B 0166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.IX pl
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECIIANICAL ?) 11 {hid l6
_ I BUILDING PROJECT IDENTIFICATION csmbo
BUILDING ADDRESS: n SANT"1'ARY NO. A'PLICAI'[ON SUBMTTTALLUUNIT
�Z, (a
OWNER'S NAME: PHONE: I QUN'TRACTOR'S NA LIC NU:
ver /'a 'e— cel, NIC coNT.ol,a
�ARCHIT CEENGINEER: L LIC NO: I ADDRESS / ❑
L�uiM� an or
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Pail by Applicant(Initial) BLDG F.LIiCIPLUMB MECH
h� �O -5 ❑ 0- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afoml that Inn,rc�scd andaf,re,"�l is of Chapter 9(e.,mmwee mg JOB DESCRIPTION
Cho tuna Smdon]aOD orobsmn3anne.asme„and Pmrexxi...Crde.n ybcen,eix RESIDENTIAL:
W O PERMIT ISSUANCE
F fall tole and effect. a7 O SFDW'L D KITCHEN REMODEL
RUU License a 1,ic.p APPLIANCES-RISIDF,N'I'IAL ❑ADDITION El PLUMBING RE-PIPE
Z W Dale eomfaClor
ARCIIITF.CTS DF,CLARATIO OMUL'rl-UNTr El STRUCTURAL
Z O Z 1 understand my plans shall be used ns public records PANELS MODIFICATION
OZ=O _ UP'rc)2(p AMY$ ❑INTERIOR ❑CHIMNEY REPAIR
t,anFW Licensed Professional 201-IM)AMI'S IMPROVEMENT DSWIMMINGPOOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMOOE /REPAIR �DF;pgOLITION
C C Q I heroby of ret that 1 am exempt from the Conlraaafa Limuse Law for the
'R=U following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHIiR
(A which requires a permit to coram,,after,improve,denadich,or repair any omcturc
F'LLO� prior faits mance,oho"a.atheapplirant tar such permit to file asignedsmmment SPECIAL CIRCUTT/MISC. sa
that be is licensed pursuant tothe provisions of(lie Commerce's License Liow(Chapter 9
I+Iz00 (commencing with Section 701 of Diawour3croe Business and Pmfcision.s Code)or TGMP.IdETERORPOLEINST. R I
a L o C thm he is exempt Ihercliom and the basis Ibr the nllegN eumptinn.Any violation of ❑NF,W BLUGIADDITION D DEMOLITION
Section 7031.5 by any applicant fora pennil,nhmot,thetpplicard ncivil penahynf POWER DEVICES ❑TENANT DFOOD SERVICE
not more mon five hundred doll.,($500).
IMPROVEMENT
SSG 0I,osowner k.athe ndtmpcny or is employees dforlhe(Ssole compcusinea, SWIMMING POOL ELECTRIC
WF.o will ProMwon,and the he Core is tots License awdoess otapply 90 W.Business DOTHER
3 w paid property
whob Code:imp over thereon.
License Law does not apply tom owner aT OUTLETS-SWITCHES-PI%TURES Q
his own whn builds or improves thereon,Inco who does such tune coed or or through
his awn employeese provided Ilett mch menti,mem,arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FI'.
momsf.-haddevea the have
th burden
n of parent ithatlhe did non wild or i m rovefor far- SQ.PT.BOOR AREA $/$Q.IF.
