99080148 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
• CMW OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'TIFIC'AIION
dUILDINGADDRFSS: SANITARY NO. (CATION SUBMI E
O 'S NA.kM.E: PIIONF:: CO AC'TOR'S AME: LIC NO:
QHNAM t sM11Yx ^UZ�V it NIC CONTROL#
CHITEC(ENGINEER: LIC NO: ADDRE. ': ❑
G 2`/17 S. ,4Qlu. Q/vo� ,
CONTACP.. PHONE: BUILDING PERMIT INFO
'C ��� l ED Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(( (-Cs w V ❑ ❑ ®— ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOC with Section 7W)(if Division 3ofthc Bisinessand Endfiesslons Code,and my license is RESIDENTIAL:
F W O in full force and effect. PERMIT ISSUANCE
i,-V License Class Lisp DSFDWL El KITCHEN REMODEL
hGL Date—Contractor APPLIANCFS-RESIDENTIAL []ADDITION BTCBMBING RE-PIPE
ARCHITECTS DECLARATION D MULTI-UNIT []STRUCTURAL
z o-'4 l understand my plans shall be teed.,public records PANELS MODIFICATION
N.
02..E UP10200AMPS El INTERIOR [D CHIMNEY REPAIR
a� W Licensed lsmfesauwl 2014000AMPS IMPROVEMENT []SWIMMING POOLS
0.•+,i�� OWNER-exempt fr mDECLARATION OVER Man AMPS O BATH RFMODEL(REPAIR []DEMOLITION
C I hatch,affirm on I am exempt from the Contractor's Coast:
t:Any c Law for the
IL 6 V which ng reason(Sermon 7031.5.Business and Professions Cafe:Any city or county SIGNS ELECfRICAI. []OTHER
3 0. which aii i.s a permit m ammrux,,he lin for such
demolish,tar repair uny aromurc
prior innocence pursuainquires theapplicant for Contenniunicensle e Law
(Chapter9 SPECIAL CIRCUIT/MISC.
y Ihmheislicenced pScrimuothe provisionu of the Cmttnn,, Licensel.,v (Chapser9
IL H that he
exempt Scctiod Rand of basis for oft be Businessandon.Any vi Code)or TEMP.METER OR I'(3LP.(NST. COMMERCIAL:
0. o K thin hu is exempt therefrom and the basis for the alleged exemption.Any violation of ( D NEW BLDG/ADDITION 0 DEMOLITION
�^,w Section 7031.5 by anyapplicant fora pem+itsubjeru theapplicant to o civil penalty of POWER DEVICES [TENANT ❑FOOD SERVICE
nut more than five hundred dollars(SNXE.
F >' IMPROVEMENT
6 D 6asowner nfthe pmpencture s m intended withwagexmtlleir er.7044,Business
SWIMMING POOL ELECTRIC
and dmhewark,ande: she Cmd isnot v Liexadorofferoll wdoes but apply I. a,Rosiness []OTHER
13 and Professions Code:The..us duaro License Law does not apply to an owner of OIJI'LBTS-SWITCHES-FIXTURES
property who huilJs or improves thereon,and who eros such work hiTnsell'or through
his own employees,provided thin such imprvroems oro not inlanded or offered for NEW RESIDENGAL ELIiCFR SQ M'
sole.lf.however,the building orimprovement ix sulJ wiNin one yearoRompletion,the Q.Ief.FLOOR AREA S/SQ.FL
ourar-hualder will have the burden of proving that he did not build or improve for put.
poseofsaleJ.
❑
I.us owner of the propeny,am exclusively contracting with licensed contractors m TOTAL:
construct the project(See.7044.Business and Professions Core.)'fhe Corsa-ax.IJ- -
censa,Law does not apply m an im nerofpmpen,who builder or improves thereon,sod QTY, PLUMBING PERMIT FEE
who cdmnms for such projects with a,murwaids)licensedpursuant m the Cnnaaclo',
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this mason
Data
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT DEVICE
1 hereby aflirat under penult,of perjury one of the fdlowing dedermiom:
I haveand will maintain aCenificateof Consent roself-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Lahr Code,for The performance of the
work far which this permit Is ixxned, FIXTURES-PER TRAP
0 1 have and will maintain Worker's Dimp,a,alion lo,oca e.u,acquired by Section
3700 of the Labor Code,for Ne performance of the work for which this permit is issued, GAS-17A,SYSTEM.I INC,4 OUTLETS OCC.GROUP (IAVN
My War 's Co pen`wF}J¢Qn lrr�� ace jpamicr
Policy Palicy�- 2
Carrier: 1.xwMAnl{ Pndicy Nn: %v/ GAS-ITA.SYSTEMOVER 4(FA) J
CERTIFICATE OFIiXI' Pf10N PROM1INONKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR BUILDING DI IISIO
(This section need not becorepletedif thopenal is forine bamlrcddollars(SI(XB GREASE TRAP
or less.) PLANCHECK ME
I ccnify that in the performanceofthe work for which this perosis is issued,l shall SEWER-SANITARY-STORM EA.200 FL
m
not employ any person in any manner so as to becoe subject m the Workers Carman- ENERGY FEL?
Oz smind Laws of California.Date WATER HEATER W/VENT/ELECFR
O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTHWI'KEATING
abecame subject at the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING le AGENCY NEW RESIDENTIAL PI_MB SQ.FT. PAID
UQ kfr hirhrnt@anberc Issued(See 30 leading agency for performanceof Date Receipt
Yr ,� the work for which this permit is issued ISa.309],Civ.C.)
O ULender's Name TOTAL:
Lender's Address TOTAL:
1 ccnify That 1 have read This uppliemion and ,are thin the above information is BUILDING FEC
V) truce.l agree m comply with til)chyand.aunty mhnan.es and state laws resting to QTY. MECHANICAL PERMIT FEE
UZ building conametion,and hereby authorize representatives of this city m enter uptm the SEISMIC ITS
show-merttioned property for inspection purposes. PERMIT ISSUANCC
(We)erg.m save,indemnify and keep handless the Cil,of Cupertino against ELECTRIC FEE '
liabilities.judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in onseyuence of rhe gramint,of this PLUMBING FEE
APPLICANT UNDERSTyt rN I ILL���[1WL�s1PLY WITH ALL NON-POIN'T AIR HANDLING UNIT(TO 10,(100 CFM)
S URCfS. / MECHANICAL FF.E
/ ) 'V0 � AIR HANDLING UNIT(OVER ItI,fl(N1 CFM) CONSTRUCTION TAX
SignaEie of App camiCmnm or !JV Date EXHAUST HOOD W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS or boom
b MATERIALS DISCLOSURE
Willthe ytheCalsertor lhmrc building mcupnm xmre2,huddle haeallouasnatariel HEATING UNIT(TO 1(I0,fX10 BTU)
as defined by the Culwninn Municipal Code,Chapter 9.12,and the lloaltb and Salary
Cade,Section 25532(u)7 HEATING UNIT(OVER IOO,OIX)BTU)
❑Yes No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant ase equipment or devices which Hare Receipt 0
it haxardous air contaminants os defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I KIM BTU) '
Distrix? TOTAL:
❑Yes DNo BOIL(?R-COME(OVER 100,000 BTU)
1 have read the hazudous materials requirements under Chapter 6.95 of the Cell- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25511.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Ef.
building does not cumntly have a unam,mut it is my respansihildy to utility the accupam
of the on,mu nems which most he met Eno,m issuona of a Cenifcnm of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE