30487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /p� 7
CITY OF CUPERTINO I BUILDING-ELECTRICAL PERMITTED. ,30487 O -f H 1
BUILDING DI VISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION sJ{
BUILDINGADDRESS: ^ .,r ipSANITARY NO. APPLICATION
E dE �Gf \enw ,11��`[PInlnu. n/�
�1✓�. AT
SUBMITTAL
DATE
OW RNAML: PHONECONTRACTOR'S NAME �� 6
- Z Z NIC CONTROL
P/EGINEDN1E2T:&,,.
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mryfAcr: PHONE;/ P� S ees BUILDING PERMIT INFO
❑JCOnsultant Pei y Applicant(n 18 � EL� PL B MECH
ul
LICENSED CONTRACTOR SS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm in.,I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�05 with Section 0000)of Division 3 of the Imsinto,cad Professions Code,andmy license is RESIDENTIAL
IUin Tull ense Cleand effect PERMIT ISSUANCE. ❑SFDWL ❑KITCHEN REMODEL
UU� License Class Cana APPLIANCES-RESIDENTIAL
]ADDITION ❑PLUM ftING RE-PIPE
vFi<W� Dam COn ❑MULTI-UNIT ��S UCTURAL
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ARCHITECTSallbecdicapa DECLARATION PANELS �f IF ATION
Op-7� lunderstand my plans shall he umd es public records UP TO 200 AMPS - ` C1 INTERIOR ,`11
F�,(".t��s Lmensed P..... nal gCJ�4 AIR
OWNER-BUILDER DECLARATION 2111-IOfNIAMPS IMPROVEM
I hereby affirm that I am exempt from the Convector's License Law far the OVER HIS)AMPS ❑BATH REMODE P ION
W aH following reason.(Section 70.31.5,Business and Professions Code:Any city.'county SIGNS ELECTRICAL ❑OTHER r��L
F IsmQ which readiness a permit it)construct,after,improve,demmi.As nr repair any. cwra - Lur-tH 1 INi I
nh.J
Prior in issuance.also regnircs the applicam for such permit to file asigned sancram SPECIAL CIRCUIT/MISC.
That he is licensed pursuant o the provisions or the Contractors License Law(Chapeau
(commencing with Section 7")of Division 3 ofthe Business and Professions Code)ar - COMMERCIAL'
W PJ p O TEMP.METER OR POLE(NST.' EW BLDG/ADDITION I]DEMOLITION
d q m eG Natio is exempt therefrom and the basis for the alleged exemption.Any violation of
4X1 tL notman]03LSby any applicvmfor a,,l$50rmit subjects the applicanuoecivil penally of POWER DEVICES
F Z i+ not more than five hundred dollars($500). NANT El FOOD SERVICE -
6� ❑ [,as owner ofthe Property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IIMPROVEMENT
will do the work,and the stmcture is not intended or offered farsale(Sec.]Levi Business ❑OTHER
mand professions Code:The Commanors License Law does not apply to an owner al" OUTLETS—SWITCHES—FIXTURES 111"U D
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELEC-PR SQ FP.
sale.iLhowever.the building orimprovememis said within one year mcomplether,the SQ.FE FLOOR AREA S/SQ.ET.
owner-builder will have the burden of proving that be did not build or improve for pur-
pose afsale,. �2 /I /(L .�C
❑1,us owner of the pmpeny,am exclusively roatmatins with licensed commsar's i- (`w7�1/l'{
construct the project(Seo.]044,Bminess and Profession Code:)The Conwemds Li-
cense Law does not apply toanownerofFropertywho builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with it contractor(s)licensed pursuant m the Contractor's
License Law.
❑1 am exempt under Sec. B&P C build,reason PERMIT ISSUANCE
OwnerALTER—DRAIN&VENT—WATE (EA)
Wte ■• VAI TION
• WOR
Thereby affKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEV( Y� ��r
irm under penally of perjury one of the following dedwations:
[II have and will ramme.na Certificate of Cmrwm to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,ARK,CO lYl
seinen,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this pemtil is issued. FIXI GETS—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Sation 11
im
3700 of the Labor Code,far the performance of the work for
GAS—EA.SYSTEM-OVER4(EA)
orrlwhich Oils permitisissued. GAS—EA.SYSTEM-1 INC.4 OUTLe(S OCC.GROUP qPN
07
e,No.
My Wo EoRl�en �nins nce cv'ggtNtl /�-�
er: [ A(j[dpi(!i
CERTIFICATEOFEXEM POINTED WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
Gids section need not be completed dike permhis Ionone hundred bill ars($1BLD (VISION FEES0U) GREASE TRAP
or lessJ PLANCHPE
Toy any that inin any maranceof the work for whichthisto permithe W isissued,'Cummen- SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- - ENERG FE
Z7r cation Laws of Cali Limit.Date
O Applicunl WATER HEATER WNENT/EEELTR GRADING F
V] NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
abecome subject m the Worker's Compensation provisions of the Labor Cada you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE ,
Q
UCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.FT. PAID.z I hereby affirm that there is a conswetion lending agency for the performance of Date a iptk
Kthe work for which this permit Is issued(Sea 3097,Civ,C.) 1
O (~ Lenders Name
LU LendTOTAL:
efs Address :
L>r 1 certify that 1 have read This TOTAL
application and state that the above information is BUILDING F
V1 comet I agree to comply with all city and county ordinances and state laws relating no QTY. MECHANICAL PERMIT PEE
U building imartmclion,and herebyamhmiurepresentatives of thlscity to enter upon the SEISMIC
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hurmlens the City of Cupertino against ELECTR C
liabllities,judgments,costs and expenses which may inany wayuccoe againstseld City ALTER OR ADD TO MECH.
In consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SCORE EGULATIONS. MECHANICAL FEE
110.� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
iguare (Applicant/Co meror Date EXHAUST HOOD(WIDUCIE HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazmdous material HEATING UNIT(TO 100.000 BTU)
us defined by the Cupertino Municipal Civic,Chapter 9.12,and the Health and Safety --
Code,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑Nu
VENTILATION FAN(SINGLE RESID) PAID Date -ReceiplM
Will the applicant or future building occupant use equipment or devices which yOILER—COMP(3HP OR IOO,fglO BTU)
mit hamrdous air control firms as defined by the Bay Area Air Quality Managemem
District? TOTAL:„
❑Yes I]No BOILER—COM P(OVER 100,000 B9'U)
I have read the hazardous m.116.11 acquirements under,Chapter 695 of the Cali- AIR CONDITIONER ISSGAIN ED
fomia Health&Safely 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 to notify the oceupam '•
of Ne requiremetns which must be met poor Io issuance cis Certificate of Occupancy.
Owarmarn rmived ngem Date TO L: ISSUED BY:
OFFICE