30737 .5rt-o us w3F ru r111L By Us runrvwl IUN WI I HIN NEU LINES-USE BALL POINT PEN ONLY - P
' CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING-MECHANICAL .30737
BU LDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
u
OWNER'S NA E'. •fir PHONE: CONTRA T R'SN rAME. 'x LIC NO:
�. V,1 -e V 'I `. �C I CONTROL#
1RCHITECT/ENG EER: LIC NO: ADDRESS: _
CONTACT: _ PHONE: - BUIL PERMIT INFO
.❑ Consultant Fees Paid by Applicant(Initial) .D ELECT PLUMB MECH
,1. LICENSED CONTRACTOR'S DECLARATION ❑ 1:1 E
I Hereby affirm that I am licensed under provisions of Chapter 9(c tmoducin QTY' ELECTRIC PERMIT FEE
OC P 6
zw
iib Second]000)of Division3 of tha Business end Profcesions Cade,and myl¢ensels 70B DESCRIPTION
� in full force ode t L /r, PERMIT ISSUANCE RESIDENTIAL
ya . F
F+�W Liedg Clan -` Lie# 1 ❑SPDWL ❑KITCHEN REMODEL
Datey d Ccntrac 1 1e APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
[_Mtn ,ARCHITECT'S DECLARATION
z O n I understand an,plans shall be used as public records PANELS ❑MULTI-UNIT. ❑STRUCTURAL.
r'Z"O UPT02WAMPS - MODIFICATION
�.y.E'tr1 Lmensed,ou—mnal ❑
201-1 WO AMPS INTERIOR ❑CHIMNEYREPAIR� OWN -ER�BUILDER DECLARATION IMPROV NT
yy �u,II 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000AMPS ❑B EMODEUREPAIr E]DEMOLID
pg30.F following reason.(Section 003P.5,Businessand Professions Cale:Any city or county SIGNS ELECTRICAL '
WW which requires a permit to Ommad ct,alter,improve,demolish,or repair any structure THE
y prior to its issuance,also requires the applicant for such permit to rile a signed statement. SPECIAL CIRCUIT/MISC.
TapNathe is licensed pursuant m the provisions of the Contractor's License Law(Chapmr 9 _
(commencing with Section]0W)of Division 3 ofthe Businessand Professions CodO)nr ,
G TEMP.METER OR POLEI - OMM R IeI
L n 2r that he is exempt therefrom and the basis for the alleged exemption.Any violator of C NEW ERCIAI
{� Section 9031.5 by any applicant for a permit subjects the applicant to a civil ❑DEMOLITION
^w penalty of POWER DEVICES ❑TENANT ❑F CE
not mom than five'hundred Dollars($SW).
� O I,as owner oRhe propery,or my employees with wages as their,sole compensation, 'SWIMMINGPOO LECfRIC 'IMPROVEMENT
�N wdl tlO the woh,and thesWeture is not intended oro8'ered for sale(SecJ044,Business IMPROVEMENT
add Professions Cale:The Contractor's License Law does not apply to an owner of OU9'LETS- ITCHES-FIXTURES
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 R DENTIAL ELECfR Q FT. '
sale.If,however.the buildingor imm
proveent exalt!withinoneyearolbompletioo,the SQ.FT.FLOOR AREA EISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
poseofsale). - _
❑I,as owner of the propery,am exclusively contracting with licensed contractors On TOTAL -
construct the project(Sec,](N4,Business and Pre'llins Cede:)The Contract.,.,Li-
cense Law does not apply to an Owner of property who builds or improves thereon,and TY PLUMBING PERMIT FEE
who contract for such projects with a contractors)licensed putsuunt to the Commwo'
License Law.
