30914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �O �i /I
BUILDING DIVISION - APPLICATION/PERMIT PLu.Memc•MECHANICAL. 1 L�
BUILpING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
x (9?LS; arwa kw eu 2 •
OWN 'S NAME: - HONP.,:� � CONTRACTOR'S NAME: LIC NO:
('IJG NIC CONTkOLa
RCHITECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
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0 e ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
G' t Rf� y� .-,LDO ❑ 1:1 El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that l am licensed under powisiam of Chapter 9(comymencing ]OB DESCRIPTION
OO
Qzz with Section 7")of Division 3 ofthe Bminessand Professions Colu ndm licenecis
�
U-. in full and effect. PERMIT ISSUANCE RESIDfATIAL
U~L]] UNepecrnu Class Dc.p ❑S CI KITCHEN REMODEL
�n ZHDate Contractor APPLIANCES-RESIDENTIAL ADDITION [IPLUMBING RE-PIPE
ARCHITECTS DECLARATION - ❑MULTTUNIT ❑STRUCTURAL
O
n Z 1 understand my plans shall be used as Public records PANELS
Z MODIFICATION
OZ— OWNER-BUILDER DECLARATION UP TO 200 AMPS ❑INTERIOR LJ CHIMNEY REPAIR
�� Licensed Professional 201-1000AMPS IMPROVEMENT
peek ❑
vyq+,0.' 1 hereby affirm that 1 am exempt from me Contractor's License Lew for the OVER 110gs"PS BATH REMODEIIREPAIR C3 DEMOLITION
In
>(O M V Ibllewing reason.ISmion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LLLL17 W O{'] structure requires a Permit to construct,alter,improve,demolish,or repair any scture
.:71 Edo,,.its issuance,also requires the.,,licent forsuch permiuo file.signed statement
Ba SPECIAL CIRCUI LSC.
hat he a� acommencingwitcensed pnrsuamlatheofDivions sionftheeBusinsssLicenseLaw(Codeer9
OOO���S� QO Iconunencing with Secuon]fKK)of Division]of the Business and Professions Code)or TEMP.MET OR POLE INST. COMMERCIAL.:
a c sY thot he is exempt Nerefmm and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
^'Y• Section 7031.5 by any applicant for a permit subjects the applicant In a civil Penalty of POWEpAEVICM
m ❑'TENANT [I FOOD SERVICE
no more than five hundred dollars($500). IMPROVEMENT
QC] do the warofthe property.accurate is etinundmiet wegesaame(ec compensation. S MING POOL ELECTRIC
will dote work,end toheCris not intendede owe do far sale,ply 1.1r Business ❑OTHER
and property
who b Code:The Cnn thereas License Law Jas nm apply,.un owner of OUTLETS-SWITCHES-ImIXTURES
progeny who builJs or improves tcrcmn,and who Jas such work himself or Ihraugh
his own employees,provide that such tmpmvemenn are not intended m o@red for NEW RESIDENTIAL ELECfR
sale.if,however,the building or improvement is sold within oneyearafcomplefSQ.FT.FLOOR AREA YSQ.PT.
mer-builder will have the burden of proving that he did not build or improve f tar-
pose of vale.). pd
❑
I.as owner of the property,sm exclusively contracting wit licensed contractors to TO
construct the project(Sm.70,14,Business and Professions Cade:)The Cortmoors Li. aa,
cense law does nm apply to an owner ofpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FE {fQYNMI
whocontramu for such f micas with a contractors)licensed pursoanuo me Cammetor s
I, xe Law. ERMIT ISSUANCE ameaem under Se. ,B&PC for this..on CITY UrLUrtHTIN
_ ALTER-GRAIN&VENT-WATER IEA) VALUATION
Owner Date
U KER'I COMPL+NSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarmoro:
❑Ihave and willmeintain.Cenific.m afCanscnnaselLinsure for Workerx Compeer- DRAINS-FLOOR,ROOF,AREA,COND. STORKS TYPE CONSTR LUN
salion,as provident for by Section 37011 of the Labor Code,for the performance of of the
work for which tis Eamon is issued. FIXTURES-PER TRAP
EI 1 have and will annual Workers Compensation Insurance,as required by Section -
37Mofto Labor Code,for the performarmc,fthe work for which this permit is issued. GAS-E&SYSTF.M-IINCAOUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
SION FEESsee nomad net he mmplercd Baea.ir is far ars one hundred dollis 100) BUILDING DIVI
,.leu)MaxaxGREA. TRAP PLANCHECK FEE
I certify that in the performance afte work forwhich this Acura sissued,l shallLass SEWER-SANITARY-STORM EA.200 FT.
nutemployanypersonin any.unar se as to becamesubject,.the Workers ComNn- . ENERGY HE
O Z salion Laswof Cishfar io.Date WATER HEATER WNENTR3LECfR
7 Applicant ,GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEM/1'ItLATING
F+ become suhjat m the Workers Compensation previsions of the labor Cade,you must SOILS FEE
forthwith comply with such provisions or permit shell he deems]revoked, WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U 2 I hereby affirm that tem is emnalmetion lending agency for the performance of Raeipta
F-r the work for which this permit is issued(Sec.3097,Civ.C.)
IL f-m Lender's Name TOTAL:
C)U Lender.Address - TOTAL.
,�I.,�r 1 certify that I have read dus...licmion and state tat the above information is a BUILDING FEE
tr ta/3 correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby aumorize representatives of this city to enter uponte SEISMIC FEE
above-mentioned propeny for inspection purposes, PERMIT ISSUANCB
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme againn said CityALTER OR ADDTO MECH.
in consequence of to granting of this permit. PLUMBING FEE
APPLICA14T UNDERSTkNDS AND WILL COMPLY WITH AL1,NON-POINT Elk HANDLING UNIT(TO 111.00)CFM)
MECHANICAL FEE
SUU tEGU .LATIO
AIR HANDLING UNIT(OVER Uk" ) CONSTRUCTIONTAX
Sign u of pelican Connmmr Data EXHAUST HOOD(WMUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ampam smre or handle hamrd....normal HEATING UNIT(TO IIIA Tlq
os defined by the Cupertino Municipal Code,Chapter 9J 2,and the Health and Safety
Cale,Section 25532(x)? HEATING UNIT(0V 100,000 BTU)
❑Yes ONo P
VENTILATION N(SINGLE RESID) Dote Receipt#
Will the applicant or future building occupant use equipment or devices which BOILERMP(JHP OR IOO,IXIp BTU)
emit haurdous air contaminates ss defined by t -o Bay Area Air Quality Management TOTAL:
District? BOIL -COMP(OVER 100.00)BTU)
❑Yes QNo
I have read tc to modous materials requimmtenB under Chapter 6.95 of date Cali- z
CONDITIONER ISSUANCE DATE
forme Health&Safety Cade.Sections 25505,25573 and 25534,I understand that if the 04 NEW RESIDENTIAL MECH. SQ.FT
building does outcome a ant,mat it is myrespons'bihty to ratify the occupant
to b whi uv ¢t prim,.issuance of a ficeu;of y.
woe mmodzed agent Data TOTAL: ISSUED BY:
OFFICE