30147 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO, O
BUILDING DIVISION >. APPLICATION/PERMIT PLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION
147
BUILDING ADDRESS: ry SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME:���� ^ PHONE: _,fq�A
ACfOR'SN ^E: LIC NO: --NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: g: � l^ ❑
^J - _0C b
CONTACT PHONE:PHONE: BUILDING PERMIT INFO
'r- t J P��,� '. rN '` 17q["� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSE'DVCONTRACTO ' ems �••• d[ 4� ❑
( RS DECLARATION' QTY. ELECTRIC PERMIT FEE'
I hereby affirm that 1 am licensed under provisions ohs Code, 9(commencing - 'JOB DESCRIPTION
I�l�OZ with Sectionae 7")of Division 3oftheBusiness and Professions Code,and my license is RESIDENTIAL:
FSB in full force ad ffecn. PERMIT ISSUANCE
U V Licens lasx ���� �33 LL Lic.M Q ' - ❑SFDW L' El KITCHEN REMODEL
y6G Dote- C_(.�Conemdor APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
F,pm ARCHITECTS DECLARAION r PANELS El MULTI-UNIT Ll STRUCTURAL*
O2 I undemmnd my plans shall be used as public records . MODIFICATION
UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
EarW W Licensed Professional 201.1000AMPS IMPROVEMENT -
,OWNER-BUILDER DECLARATION �/-
M' Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REM OEUREPAIR ❑ 'MO ITION '+
ip5,O d U following reason.(Section 7031.5,Business and Professions CWe:Any city or county SIGNS ELECTRICAL ❑OTHGR I ,W
sa+ WO mFe• which requires a permit to consumer,alter,improve,demolish,or repair any structureQ A 1 1'1
m.] prior to its issuance,also requires the applicant for such pemtitto file a signed statement SPECIAL CIRCUIT/MISC. e
G� that he is licensed pramentm the provisions f,he Crucifer,License Law(Came,9
O� (commencing with Section 7")of Division 3 of the Businessind Professions Coi TEMP.METER IOR POLE INS T. COMMERCIAL t
q M ez that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION [I DEMOLITION
i4Ci Yy Station l031.5 by any applicant forucermit sub eels the applicant toacivil penalty of POWER DEVICES []TENANT [I FOODSERVICE
I„1 y not more man five hundred dollars($500). IMPROVEMENT
Q ❑ Lasowneriefthe properly,or my employees with wages as theirsole compensation, SWIMMING POOL EL TRIC
will dome work and the structure is not intended methanol muscle(See.7044,Bu sines - ❑OTHER
Wh and Professions Cole:The Contractors License Law dna not apply m an owner of TOUTLETS-SWITCHES FI TURLS
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements aro mot intended or offered for NEW RESIDENTIAL EL SQ ET.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.ET.
ownerEuilder will have the burden of paving that he did not build or improve for port- ppi�tt
'poseo.1 ma
TO y^' �1 p
❑Las owner of she Property,amuvexclusivelycnd contracting with licensed eomneum, to "U C
onswat the pmJmt(Sec.]044,Business and Professions CaleJ'Tha Contracmrs Li- `
range Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT PEE O '
who contracts for such pajects with a commuters)licensed pursuant m the Cenumco is V A
License Law. PERMIT ISSUANCE }•♦., r7
I am exempt under Sec. B&P C for this reason _ cr I l t _ 6
ALTER-DRAIN&VENT-WATER(EA)
Owner � Date - �-VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE �y,�ifgV
I herebyaffirm under penalty of perjury one of the fellawingdeclamtiovs,
have and will maintain a Certificate of Consent to self-ins Mm Worker,Compen- DRAINS-FLOOR,ROOF,AREA. ND. STORIES TYPE.CONSTRUCTION
armor,as provided for by Section 37W of the Labor Cade,for the performance.1 the
work for which this Permit is issued. FIXTURES-PER TRAP '
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work fit Policyor which�this permit is issued GAS-EA.SYSTEM-I INC.4011TLETS OCOGROUT APN
CnWfr is Com ensmien nsurencYQ•r�'rPN iy,Ne�(S� GAS-EA.SYSTEM-OVER 4(EA)
CE IFICA'TE OPlIER'E''Mam
PTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE FP3:S
(This vacuum need not be completed if the parmit is forone hundred dollars(SlOi) BUILDING pIVISION
orlese) - GREASETRAP -
I cereify that in the performance ofthe work for which this permit is issued.I shall PLANCHFAK FEE
rm,a oy any Person in anY manner suss to become subect to the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. -
'
OZ cation Lacca of Culifomis.pate ENERGY FEE
WATER HEATER WNENT/ELECTR
O Applicant � LEADING FEE
In NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING '
abecome subject 1.the Worker's Compensation previsions of the Labor Code,yon must SOILS FEE
{✓a forthwith comply with such provisions or this peonit shall he deemed revoked. WATER SERVICE '
04
z CONSTRUCTION LENDING AGENCY_ NEW RESIDENTIAL PLMB. SQ.FT PAID
V I hereby affirm that there is a construction lending agency for the performance of - Data Receipt#
W F the work foi which this permit Is Issued(Sec.3097,Civ.C.)
Q Lender's Name TOTAL:
LU Lender's Address TOTAL:
1 send,that 1 have read this application and stale that the above information is BUILDING FEE
Fw V) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V,Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned Property for inspection psrposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
the ,still,
ex this stoat, may inany way ncerve against said City ALTER OR ADD TO MECH.
in consequence of the graining of this permit. PLUMBING FEE '. 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1X10 CFM)
S CE REGULAT MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTIONTAX
Si
wo
gnawre of pplicanVContra tar ate EXHAUSTHOOD(W/DUCT),
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store of handle hazardous material HEATING UNI'P(TO 100,000 BTU) , _
as defined by the Cnpcimem Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 - CHEATING UNIT(OVER 100,000 BTU)'
❑Yes
W. VENTILATION FAN(SINGLE RESID) PAID,
Date Receipt#
Will the applicantorfuture definedding occupant use equipment ordevices
ement BOILER-COMP(3HPOR 100,000 BTU)
mit hazardous air contaminants as define)by the Be,Area Air Quality Management -
Distnct4 �J BOILER-COME IGINEBTU) - TOTAL:
❑Yes - No - '
I have read the hazallous materiels reoiremems unJer Cha tar 6.95 of the Culi- AIR CONDITIONER
9 p ISSUANCE DATE
humin Health&Safety Code,Smfiom 25505,25533 end 25534.1 understand mat if me NEW RESIDENTIAL MECH. SQ.FT.
building does not cumendy have a tenant,that it is my responsibility to notify the occupant
f the requi mems w use be met prior to ismance of a Certificate of Occupancy.
S;3i4 ys.a 7^3-9
Owner.1rthme,rd a gent Data TOTALISSUED BY:
OFFICE