❑1 Om ezemPt under Sea ,B&P C for this mason PERMIT ISSUANCE
Owner • Date ALTER-DRAIN&VENT-WATER(EA) JVALUATION
WORKER'SCOMPEMATIONDECLARATioN BACK FLOW PROTECT,DEVICE Q
I hereby affirm under I...try of peimy ne of the following declarations: /• ,r/)/�®ta,
I have and will maintain.Certificate of Consent to self-insure for Worker's Comped, pRAINS-FLOOR,ROOF AREA,GOND. 1 sf'W
nation,ns provided for 1j Section 3]00 Of the Labor Code,for the performance of the STORIES TYP INSTRUCTION
k for which this permit ie is sued.' FIXTURES-PER TRAP
and
out
quired
Section
.�00 of the
Lead
nrlC den(nr the Performance ofthe work for which the permit is issued, GAS-EA.SYSTEMA INC.4 OUTLETS
My Wmker's Corypensptinniggurre�¢„ierand Policy n❑mb¢ - OCG GROUP APN
Cariev F �dlicy No.: ` GI O7� �- GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ve� 3
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE I RCEPTOR
(This section need not M cempled,d if he permit is for one hundred dollars($1 W) BUILDDprrI���..NN¢G DIVISION FEES
or less.7 GREASE TRAP PLANCHR&DK'R}lE. VD
I certify Nat.the performance of the work fine which this permit is ers'C. ,O-
Znim,Law any fCidi rein.Dy runner so ue mbecome subject to the Worken'Compen- SEWER-SANITARY STORM EA.2W FT. ENERGY FEE
A I Laws of California.Dote
O Applicnt WATER HEATE /VENT/ELELTR •
.r NOTICE TO APPLICANT:If,after making this Cendenic of Exemption,you should GR
P4N WATERS M/fREATING
become subject to the Workers Compensation provisions of the Labor Cole,you must SOI FE
forthwith comply with such provisions Or this permit shall Fs deemed revoked.
� (� WATF SERVICE i
sJ z CONSTRUCTION LENDING AGENCY
UO 1 berebyafOrm that there iso communion lendin RESIDENTIAL PIMB. SQ.FE PAID
g agency for the performance of R
0 H the work for which this permit is issued(Sec:3097,Civ.CJ D eceipt#
_
0 U Lender's Name -
y yLenders Address TOTAL: TOTAL
I certify that 1 have read this application end said,that the above information is
DING HE
ti
to cored f agree to complyand with all city and county ordinances of and store laws r upon the Q7•y MECHANICAL PERMIT FEE
V
building conswction,and hereby amhonprposesenmtives Of Niscity mentor upon the SEISMIC PEE
shove-mentioned property for inspection purposes. -
(We)agree to save,indemnify and keep harmless the City of Cupertino PERMIT ISSUANCE
P d ELECTRIC FEE
inexinacq arcafindcosts and expenses which tray in any way accrue against said City
inconsequence UNDERSTANDS
SthisD WIL. ' ALTER OR ADD TO MECH. PLUMBING FEE '
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT UD 10,000 CEM)
SOU 'REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0)0C ) MECHACONSTUCAL F TAX
a tore of AppllcanVCanaactoe Dote EXHAUST HOOD(W/pUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant.store or handle hazardous material HEATING UNIT(TO itatWO )
as defned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(.)1 HEATING UNIT(OVER t"BEE)
❑Yes. ON. p
7 VENTILATION FA ,INGLE RESID) PAID'
r Will the applicant or future building occupam use equipment or devices which ate Receipt#
mhicaz.rdoairincormminams as defined by the Bay Area Air Quality Management BOILER-CO (3 HE OR 100,001 BTU)
Disvict, TOTAL:
❑yes ON. BOILER- MP(OVER 100,000 BTU)
I have read the bargaining materials requirements under Chapter695 of the Cali- AIR DITIONER i
been Health&Safety Code,Sections Z5505,25533 add 25534.I understand that if the ISSU NCE DATE
building dcexnot currently have atenant.that it is my respnnsibiliry to notify the occupant N RESIDENTIAL MECH. SQ.FT.
of the requirements which most be met prior to issuance ofa Cenifieum of Occupancy, '
Owner or aunn000e.agent Dam TOTAL:
, t ISSUED BY
OFFICE