cr-huilJcr will have the buNun of proving that he did not buil)or improve for purof
-
p�enr,me). ,
E]1,a,awtmr of the property am exclusively contracting with licensed rontmcmrs to A
instruct the project(Sec.9(90,Husinevs and Professions Code:)Him Contractors Li-
nuLaw duct,not apply to an owner of property who builds or improves thereon,and QTY._ PLUMBING PERMIT FEF,
who amtraela for auch projects witha contr a or(s)licensed pursuanne the Corenctor's
License Law, PERMIT ISSUANCE
❑ I am exempt under Sm. ,B&P C for its reamn
Owner Date ALTER-DRAIN&VENT-WATER HiAr VALUATION
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT..DEVICE
I hemhy affirm under penalty of perjury one of the following derlarromis:
I have and will maintain a Certificam of Consent oself-insure for Worker's Campeau- DRAINS-FLUOR,ROOF.AREA,COND. STORIES TY PE CONSTRUCTION
ration,.1 pervidcd fur by Section 3]00 of the Lubar Cale,far the perhnmmmc or the
work for which this Permit i,issued. FIXTURES-PER TRAP
1 have and will arde nin Worker's Comperwmion Insurance,as required by Section
3]11(1 of the Later Calc,for performance to work for which this permit is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP MIN
My Worker',Compenamion Inwmnce carrier and Policy number ala:
Currier. Policy No.: GASB-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE IN BUILDING DIVISION FEES
(Ttiisartionnmdnolbecumpleed ifinepermil isforonehunNNdollan(Mlp) GRF,ASE 9'RAI'
Or Ica,.) PLANCHECK TEE
Imnifymmmilaperformarmufthe work ferwhich Nisp.mit is issued.Inhall SEWER-SANITARY-STORM EA.200 FL
not employ,try any manne asmhconm ha bjgn case y r' aspen- ENERGY PEE
z .Z ion Lasso ll�omin Dam WATER HEATER W/VHNT/ELECTR
O APPlican�(Z(Yln / ` GRADING FEE
ti NOTICE TO APPLICAN If, far as kit,this Ciammev a of Exemption,you should WATER SYSTFMrFU TING
a > lerame subject to the W Compensation pmvi,iam,of the labor Code,you must SOILS FEE
IIJ forthwith comply with such provisions or this permit shall le,deemed revoked. WATER SERVICE
0
.0.7. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIB. SQ,FT. PAID
L) 0 I he
rebywhichinn that i i,aed(Seconstruction 30G,Cis.aguncY forthe perfom,ana of Dam Receiptp
Uthe work far which this permit is issued(Sec.J09],Civ.CJ
Lcndm's Name TOTAL:
r 9L I Ilndcr' Addles TOTAL:
cene
ily Ihat 1 have read Ihi,application and ase that the ateve information is BUILDING FEEFO) concet lagrce mcnmply with all city and county ordinances anJ sae laws mLting to QTY. MECHANICAL PERMIT FEE
U Z building retroaction,and hereby authorize representatives ofthiscity menmrupon the SEISMIC FEE
above-mentioned property for itspec ion purposes. PFRMI"T ISSUANCE O
(Wif name to,are.indemnify and keep hamticss the City of Cupertino against ELECTRIC PEE
Iiahiliies,judgmentc,costs and expenses which may in any way norne against said City ALTER OR ADD TO MF.CH.
in consequence uence of the granting of this Permit PLUMBING FEIi
APPLICANT UNDERSTANDS AND WILL COM PLY WITH ALL NON-PO IN'T qIR HANDLING UNIT(TO IO.fpOCPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNI'r(OVER I0dg10 CFM) CONSTRUCTION TAX
Signature of Applicant/Convacmr Date EXHAUST HOLD(W/DUCT') HOUSING MITIGATION FEE
IIAEARDOUS MATERIALS DISCLOSURE
Willlheapplicam or future buildir,cerupantsorc or honAle haraman,material HEATING UNIT(TO HgL00)if rut
as defined by be Captain Municipal Cale,Chapter 9.12,and the Health said Safety
Cale,Section 25532(a)] HEATING UNIT'(OVER 100,001 BTU)
❑Yes
VIiNT11.AT1(IN IRAN(SINGLE RESIU) PAID
Will thea applicant or future building t use equipment or devices which Dam Receipt a
pp blt the
Area
BOILER-COMP LUIP OR 100.000 BTU)
mit hsmNouv air contaminants as defined by the Bay Uma Air Quality Management
Dtsvmrt Yes /VqSIIIA
pHit,"BOILER-COMP(OVER Hit, BTU)
I have sadv
the hadoam
sateri, e
aca,ircerd.maunder Chapter Chapter 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
Ii,mio Health&Safety Cade.Sections ,he ,25533 and 25534.I to notify
ota yth that Him NEW RESIDENTIAL MECH. SQ.FT. r -2, `O
buil ' Health&Safet Coreveamnaotthml -say res 2553,1bility rcdivirwtolthat im a
or rent, hi hmu' are,Pi., ofa nificam of Occu ,'�^ r�p( T
Uvvcroramh agent Date TOTAL: ISSUED.,: `-��[� ��` Q
OFFICE