30187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUYN:RTINO BUILDING..ELECTRICAL. , PERM]TNO.
BUILDING PER IN APPLICATION/PERMIT PLUMBING,MECHANICAL, _ 30187
BUILDING PROJECT'IDENTIFICATION
BUILOINGADDRESS: s SANITARY NO. APPLICATION SUBMITTAL DA'T'E
/473
pgr�µ N ,NIi: PHONE: CONTH DR'S NAME: LIC NO: N/C CONTROL#
OWNER -:rr- ❑
ARCHITECT/ENGINEER LitC NO: ADDRESS: e
CONTACT: PHONE: EUILDING PERMIT INFO
/p _,� „-D ��^ 7�� ❑
Consultant Fees Paid by Applicant(Iniliap BLDG Ii IPLU❑MH StV/wt LI '.NSEDC RACTOR'S DECLARATIONQTYQTY. ELECTRIC PERMIT FEE IL'�-'
/ (�'
I hereby alarm that Tam lierred maker laravisbns.f Chapter 9(cantmenan g I JOB DESCRIPTION
„Drop with Section 7(Ngl of Division3of the Business and Prnfnsions Csde.and mylicenm is RESIDENTIAL,
F PERMIT ISSUANCE
in full fmccand effect. ❑SFDWL ❑KITCHEN REMODEL.
K U License ClassLic.N PLUMB
Q U APPLIANCES-RE.SIDEM'LAC ❑ADDITION ❑STRUC URAL PE.
FZZ W Date C.mrnn.r
y<c, - - ❑MULTI-UNIT []STRUCTURAL
F'y ARCH1TIiCT'S DECLARATION PANELS
ZOWz Ivndemand my plans shall he used as public t¢nrds pPTO200AMPS MODIFICATION
Oy—� ❑iNTER10R ❑CHIMNEY REPAIR
F an�tY Licensed Professional OWNER-DUILD201-1000AMPS IMPROVEMENT
��dd •.t I?It DECLARATION 1000 AMPS ❑BA'T'H REMO ELIREPAIR LDEMO TIO
^j I hereby affirm that I am exempt rrom the Contractors License Law for the
�y("' U fallowing reason.(Section]071.5.Business and Professions Gde:Any citymentintY SIGNS ELECTRICAL. ❑OTHER ��t �
W 3 W y which requires a permit to caa,mc,allf,improve,denmlib,ur repair any structure
< prior o its issuaace,aim requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/,MISC.
�p. that he is licensed pausmnt to the lmvi,imo of the Contractor's Umrw Law(Chopter 9 - -
WaG£O (commencing with Section 7000)of Division of the Business and Proressions Code) 'rEMI'.METER OR POLE INST. COMMERCIAL:
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of OF 0 ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by my applicant for u permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1„ "y urn morethan five hundred dollars(5500). IMPROVEMENT
560 71,a,ovocrofthe proptoyo,my employees with wagcaaa their sole camleneation, SWIMMING POOL FILE
p.. will d.The work.and thesuudure isnot intendicimmIered far sale(See.7041.Rates []OTHER
mand Professions Code:The Contractors License Law does not apply to an owner of OUTLE'T'S-SWITCHES UR
property who builds or imports.thereon,and who diwa such work hitamlf or hough
his own employees.provided that such improvements are not intended or n0emd for NEW R[SiDCN11A1.F.LF.T'ST'R 5
sole.IL however,the building or improvement is sold within one year or completion,the SQ17,
F//LO� A 8/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve fm par- IV I
❑ 1,as owner of the pr.peny am exclusively commuting with licensed contractors tor'C'17
cumama the project(Sm.T44,Bsiness uad Professions Cade:)The Comment,'a Li- - ///V�
Li-
cerise Law does not apply in an owner of property who builds or improves thereon,and Q'I'Y. PLUMBING PERM FEE
wTo contracts for such projects with o cona.d.0,)lamixed pursuant to the Cnnwaor'e' _ -
License Law. PERMIT ISSUANCE
sures,
m exempt under Sec. ,R&P C for this reason
O iter me ALTER-DRAIN&VENT-WATER(EA) VALUATION
O ER'S COMPENSATION L ATION I13ACK FLAW PROTECT.DEVICE
I hereby of rom under penalty of perjury ane or the following declarmi.ns:
0Thaveandwill maintain aCcnificate of C.nsem to selLinsumfor Woder's Comped DRAINS-FLOOR.ROOF,AREA,GOND. S'I DRIES TVPH CONSTRUCfION
salon,as provided for by Sermon 3700 of the Luhm Code,for the peforma.ce.f Ibe
work for which This permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,its required by Section
3700 ofrhe Labor Code.for The perrommnce oflhe work for which this#emit is,issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
My Worker's Campeneatian Insurance carrier and Policy number arc: -
Currier: P.Iicy No, GAS-IIA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS ❑IiEASPJINDUS'I'RI.WASTE IN'IERCIiITOR
COMPENSATION INSURANCE BUILDING DIVISION RPS
•(niuwtionn dnmbecomplete ifthepennitisforonehundr doll:us(SI(M) GREASE TRAP
nr less.) PLANCHECK FEE
I cenify that in he pe,fomtarecifthe walk rnr which this permit is issued.I shall SEWER-SANITARY-STORM HA.200 Fp.
not employ any person in any manner so as m become subject m the Wnrkets'Camilla. ENERGY PEE
Z serum Law,of California Dale WATER HEATER WNENWELECTR
O Applicant- GRADING FEE
N NOTICE TO APPLICANT:,IL after making this Cenificam of IExemption, no shouldWATER SYSrUIMITREAT'ING
F '„^ become sobjeca the Worker's Compensation Provisions of the labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be duetted revoked. WATER SERVICE
aQ
Uz CONSTRUCTION LENDING
ngAGENCY NEW RESIDENTIAL PLMR. SQ.Er. PAID Date Receipt ft
V 0 l frwhich Thi that there isaco!(Set,30 len ding agency for the perfomtence nl'
H Newalk for which this permit is ismW(Sec.3(191,Civ.C.)
{I•t Ixndeds Name TOTAL"
V Under',Address TOTAL:
BUILDING FEE[.,. 1 dertifY that I have reoJ thisimplication and one that the aMrve infonnmi.n is
N7 correct.I agree to comply with all city and county ordinances and slam lows relating m QTY. MECHANICAL PERMIT FEE
z
V builiingc.nstructicammil herchyeuthodre represciniivesefthisciry m enter.,.,he SEISMIC FEE
aMrve-mentioned property Tor inspection purposes. PERMIT ISSUANCE
(We)agree 1.save,indemnify and keep harmlen the City of Cupertino again ELECTRIC Pit
liabilities,ludgmen".e...".ad expenncswhich may iamy waymmos gaunt said City ALTER OR ADD TO MICA.
in cmbequenee of the gnotti.,.f Ida permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULAIONS. MECHANICAL FEE
T
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT ION TAX
Signature of Applicant/Conuaclor Date EX HAUST HOOD(W/DUCD HOUSING MITIGATION THE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mainland once,or handle moralistic material HEATING UNITG'O I103,01ga BTU)
as defned by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)t IIL'ATINO UNIT(OVER 100,000 BTU) -
❑Yea ON. - PAID C"b
VIiNT11.ATiON PAN(SINGhE RESID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which
BOILER-COMP OHP OR 100,000 BTU)
emit hamrdous air comaminanry as defined by the Bay Area Air Quality Management r'0
District?
❑Yes ON. BOILER-COMP(OVER Iq),(NIO BTU)
' d The br ardour mmedels µ AIH CONDITIONER
I have rea
tequirtments under Cha ter695 of The Cali _ ISSUANCE DAT61
fornia Health&Safety Code,Sections 25505,2$533 and 25534.1 understand thin if the NIIW RESIDENTIAL MECH. SQ.IT
building does not currently have a tenant.that it is my responsibility mnolify the matsons -
of the requirements which all be met Iria,1.issuance of a Cenifiante of Occupancy. ,
Owneroranharired agent Date ISSUED BY, -
OFFICE '