
F.Iz in full forceund aBeo. I ❑SFDWL ❑KITCHEN REMODEL
�UV License Class Lic.x APPLIANCES—RESIDENTIAL El ADDITION ❑PLUMBING RI7.11IPE
N6y Darc Camru0ur ❑$TRDGTHRAI.
ARCHITECTS DECLARATION I'ANIiIS ❑MUTALUNI'1'
ZO Z N 4 1 anderstand my plans shall M cold as puhlic records UI'TO 2(I,l AM15 MODIFICA'I'I(JN
❑PrI ER10R ❑CHIMNF.YREPAIR
P-ntm1 I.ieaaed Pnde"imul 201-10(N)AMPS IMPROVEMENT SWIMMING POOLS
�X .,J OWNER-BUILDER DECLARATION OVER 11100AMi5 ❑BATH REMODEIJREPAIR El DEMOLITION
C W U 1 hereby affirm cal I 1 exempt from the e,,lrax Ca License Law for the
�y(0 W 4 IiJlowing reosrn.IScc0nn 00315,Husinel.<unA Prnfcaxiona CnJe:Any city nr county SIGNS ELLCI'NICAL 0OTHER
ywhich requires a Parini,to construct•alter,improve.demolish ar repair any structure
F-MI prior to its issuance.also requires the applicant for such perm tto file a signed statement SPECIAL CIRCU ITIMISC.
that he is licensed pursuant m the provision,of me Contractors License Law(Chapter 9
0 (rnmmenei IS wall Sector 7000)at Division 3 O the 11 uaineas and Prdesdnrs Code)or 'I'17M It MET I:R OR POLI:)NST. COMMERCIAL:
G a o yy� that he is exempt therefrom add the basis for the alleged exemPJnn.Any violation at ❑NHW BLDG/ADDITION ❑DEMOLE"PION
X'^,N Section 90315 by any applicant far a per ixubija,s,he epplinmlto a civil penalty of POWER DEVICES ❑OINANT ❑FOOD SERVICE
Zyact m are than live hendmd unit...(8500). IMPROVEMENT"
yC ❑OT
❑I,asnwnerofthcprnpeny,ormyemployceswi'hwngesusiheirnnlceompennution, SWIMMING P( .ELECTRIC
b. will do work.mal lheswcwre is not intendcJoroffea:l farsalc(Srn:AM4.lbome.a IIIiRti
Wand Probes ions Code:The Contractors License Law does no,apply,o an owner of OUTLET. ES—•EXTURBY
6 3 property,who builds or impoi thereon,and who do such work himself or through /)
Ba,own employee..provided than such impmvcmmus um ad intended m offered for NEW RE. DB PIAL F,i ' SQ Irl'.
sale.If,huwevecthe building or improvement is sold within one year ofcompletion,the SQ. i'.9LOORAREA VSQ.ER
ser-builder will have the burden of proving aha,he did no,build or improve for put-
M,m of sada). �Y
I,ax owner aline pmpeny,ran excla'Naly evnweda,with licensed ctmtractms u) TAI"
construct the pmjec,(Sec.90,14,Rustiness mad Profenlons Cale:)The Cam rahn,LI- q
arae Law ares do,applymlarval,of haperiy who nudes nr impravestherean,sad QTY. PLUMBING FEF
who counters for such projects with.contrecmr(s)licensed punuan,.the Contractors
Licem,Law. PERMIT ISSUANCE
1 ant exempt ade_r Sec B&P C for his reason
Dam
AGIER—DRAIN&VENT—WATER(FA) OF VALUATION
\ N under
COMPF.NS ma DHC c Mica ON RACK FLOW I'ROTF:CT.DEVICE. 0e O
)hereby afftnn under penalty of per,. one nf,hc fnlEmving declam'Ira:
❑Ihuvc and will mainmina Certificate of Crnsenun self-insure for Worker's Compact- DRAINS—FLOOR.ROOR so. STORIES TYPE CONS'FRUCfION
cation,ns provided for by Section 37M of,he Labor Code,for the performance of the
work for which this plana is issued. FIXTURES—1'I7R TRA I'
❑I have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code,for the ptfnmtaraccofthe work for which this permit is ismed. GAS—FA.SYSTEM-I INC.40UILE'1'S OCC.GROUP AIN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy Nix: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASI%INDUSTRL WASTEINTERCEPTORCOMPENSATION INSURANCE BU1 )ING 1/VISION PEES
d, amondda,becompleted Ohepennit is for one M1undreJ dnllura(SIgR GREASE TRAP
or Eesx](TweaPLANCHECK FP.
