S 0630 (2) APPLICANTTO FILL IN,INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY y/�
CI TY OF CUPERTINO BUILDING-ELECTRICAL PEgk11T ND. O V �O
BUILDINGDNISION APPLICATION/PERMIT PLUMBING-MECHANICAL ``J
BUILDING PROJECT IDENTIFICATION
B LUINGADDRCSS: r�r- SANITARY NO, APPLICATION SUBMITTAL DAT I:
10 15 DE N G�VD. 1LIRIA114 LN. Z
NER'S NAME: PHONE: CO CTOR'S NAME: LIC NO:
- N/C �k//CO��NTROLP
lIIIIIIIIIIIIIIIIIRCHITECIVENGINEER LIC NO ADDRISS: , El
C . - IIS06 v7 `
corrrAcr: PHONE: BUILDING PERMIT FO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LE 1' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm tm hI am licensed under pnwieina of Chvpmr 9(commencing JOB DESCRIPTION
Owith Section 7fllNb of Div'sinn3of the Business and Pmfcxsions Gyle,and my license is RESIDENTIAL
p PERMIT ISSUANCE.
in Tulle ClassJeRcet. ❑SFDWL [I KITCHEN REMODEL
QUU Lterm Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
1g... Iu7D Dme Contractor
fn a ❑MULTI-UNIT' ❑STRUCTURAL
F 7 y ARCHITECTS DECLARATION PANELS
MODIFICATION
Z4, lundemand my plans shall he used us pnMic records
OZ`30 UI'T02IXIAMPS ❑INTERIOR F1 CHIMNEY REPAIR
F 4I:W Licensed Professi.al 201-1000AMPS IMPROVEMENT SWIMMING POOLS
p¢� � OWNER-BUILDER DECLARATION
yry C Q 1 hereby nthw that I am exempt from the Contractors License Law far the OVER 10011AMPS ❑BATH RC•MOUELBtEPAtB ' EMOLITION
Dd a L U following reason.(Satin.7031.5,Business and Professions Code:Any city or count, SIGNS ELECTRICAL ❑OTHER ^^_ - _
which requires a permit to construct.alter,improve,deam iso rr repair any structure,
w.4 prior to its issuance,also requires the applicant for such Permit file a signed statement SPECIAL CIRCUITIMISC. xar
�y that he'so"osedpuroam.NeprovisionsoftheContractorsLicenseLaw(Chapter9 ^V--
W11 0y (commencing with Section 7")M Division 3 ofthe Business and Professions Code)of TEMR.METER OR POLE INST.
d nthat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ B 1 tW Ipf-� LITTON
N Section]1315 by nny upplia.t fora parmit suhjcd,the upplicmn m n civil penally of POWER DEVICES ANT SERVICE
not marc then five hundred dollars 185001. IMPROVEMENT
Q ❑I.as;ownerofthe propedy,or my employees with wages m their sole compensation, SWIMMING POOL ELECTRIC
Sec win dethe work andthesuucmm Now inmadecim.ffered forsale(See 7014,Business []OTHER
most Professions Code:The Commemda License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
63^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvnnans are not intended or offered for NEW RESIDIRSH IAL BI.EC'I'R S
smle.IL however,the M1uilJing orimpmvemem is wqd within one yeurofcompininn,the SQ,IT.FLOOR AREA SISQ.FT.
neofs older will have Ne burden of proving that he did not build m improve for par-
Else assalt).
El Las owner of the pec.704,Business cxdus and Professions with licensed contractors i- TOTAL'
mm La thedoes
not apply
o an owner
fand property
who onsbuilds
ds or improves
Cnnvereon,Li-
cense Law docs nm apply m an owner of property who builds or improves therm a end QTY. PLUMBING PF,RMI P.
