30027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATIONIPERMITPLUMBING-MECHANICAL 3002
7
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITTAL DATE
OWNER'S NAME: PHONE: CONTRAC'TOR'S NAME': LICNO:
gilpe NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
S Sc )
CONTACT: PHONE: BUILDING PERMIT INFO
I I') g 1 1 `�j.L���.- / �•���� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
l�V /V N N ❑. E� ❑ ❑ .
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
�t1 hereby. ion that I am Ransed ager pmvisloas of Ch.pter 9 uammenel., JOB DESCRIPTION -
58zc with Section 7") Division 3 ofthe Business and Prafessiuns Code,and my license ix RESIDENTIAL:
DO PERMIT ISSUANCE
wF. ata Torecan t. ❑SFDWL 0KITCHEN REMODEL
�y1 Uz111f---J... License Cla Lie.# / CADDITION []PLUMBING RE-PIPE
F. Dare Contractor APPLIANCES-REg1UENTIAL
ARCHITECTS DECLARA IONPANELS []MULTI-UNIT []STRUCTURAL
F 7 y
MZ Z 1 understand my plans shall od used as public records s MODIFICATION
K4HUL-I"AMPS []IMPROVE []CHIMNEY REPAIR
Licensed Prafwsionul 2111-I(NM)AMPS IMPROVEMENT
'� OWNER-BUILDER DECLARATION
O w 6 1 hereby affirm that I am exempt from the Cnauucmrs Liecnm Law tis the OVER 1000 AMPS ❑BATH REMODEIIREPAIR []DEMOLITION
KL U following reamn.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL C OTHER
w which requires a permit m conswct,alter,improve,demolish,or repair any structure
ffi>. prmam its ismance,dm requires the applicant for such pearnimo fleasignedemtemem SPECIAL CIRCUIT/MISC.
shat he is licensed pumuant to the previsions of the Contractor's License Law(Chapters)
CO£ (commencing with Section 7000)nf Division 3 of the Business and Professions Cade)or TEMP.METER OR POLE INST.
L that he is exempt therefrom and the basis for she alleged exemption.Any violation of []NEW BLDG/ADDITION []DEMOLITION
s+
Section 7011.1 by any applicam fm a permit abjectsthe applicam to a c!,it penalty of POWER DEVICES
'[]TENANT []FOODSERVICE
nos mom than Ove tonal dollars($S(X). IMPROVEMENT
C]6 I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
y G will do the work,and the structure is not intended oro]Tered far.1,(See 70414,Business COTHER
til and Professions Code:The Communes License Law dues not apply m an owner of OUTLETS-SWITCHES-PDOFURES #
property who builds or improves domain,and who does such work himself or through
his own employees,provided that such improvements are nut intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
at.If,however,she huddling or improvement is sold within one yem.LmmpIcimm,the SQ.FT.FLOOR AREA s/SQ.PT.
mover-builder will have the burden of proving that he did not build or improve for put-
pose of sole.). L' 'LL
❑1,as owner of the property,am exclusively contracting with licensed coruc
nttots 1. TOTAL:
construct the project(Sec.7044,Business and Professions Cade:)The Contmetars Li.
cinve Law does ma apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE JUN 10 1996
who contracts for such projects with a conva,ums)licensed Pursuant o the Contmemra
License Law. PERMIT ISSUANCE
Cm
laesemptunec
de,S . ,B&PCfmrhisrwxm CITY Lit. uurerTtiN
Owner - Data ALTER-DRAIN&VENT-WATER PEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby offirm under penalty of perjury one of the following declarations:
❑I have and will maintain a CenifcateofConsenuo scli-insurc fur Workers Compen- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONSTRUCr10N
nation,os hick this
for mi Section 3]00 of the Labor Code,for 0o perfornanee of the --
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation the
work
hi h required by Section
l]IlO of me labor Code.for the performance of the work for which this permit ixissuW. GAS-IIA.SYSTEM-]INC.4OUTLETS OCC.GROUP APN
My Wmkcts pensation lnsumnce(( and Policy n r
[]entice 3A/ Policy No.: — GAS-EA.SYSTEM-OVER 4(EA)
CERTIFlCIF PfION FROMWORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Tbissnetionneed not becomplesed ifinepamit is Wore hundred dollars($100) GREASETRAP
odes.) L K HE
icenifymasintheperfo roof Neworkforwhichmislmnit isissuW,ishnlI SEWER-SANITARY-STORM EA.200 PT.
.at employ any person many manner so as tybe���7vvl to the Workers Compen- EN .E
z ,Z moon Laws of Cxlifomia.Dam ffee (� (o WATER HEATER WNENT/F.LECTR
Applicant ��� GRADING FEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYS'rEM/TREAG NO
a ^ become subject to the Warkers Compensation previsions of the Labor Code,you must SOILS FEE
G forthwith comply with such provisions or this permit shall he deemed revokul, WATER SERVICE
a
r7z CONSTRUCTION LENDINGng ENCYagency NEW RESIDENTIALPLMB. SQ.FT. PAID Date Receipt#
V 0 I hereby union that mem isaconswc.3 lending agency l'orthe performance of
the work foi which this permit is issue)(Sec.J09],Civ.CJ
LLx F lindcrs Name TOTAL:
U Lenders Address TOTAL:
L1J I cenify that I have read this application and stain that the shove information is BUILDING FEE
(A correct.l agrteto comply with ell city and coontyoNinancesandsumlawsmlatingtu QTY, MECHANICAL PERMIT FEE
U building construction,and hereby ambiance representatives of this city to enter upon the SEISMIC FEE
above-mentioned properly for inspection purppscs. PERMIT ISSUANCE
(We)agree a.save,indemnify and keep harmless she City of Cupertino against ELECTRIC PEE
Iiabilaics,judgments,costs and expenses which may in any way accrue againsland City ALTER OR ADDTO MECH.
in consequence of the grunting of this Permit. PLUMBING FEE
APPLICANT UNDER A AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFEE
SOURCE REGULAT S
s� / j / AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTIONTAX
Si4natureof Applirapu anFE
con (J to NN ( EXHAUST HOOD HOUSING MITIGATION E
H RDOUS MATERIALS DISCLOSURE
Will the applicant or future building race....sme or handle hexurdous material HEATING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hcslth and Safety
Code.Section 25532(.)? JJ HEAT]NO UNIT(OVER 100,000 BTU)
❑Yea I/JNn PAID
VF.NTIfAT10N FAN(SINGLE BESIDE Data Receipt#
Will the applicant or future building occupant use equipment or devices which
emir haearAous air commalmoa as defsnWb the Ba Area Air Quality Management BOILER-COMP(3HPOR L00,000BTIE
y y y TOTAL: 's3
Distinct? / - BOILER-COMP(OVER 100.00)WITE
11 Yes Zf<.
I have reed the h trardous materials requirements under Chapter 6 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
huilding docs not cunt,have a tenant,that it is my responsibility to notify the mcupuot
of the ox,motenu which most be met pd.".issuance of a Cenificare mf Occupancy.
Owner or euthorired agent - Data TOTAL: ISSUED BY:
OFFICE