I certify that in the Performance efthe work for which this permit is iuued.Ishu11 SEWER—SANITARY—STORM V.A.200 Il
no,employ any person in any manner so as to become subject m the Wallen'Compen- ENERGY i'1"
ZZ .titian Luwsof California.Dam WATER HEATER WNENTIELEM R GRADIN FEE
Applicant
.N.. NOTICE TO APPLICANT:If,after making this Certificem of Exemption,you should WAIER SYS'HRsIGT I3A'I ING
(~ become.object m the Workers Crmpenmtion provisions of the UK"Cale,you mus' SOLI 4 P
forthwith amply with such provisions or this permit shall be all revoked. WATER SERVICE
CONS
attherRUCcons LENDING AGENCY NEW RESIDIiNTIALI'hMR. SQ FC PAID Da, Receipt V p work
rwhich Box that issued(Sec.i30len ding agency Tonne performance of
ELFIhewrrk for which,hicpermit is issued(Sec.309T,Civ CJ
Lender's Name TOTAL.
W Lenders AJdrecc IT1TA1..
,Lys 4 1 carify,hat 1 have read this application and state that the ohne information is B t1.DI NG F i
F h urocal.I agree orcnnply with all city and ammy oninndces and store laws relating to QTY. MECHANICAL PERM IT FEE SEISMICFEE
L) z building enstmction,add Ince,, mhrrircreprecen'wives of this city Ili enter craft the
above dtatdionad unready for inspection purposes. PERMIT ISSUANCE
(We)agree Ensure,indemnify and keep harmless,he City of Cupertino against F.LECIRIC PE'
habil hies,judgments,costs and expenses which may in any way name agui ns,said Ci,y' AL TER OR ADD TO MECH. PLUMBING FEIi
in nxeg.ence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON)F(TO 10.000CF1,f) M17CIIANICAL FRE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 1400H)CFM) CONS'IRUCTION'TAX
Signatumof ApplicanVConlmnor Data F.XHAUSTHOOD(WIDUC'D HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building nwci pan,mea or In III haaardoux material I IEATING UNIT(TO 11X),000 BEIGE
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hem,h and Safety
Cole,Section 25532(a)T BEATING UNIT(OVER 100.000 IITU)
0yee 01so VRNTILAI ION FAN(SINGLE RESID) PAID
Dine Receipts
Will the applicant or future building occupant use equiPntant rr devices which y.ILER—COMPOHPOR 100.000 BTU)
it haeandous air contaminants as defined by the)lay A.Air Quality Maagemedt TOTAL:
District? BOILER—COMP(OVER Rky0(x)BTU)
❑Yes �Nn
I have read the huardemc memn.ls requirements under Chapter 6.95 of the Cali- AIR CONDI'rION[R ISSUANCE DA'I'S
Erotic Ilea1,h&Safety Cade.Sections 25505.25533 and 25534.1 undersmdd that if the NEW RESIDENTIAL MECH, SQ.FT.
building Jews not cuaenlly h riv a tectum,that it is my recparvsibilhy m notify ILerxuopout
of the requiretam which mus'be me Prior m issuance of a Certificate of Occupancy.
Owner or authorized.gent Date 'TOTAL: ISSUED BY:
OFFICE