30547 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 11�� y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL ' 30x,V4
BUILDING PROJECT IDENTIFICATION 1
BUILDING ADDRESS� �,/C
�• /. SANITARY NO. APPLICATION SUBMITTAL GATE
AME ¢G C Cr tJ CltlTo r �O
OWNER' AMEN�. J) - • pHON {�/ rJ C ,RACT R'S NAME: LIC NO:
�� V� U xJ (/p j _ W/(���� N/C CONTROL#
ARCHITECT'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby off that 1 am Itches..)under provisions o.Chapter 9(commencing TOB DESCRIPTION
{Q{Q WW with Section
eandefe Division3 ofthe Business and Professions Code,and my licenseis RESIDENTIAL,
FU.. in full force end effect PERMIT ISSUANCE
�UT.E License Class Lic.# OSFOWL El KITCHEN REMODEL
Nae. Date Contractor. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
C y.Z. I understand my plans shall he used as public records MODIFICATION
UPTO 200 AMPS
rr E'O Incensed PnNensmnal ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2041000AMP5 it IMPROVEMENT
�Gv y OVER HNOAMPS El REM E
yy 1 hereby,(Sect the.1 am exempt from the Contractor o License Law for the T JAR !`-
pg a 6 F fallowing reason(Semon]031,5,Business and Professions God.:Any city or county SIGNS ELECTRICAL El OTHER w
kkll
onwhich requisu a permit re constrict.nlreq Improve,demolish,m repair ed tatucmre
primmits issuance,also inquires the applicant for such permit to fileasigneJ statement SPECIAL CIRCUITIMISC.
is that he is licensed pureuanno'he provisions of the Commerce's License Law(Chapter 9
AO (commencing with Scott..7000)of Division Sof the Business and Professions Code)or TEMP,METER OR POLE INST COMMERCIAL
6 ry,o y thin he is exempt therefrom and the basis for the alleged exemption.Any Admion of [INEW BLDG/ADDITION ❑D OL N
.`nr Section 7031.5 by any applicant for a permitsuhjectn the applicant to a civil penalty of POWER DEVICES
a j'., not more than five hmrdmd dollars($500). ❑TENANT O FO SERV
C1,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
wJl do rhework,and rhe swnura is not mli nded or offered forsala(SeeA(W4,Business D OTHER
mend Profession,Code:The Contractor's License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES
4i prnpeny who builds or improves th dmon,and who does such work himself or through
his own employees,provided that such improvements are not intended or office for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is.sold within one your of completionthe SQ.FT.FLOOR AREA $/SQ.ET.
tuner-builder will have Me burden of proving that he did net build or improve for par-
pose of sale.).
El 1,as owner of the property,um exclusively contracting with licensed contractors to TOTAL: Qpw^
construct the project(Sec.7044,Brormas and Profession,Code:)The Contraetods Li. 4r
cense Law does not apply to an owner of prnpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE �99(C
who contracts for such projects sbilb o commences)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE {d
❑I em under Se ,B&P C for this mason (•(,yw�N'r
ALTER-DRAIN&VENT WATER(EA)
Date1 VALUATION
WORKER'S COMPENSATION DECLARAI'IONBACK FLOW PROTEGE DEVICE
• I hereby affirm under penalty of perjury one of The followingdealantions: 1�
I ha
❑ ve and will maintain a Certificate of ConsenOo self-insure for Worker's Compen- DRAINS-FLUOR,ROOF.AREA,COND.
satins,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
El I have end will maintain Worker's Campemetion Insurance,as required by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP qPN
My Workers Compensation Insurance carrier and Policy number are:
Cams, Policy Nu: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifthe permit is for one hundred dollars($100) BUILDING DIVISION PEES
m
or less.) GREA$ETRAP - PIANCHECK FEE
any
(certify Nut in the of Nework for which this permit is issued,I shall
not employ any person in any manceannmso as to becomeIwb edmthe Wnrkeri Com SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
cation Laws of California.Dam Pen-
O Applicant WATER HEATER WIVENT/ELECTR
,� rr GRADING FEE
y NOTICE TO APPLICANT:If,after tanking this provisions
of of Exemption,you shams WATER SYSTEM?BEATING
becomeh comply
y the Wnrkm'n Compensation provisions of the Labor Cade,you most SOUS FBB
� Q forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE •
P
0 �.
CONSTRUCTION LENDING AGENCY NEW RESIDF.NTIALPLMB. SQ,FT. PAID
U O I hereby affirm that issued((So,,3097,
agency forthe perfommnce of Dam Receipt It
V. H the work for which this permit is issued(Sec.309],Civ.CJ
0 U Lender's Name TOTAL:
0. Lender's Address TOTAL,
I certify that I have read this application and state that the above........nation is BUILDING FEE �s
.: N correct.I agree to comply with all city and county ordinances and state laws refirmi QTY. MECHANICAL PERMIT FEE
U Z building connotation,and hereby authorize representatives ofthis city to enter than the SEISMIC FEE
above-mentioned property for inspection proposes.
(We)agree insavv,indemnify and keep handles,Be City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabildies,judgmems,costs and expenses which may in any way acme against said City AUIERORAUDTOMECH.
consequencein of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT(TO 10,00)CFM) MECHANICAL FEE
T
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTIONTAX
Signature o.ApplicantAtimuctor Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle hazardous material HEATING UNIT GO I W,OW BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Heald,and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ONo r VENTILATION FAN(SINGLE RESIO) PAID
Will the applicant or future building occupant use equipment or devices which
Date Receipt#
emitnus sir contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100, BTU)
District?trict' TOTAL:
❑Yes E]No BOILP.R-COMP(OVER I00,000 DTD)
I have read the hanudous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
humid Health&Safety Code,Sections 25505,25533 and 25534.1 understand That if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a tenant,that it is my responsibility in notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy. '
Owner or authorTud agent Dine TOTAL:
ISSUED BY:
OFFICE