who contractsnuchp jests with aconuacmgs)licensed pursuant to the Commences
License Law. I PERMIT ISSUANCE
❑ I am exempt under St . ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'SCOMPENSATTONDF.CLARATION BACK FLOW PROTECT.DEVICE alkM OI1/a�
s I hereby aRw under penalty of perjury one of the following declarations,
�'I have and will maintain a Certificate of Consent to self-insure for Workers Gnnpen- DRAINS-FLOOR,ROOR ARRA,COND. STORIES TYPE CONSTRUCTION
sptirn,as provided for by Section 37(X1 of the Labor Code,for the Emommonce rf the
work for which this permit is issued. FIXTURES-1'17R TRAP
❑I have and will maintain Worker's Compensation Insurance,os required by Section
377 ofthe lsbar Code,for the paformence of the work for whichthis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLEis OCOG U APN
My Wu mc,Compcnpmotion Insurance cancer and Policy number am:
Policy Nn: bWr j7Z,7 ,_9a0 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE:INTERCEPIOH D TNG DIVISION FEES
ur leas.)
(This section need not be completed if the permil is for me hundred dollars HTOT) GREASETRAP PLAN(CH jj /
l certify that in the performance ofthe work for which this pewit is issued,Iahall SEWER-SANITARY-STORM EA.2(N)Ff.
not employ any person to any manners..,m hero ar,ubjen m the Worker;Cope.- ENERGY FE
z ,2,r sati.n Laws of California.Dow WATER HEATER WNENT/ELECfR
0 Applicant 1 GRADING PER
.w y NOTICE TO APPLICANT.If,after taking this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
I" ^' became subject to the Workers Compensation provisions of the Labs Code,you must
!p Q fonhwith comply with such Provisions or this pewitshall be deemed revoked. WATER SERVICE
:D CONSTRUCTION LENDING AGENCY NEWRFSIDIMIALPLMB. SQ.ET. PAID
O
V tiThereby aRwthm them isaconswetion lending agency B..he perfawanee of Dare ci t#
P the work for which this Pewit is issued(Sec.3097.Civ.C.)
0TOTAL:Lender's Name OTAL:
wLender's Address '
Oa I certify that I have red this application ad same thm the aMve infowmi.n is BUILDING F[I? YV
f/T
correct.l agree to comply with tall city and county ordiancez and state laws refining to QTY. MECHANICAL PERMIT FEE
U y building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEcorrect.
immen-mentioned property for inspection purposes. P17RMIT ISSUANCE
(We)agree m nave,indemnify and keep harmless the Cay of C.'ron.against IB,ECTRIC FEL
habildics,judgments.costs and expenses which may in any wayaccam agaial vmd City ALTER OR ADD TO MF,CH.
in consequence,of the granting of this Permit.
PLUMBING PEE
APPLICANT UNDERSTAN f!tD WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000,CFM)
SOURC REGUL.TIONS. MIiCHANICA1.lEE
ley/1g AIR HANDLING UNIT(OVER 10,0(x)CFM) CONSTRUCT ION TAX
Signmure mApp]aandCumcmr nt4 of 17XHAUST HOOD IW/DUCT] HOUSING MITIGATIO IiE
HAZARDOUS MATERIAI S DISCLOSURE
Willthe...],a.,or faire building oecu.atsmm or handle hamdrus mamHal BEATING UNIT('1'0100,00X)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
HEATING UNIT TOYER I100j)(9)BTU)
Cede,Section 25532(.)7
❑Yes Fl No VENTILATION PAN(SINGLE RESID) PAID
v
Data Receipt#
Will the applicant or furore building occupant use equipment or devices which
hazardousa
coir c.nmmlats as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,000 BTU)
TOTAL:
_ inn?
/ ❑Yes ❑No BOILER-COMP(OVER IIN),INXI BTU)
I have red the hawdws materialsAIR CONDITIONER ISSUANCE DATE
requimmems oder ChuMcr 6.95 of the C.li-
fomiv Health&Safety Curb,Section,25505,25533 ad 75534.1 understand that if the NEW RESIDENTIAL MECH, SQ.FT.
building does not currently have it tenant.that it is my responsibility m notify the occupant
of the requirements which must Is,met prior an issuance of a Cenificme of Occupmmy.
Owner or ambmizd.gent Dam
TOTAL: ISSUED BY:
OFFICE