30136APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONWERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT N0. 301 3
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BUILDING ADDRESS:
h (0 h 0 r� Aro o (am.
SANITARY NO.
APPLICATION SUBMITTAL DATI
G S �p6
OWNEryS BA=E: O PN[J(v'
CONTRACTOR'S NAME C fLO-4M1 1O
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NIC
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CONTROL#
ARCHIT[CT/ENGINEER: LIC NO:
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ADDR sr) L)
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CONTACT': PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1:1 EJ
LICENSED COM'RACUR;S DECLARATION
1 hereby affirm that I um licensed under provisions of Chapter 9 (commencing
with Section 7") of Division 3 of Ne Business aoA Professions Code, and my license is
in full force wde 1 _ O 4"13 oI
Disease Claa Lic.p l
Date. - Contractor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDf170N [I PLUMBING RH-PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR L1 CHIMNEY REPAIR
IMPROVEMENT
❑ BATH RFMODEUREPAIR 0 DEMOLITION
[]OTHER
PERMIT ISSUANCE l\
V
APPLIANCES -RESIDENTIAL
j ARCHITECTS DECLARATION
1 1 understand my plans shall be used as public rccruus
Licensed Professtamal
m Ce ConamON
thatOWNER-BUILDER aexemptfrom
I hereby affirm that I em exempt from the Commerors License Law for the
following rcaon lgwaion 703 1.5, Business and Profusions Cole: Any city or county
which sequin s o permh to construct, niter, improve, demolish, m repair any structure
priormit issonnce. also reyuires the applicam for such permiuolilcasigned sulmmem
thatbe is licensed purstan to the provisions of the Contractors License Law fChapter9
(commencing with Section 7") of Dordon 3 miles Business and Pmfcssions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subject the applicant to a civil peva ly of
but more than live hundred dollars ($500).
I, us owner nfthe properly nnny empinyecs with wages as their snte compensation,
will do Ne work, and me sammiu a is not amended or offered historic (See. 7044, Business
and Professions Code: The Comracdors License Law docs not apply to an owner of
pmpa rly who builds or improves thereon, and who docs such work himself or thmugh
his own employees, provided that such improvements am not intended or offered for
sale. If, however. the Wildingor improvement is sold within one year ofcompletion,the
coverobuilder will have the burden of proving that he did not build or improve for put.
Prove of sale.).
❑ h as owner of the properly, ism exclusively connecting with licensed contractors to
Dreamed the project (Sec. 70W, Business and Professions Cade:) The Centimeters Li-
lenseLaw does not apply to an owner ofpropcny who builds or improves thereon,and
who contracts for such projects with a comractor s)licensed pu manuo the Contractors
License Low.
1 am exempt under Sec. , B & P C for this reason
PANES
UP TO 200 AMPS
201-1f0BAMPS
OVER 100AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
TEMP. METER OR PULE INST.
COMMERCIAL•
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
BOTHER
POWER DEVICES
SWIMMING POOL ELE IC
OUTLETS - SWITCHES -F
NEW RESIDENTIAL ELECTR Q FT.
SQ. FT, FLOOR AREA
b/SQ. FT.
TO A 9 V
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER IFA)
OwnerDae
-. (•e ypLIk1T10N
Q 1gy�
O
Rigs • TYPECONSTRUCTION
SW
s )�
COMPENSATION DECLARATION
1 affirm
1 hereby arm under penalty ofpejury one of the following declarations:
I have and will maintain a Certificate ofConrcatto self -insure for Workers Compen-
cation, as provided for by Section 3710 of tits Labor Code, for the performance afire
work for.which this perms is issued
❑ 1 have and will maintain Workers Cruclec mien Insurance, as required by Section
3700o1rine Labor Cade, for the perfies.sellfine work for which this permit is issuW.
My Workers C. satamblamencre cradd Pdicynutpbet ore:
Camicc (AIIWI p'Y"LV?7W Policy IN AT! RQSGA
CERTIFICAI B 01; EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section neeco he t is for one hundred dollars is 100)BUILDING
l not he mpleted iOennit
or less) p
this Perthe Wokt is ers'C. pactshal
intoe Perany mummer Dfine beralk me subject
Loy any
not employ tory person in any mummer u as to become mM1jea to the Workers' Compact.
cation Laws of California. Dam n
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOK AREA, COND.
FIXTURES - PER TRAP
GAS -IA. SYSTEM -1 INC. 4 OUTLETS
(QCC. GROUP
APN
GAS -EA. SYSTEM -OVER 4 DA)
GREASEIINDUSTRL WASTE INTERCEPTOR
DIVISION FTiIi.S
GREASE TRAP
PLANCHECK FEE
SEWER-SANITARY- STORM EA. 200 F1'.
ENERGY FEE
WATER HEATER W/VEN/ELECfR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Cenificam of Exemption, year should
become subject m the Workers Compensation provisions of the labor Code, you all
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I herchy affirm manhere isnuonswaimt lcnd'mg agency for rhe perfonnance of
Ihewodr for which this permit is issued(Sec. 3097, C1v. C.)
Lenders Name
WATER SYSTEMIfREATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ, F.
Daae Receipt
TOTAL:
Lenders Address
TOTAL:
1 ecnify, that 1 have read this applicmian and sate that the above information is
correct. l agree to comply with all city and county ordinances and state laws reining to
building constrogion; and hereby authorize representatives of this city to enter upon the
above-mentioned proper, for Inspection pri,osex,
(We)agreetoarcs. indemnify and keep harmless the City of Cupertino ogoinst
liabilities, judgments, cosh and expenses which truly in any way accme against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE ftfGUA TIONSes xr IG
\nY�n/(JY`JI(,U-(//_` ��
BUILDING FEE
QTY. MECHANICAL. PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE !`
ISSUANCE
V
ELECTRIC FEEU
ALTER R ADD MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10," CFM)
MECHANICAL METIONT
O• O Cl
AIR HANDLING UNIT (OVER Il1,0IX) CPM)
CONSTRUCTIONTAX
__Z1
Signamrc 1 ;rplican Crameremr Dote
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicanmr futore building occupant smrc urhandle hazardous maenad
ns defined by aha Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532m)7
❑Ycs 7NVENTILATION
Will the applicam mr mantra building use equipment or devices which
emit lacerations air contaminantsazDefined by by the the Bay Arm Air Quality Management
Disuicr!
Myer;- MNu
(have real the haruNous materials rcquircinents under Chapter fi.95 of the Cali-
f calla Health & Safety Cede, Sections 25505, 25533 and 25534.1 understood that if the
building docs not Currently have a tenant that it is my responsibility to notify the a e,sub,
of the d quirearents which must R mea prior to issuance of o Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,010 BTU)
HEATING UNIT (OVER 101,1X0 BTU)
PAID
Date Receipt#
FANS INGLE RESIDI
BOILER - COMP UNP OR 100,0011 BTU)
TOTAL:
!t
V
BOILER-GOMP(GVER 1(0,000 BTU)
-\
AIR CONDITIONER ^E)
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Owner or authorised agent hate
TOTAL. OaO
OFFICE