30133 APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
UlIYQI2CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT' PLUMBING-MECHANICAL 3 0.13 3
BUILDING PROJECT IDENTIFICATION N/ V
BUILDING ADDRESS: - SANITARY NO. - APPLICATION SUBMITTAL DATE
1124
OWNER'S NAME: - PHONE: CONTRACTOR'S NAME: LIC NO:
J14LL— NIC CONTROL#
.CHI /ENGINES LIC NO ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
• �`+,�1 y4w fw —7 2 7 �_O r A ❑ Consultant Fees Paid by Applicant(Initial), ' BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR,DECLARATION QTY. ELECTRIC PERMIT FEE
1 herebinfiffirm 0).fI Nal l nm licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
OZ wiNSretai retained arrival,
Business and Professions Code,and my license is PERMIT ISSUANCE V RESIDENTIAL
I.PoII force and effect.
�UU�U" License Class Li,. ❑SFDWL - ❑KITCHEN REMODEL
FggW Date - Conti for APPLIANCES—RESIDENTIAL'
mQ6, ❑ADDITION ❑PLUMBIPIPE
p.yT'S
ra ARCHITECDECLARATION ❑MULTIUNIT ❑STRUCTURAL
URAL
O Z 7�.1 understand my plana,hall be useJ as public rernPANELS
rds - MODIFICATION
UPTO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
�.� Licensed Pmfessional
201-IIXIOAMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION
O
Q I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODELBEPAIR ❑DEMOLITION
a LL F following reason.(Section 7071.5,Business and Professions Code:Any city m county SIGNS ELECTRICAL - CIOTHER n
� y6 which requires a Permit to conswct,alter,improve,demolish,or repair any swmure
W prior to its issuance,also requires the applicant for such Perrot to file a signed statement SPECIAL CIRCUIT/MISC.
p. that bels licensed purampt o the provisionsoftha Contractor's License Law(Chapter9 _
QD (commencing with Section 700)of Divolon3 ofthe Bmiaesasnd Professions Code)in TEMP METER OR POLE TEST. COMMF.RCLAI '
4
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 1
Section 7031.5 by any applicant for a period subjects the applicant to a El DEMOLITION
-civil penalty of POWER DEVICES
not more than five hundred dollars($51)[0). - ❑TENANT ❑FOOD SERVICE
O ❑I,as owner of due Property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the savctme is not intended oroffeed for sale(Sec.7014,Business ❑OTHER il
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
.r property who builds or improves thereon,and who does such work himself or through _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however,the building or improvement is sold within one year ofcOmpletion,the SQ.FT.FLOOR AREA '$(SQ.PC
caner-builder will have the burden of proving that he did not build or improve for pant-
rose of ade.), '
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to n TOTAL:
onatrtrcl Ne project(Se,.7014,Business and Professions C`S:)The Contractor's Li.
cense Law does oat apply to an owner of property who builds or improves thereem,and Q'ly, PLUMBING PERMIT FEE 49 0 � .•
who contracts for such projects with a cum a[tons)lleonsed pursuant to the Commemes
License Law.
❑ 1 am exempt under Sec. ,B&P C for Nis reason PERMIT ISSUANCE
Owner G ALTER—DRAIN&VENT—WATER(EA)Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK BACK FLOW PROTECT.DEVICE t� /,
I hereby affirm under penalty dffmoury one of the following declarations: - un VI• LUI rmiNO
❑I have and will maintain a Cenificate ofConmnt m.self-insure for Worker's Comped- DRAINS—FLOOR,ROOF,AREA.CONE.
section,as provided for by Section 37W*of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 ofthe Labor Code,for the Performance ofthe work for which this permit is issued GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.MY WOrkm'a Compensation Insurance sander end Policy number are: APN
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE INTERCEPTOR
(This aeeticn need our he completed ifthepermit is forone hundred dollars is IW) - - BUILDING DIVISION FF.RS
or less) GREASETRAP
PLANCHECK FEE
(certify[hit in any performance workfe hich Object
permit isissnad,I'liallCoarsn- SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as m become subject to the Workers'Comped- ENERGY FEE
cation Laws of Culifnmie.Date
0 z -
Applicant WATER HEATER WNENT/ELECTR
y Q
G y NOTICE TO APPLICANT:IL after making Nis Cauldron,of Exemption,you should WATER SYSTEM/TREATING GRADING FEE
a become subject m the Workers Compensation previsions of the Labor Cole,you must SOILS FEE
W forthwith comply with such provisions or this Permit shall be deemed revoked.
WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB SQ.ET PAID
V 0 (hereby affirm that there isbcnnswdion lending agency fanhe perfomunue of Date Receipt#
{L h the walk for which this permit is issued(Sec.3097,Civ.CJ
Q
Lenders Name U
{kI Lenders Address TOTAL: TOTAL'
Qr I certify that I have read this application and state that the above information is BUILDING FEE
#r N coiled.I agree to comply with all city and county ordinances and state laws relating he QTY. MECHANICAL PERMIT FEE
U above-mentioned
propend hereby amtion purposes. SEISMIC alibis cirymenmrupm the SEISMIC FEE
shove-mentioned propene for inspection purposes.
(We)agree m cava indemnify wipsy and keepharmlessaimy w city of Cupertinord s a slosh PERMIT ISSUANCE
Yg ELECTRIC FEE
inconsequnce of to gmadind experts ermit,hmay intros way scent,agaio£h said City ALTER OR ADD TO MECH. '
consequence of the UNDERSTANDS
nftA Dermic
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,BOn CFM)
SOURCE REGULATIONS. � � MECHANICAL FEE
AIR HANDLING UNIT(OVER to."CFM) CONSTRUCTION TAX
Signature of AppllcannConnacmr Das EXHAUSTHOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant scam nr handle hamrdaus material HEATING UNIT(TO 100,000 BTU)
as di fned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P 1 HEATING UNIT(OVER 100,000 BTU)'
E3 Yen; - ❑NO
VENTILATION FAN(SINGLE RESID) PAID _
Will the applicant or future building occupant use equipment or devices which Date Receipt#
ran hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP OHP OR I Was)B'fU)
19111[17 TOTAL:
L
❑NO BOILER—COMP(OVER 100,000 BTU)read Ne hamrdous materials requirements under Chaphu 6.95 of Na Caii- AIR CONDITIONERISSUANCE DATE
&Safety Code,Sections8505,25571 and 25534.I undersmnd that if the NEW RESIDENTIAL MECH. SQ.PT.not cumntly have a tenant,that it is my resp risibility to notify the Occupantents which must be met prior m issuance of v Caddish,ofOccupancy. -Mo d agent Date TOTAL: ISSUED BY:
OFFICE r^