30714 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT I PLUMBING-MECHANICAL
BUILDING ADDRESS: O �I A,
BUILDING PROJECT'IDENTIFICATION 1 f-F
SANITARY NO. APPLICATION SUBMITTAL DATI
8 Gr2,oVE �
OWNER'S NA
RCHITECT/ : CONTRACTOR'S NAME:pp`
N/C
L 5 LRi3aq
CONTROL
......EEADDRESS
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CONTACT PHONE: ' Oditc, Au gird
BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT ❑ ❑ ❑
1 hereby affirm that I am license under provisions of Chapter 9(cummcncing FEE .LOB DESCRIPTION
C00 th Section 70( of Division 3uflha Business and Professions Code,anlmy license in
Y �t wt
FF mfense force it eff PERMITISSUANCE RESIDENTIAL
Licf.Otn KITCHEN REMODEL Contmca 'fetr APPLIANCES-RESID17NTIAL EIADDTION CPLUMBING RE-PIMARCHTECTS DECLARATION
OZ�'• I understand my plans shall be used as public recprta ❑ ❑
PANELS MULTI-UNIT STRUCTURAL
UPT02MAMPS MODIFICATION
Larnaca Profemrotul ❑INTERIOR 0CHIMNEY REPAIR
90OWNER-BUILDER DECLARATION lBl-IOW AMPS IMPROVEMENT
3 IWr] 1 hereby affirm that 1 out ssempt from the Contractor's License Law for the OVER IOL AM Pg El BATH REMODEU EPAIR QDEMOUTION
L F following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Cwhich requires a permit m construct,ahv,improve,demolish,or repair any structure
vN prior m its issuance,ago requires theapplicant forsuch pennu0 file.signedsmmmeut SPECIAL CIRCUIT/MISC.
vWW11} that he is licensed pnrsuau
no the provisions of the Contractor's license Law(Chapter 4
(commencing with Section 90111 of Division 3 of the Business and l'rofcesions Code)in TEMP.METER OR POLE INST. COMMERCIAL
M. n y [big,he is exempt therefrom and the basis for the alleged exemption.Any violation of
YWy SemonlWIS bymy applicantforulmonitsubjecls thcapplicanl macivil penaltyof POWER DEVICES t [INEW BLDG/ADDITION C1 DEMOLITION
G not more than five hundred dollars($500). ❑TENANT
❑FOOD SERVICE
F G I,m owner of the pmpeny,or my employees with wages as their sole cam IMPROVEMENT
8 ,Business SWIMMING POOL ELE C
will do the work,and the he C ureant is rpt intended oro w do s not apply 7W4,Business ❑OTHER
and arty who
Code:The Contractor's License Law does not apply ro if owner of OUTLETS-SWITCHES-FIXTURES
his o
property who M1uilJ,or improve t such improvements and who does such work ded.1 or through
his own employees,provide)Nm such oldw are not intended of cors p0emd for NEW RESIDENTIAL ELECT SQ
owner-hpweva,thebuilding vethburde burden
issoldhe
none tbuild or improve for put.
- SQ;V.. IL RAREA - WSQ.PT.
prone.-builder will have Ib<bueen of proving that he did not buil)ars improve for Aur- aT] wYY
pro
C2 1.as
owner
tCC �
❑has owner of the pee 7041 .B exclusively contracting with licensed amammra U.
cense La the project(Sec.o an Business and Professions Code:)The Conlmcton.Li-
cenulawdocarotapplymaswitha ofpmpeny who
censedda0 antro the Commnand QTY. PLUMBINGPERMIT FEE ( w�'\
whocontractsLa is for such projects with acontmctoKs)licenced pursuant to the Cnmmaor'e tN\`t`v
License Law. PERMIT ISSUANCE
❑lam exempt underSec. ,B&PCfor this reason '
Owner Dole ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herebynm under penalty of perjury one pf the following detlamtiona: _
❑Ihave and will mainminuCertificolc of ConxenuoselGinsure for Wmkcr'e Cmnpen- BRAINS-FLOOR,ROOF.AREA,COND.
don,as provide for by Section 39W of the Labor Code,for the perfomunce of the STORKS TYPE CONSTRUCTION
�m which this pe.mit is issued. MIXTURES-PER TRAP
®'f have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the labor Code,for the perfammuce of the work for which this permit is issued. GAS-EA,SYSTEM-I INC.40UTLEIi
MyWCp�gWS+{ n
Insunceca.rierand Folic umbcra OCCGROUP APN
Policysl.WT S ZOO GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
or less.)
(This section need nut be completed ifthe permit is for one hundred dollars(SI WGREASETRAP) BUILDING DIVISION FEES
1 certify thin in the perfrommue Of the work for which this permit is issue,I shall PLANCHFCK FEE
"m employ any person in any manner su as to become subject to the Workers'Com n- SEWER-SANITARY-STORM EA.2M FT
Oz colied Laws of Cali fomia.Dole ENERGY HE
7 0 Applicant WATER HEATER W/VENT/ELEC R
s•s NOTICE TO APPLICANT.If,afvr making this Car ificote of Exemption,you should GRADING FEE
ah G
[^ become comp to it Wahers Gaon or tis provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisinnx or this permit shall he deemed revnkeJ, WATER SERVICE
d Q
] z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 I hereby affirm that them is a cons0uction lending agency for the performmnce of Date Receipt«,
V. F the work for which this permit is issued(Sec.3099.Civ.C.) -
0 U Lenders Name TOTAL:
W Lenders Address TOTAL
C4 1 certify Ihnt I have rwd this application and state that the ricer information is MECHANICAL PERMIT FEE BUILDING FEE
N carter l agree m comply with all city and county ordinances and state laws mining to QTy.
U ti building construction,find hereby authorize representatives ofthis city to enterupon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify amt keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmenu,costs and expenses which may in any way seeme against said City ALTER OR ADO TO MECH.
in consequence of the granting of this permit. - PLUMBING FEE
APPLICAN UN RSTA S AN WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TD 10,000 CFM)
SOURCE -G ,❑O MECHANICAL FEE
8� S - AIR HANDLING UNIT(OVER 110,0X0 CFM) CONSTRUCTIONTAX
mrca Appli p Die EXHAUST HOODDYMUCT7
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will
yinge applicant
etim future Muni buildiocie.Chantsrore2, it a HgwRb rad Safety HEATING UNIT(I'Q 100.000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.13,and He Health tad Sa(ety
Code,Sudors V1532 aC HEATING UNIT(OVER 103,000 BTU)
❑Yes Fl No
VENTILATION FAN(SINGLE Rom) PAID
Will the applicant or future building Occupant use equipment or devices which Date Receipt«
mit harodous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR i00,00i
Dindct9 '
❑Yes No BOILER-COMP(OVER 100"BT it TOTAL:
I have reud the Meanings materials ostuiremenb under Chapter 6,95 of the Cali- AIR CONDITIONER
fomia Health&Safety Cade,Sections 25505,25533 and 25534.1 uoderslvW Nol if the ISSUANCE DATE
building d«s not curse"By have a tenant,that it is my rtspinsibilityto notify the occupant NEW RESIDENTIAL MECH. SQ.FT.
of Bat H go mments which must be met prion.issumce of u Cenifcme or Oecupmu,
Owner oT authorized agent Date TOTAL:
- ISSUED BY,
OFFICE /