30291 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO 'u BUILDING-ELECTRICAL, PERMITNO.' O
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - l (SANITARY NO. APPLICATIONSUBMITTALDAU
16199 s air, Ave Caper ThioI C' A 95-N � • . Q.
OW R'SN;ME: f r•�rm� PHONZE: -�� - CONT15pCTOR'S NAME: LIC NQ: s
G. ✓ S NIC COMROLK
'RCHI1 EGTV• (NEER: LIC NO: AD R S. ` ,r� ❑ t
CONTACT: - PHONE: BUILDING PERMIT INFO
� / �5��_ D_/,/ ❑ Consultant Fres Paid by Applicant(Initial) .BLDG ELECT -PLUMB' MUCH
LICENSED CONTRACTOR'S DECLARATION YY QTY. ELECTRIC PERMIT FEE ❑
(hereby affirm that I am lactated under provisions of chapter 9(commencing JOB DESCRIPTION -
�OZO with Section70(add Division 3of the Business and Toamasina,Code,and my license is -
F Iy F in full force and If t. �. 2s-29 / PERMIT ISSUANCE
U U License CI Lie.N G < )) FDW L r ❑KITCHEN REMODEL
PVal Dnre�Command,
z�isratiA�rr - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
[yF..py "' ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT. ❑STRUCTURAL
y0 p tr�'� I undeamntl my plans shall be used as puFlic acords MODIFICATION
UPT0200 AMPS El INTERIOR C1 CHIMNEY REPAIR
�"[zJ tttrr�111 Licensed Professional,�bdOWNER-BUILDER DECLARATION �� 201-IUW AMPS IMPROVEMENT
09 CCCC Q 1 hereby affirm that I um exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR''0 DEMOLITION
?p5,O y U following reason.(Section 903 L5,Business and Professions Code:Any city.,county SIGNS ELECTRICAL ❑OTHER
W F which requires a permit to construct,alter.improve,demolish,or repair,any s.uaure A R F
y prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIACCIRCUIT/MISC. •n
yWWy ACIV V^1.
met he is licensedp.reuant to the providnsof the Carl...to,',License Law(Chapter 9 A-✓-
(commencing with Sermon]000)of Division 3of the Business and Professions CnJe)o�
TEMP.METER OR POLE TEST COMMERCIAL:
y e K that he is exempt therefrom and me basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
fi�C ty
not
th LS by any applicant fmapertnit subjects me applicant roucivil penahy of POWER DEVICES ❑TENANT ❑FOODSERVICE
Z.Sy not El 1,-1-wan fveh.ndrWd1a.1 toy
employees
x� hos he wor ' the pmpeny.,myemntended wimwages astheirauto ee704.Business SWIMMING POOL ELECTRIC .IMPROVEMENT
�, will do he work'
aad the swcmrcisnots License La does of apply to
Business ❑OTHER
kd] ' and Professions Cnde:The Contractor's s License Law does not apply t.an owner 6f I OUTLETS-SWITCHES-FIXTU
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are ant intended or offered for NEW RESIDENTIAL ELECTR' FT.
sale.If.however,the building or improvement is sold within one yearof completion,the kLhPiM IODAREA $/SQ.FL
owner-builder will have the burden of proving that he did not build or improve for par- - F"' .
pose of eaten. - O
❑1.as owner of the property, exclusively contracting with licensed contractors i-
co - RUG
14 PEco
nsdwet the projem(Sec.]044,,B Business and Profession,Code)Tha CanOBVN
an.fs Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT
who contracts for such projects with a emnmcmr(e)licensed pursuant to the Commerce's �IY UY ppI�!!'�
License Law. PERMIT ISSUANCE Uf V CPIIIIYV
ID ❑I am exempt under Sec. ,B&P C for this reason
Owner - Data ALTER-DRAIN&VENT-WATER CA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of pejury one of the following declarations: ,
❑Ihave and will maintain aCettifiwte ofConsenuo self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sntion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES-.PER TRAP
Q�''1 have and will maintain Worker's Compensation Insurance,.required by Section
'S]Ilfl of Ne Lnbor Cade,for the performance of the work for which this permit is iss.ed. - GAS-EA.SYSTEM-I INC.40UTLETS ,OCC.GROUP APN
My Works's C n�penvtlo Insumnc aortia,and Polley nu�pe� y�e -
Carriec��.Policy No.:-Z=4,OXIOZ6r9 GAS-FA.SYSTEM.OVER 4(EA)
CERTIFICAT EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE "Coas"INDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars($100) BUILDING DIVISION FEES
or less.) GREASE TRAP -
PLANCHECKFEE
Ioy any Per in the fieffoanyannerpaht wnrvWsoicatto perthe it is Workers
ad,],hallCiminero-
SEWER-SANITARY-STORM EA.2110 lep
not employ any person in any mannerkp15 c subject to the Workers'Compen- ENERGY EEE - if
OZ cationarm of Ca to rel 9� "
O A lICE �f,a WATER HEATER W/VENT/ELECTR
�- PP GRADING FEE
w" NOTICE TO'APPLICANT.If,coat making this ifcate of Exemption you,should
WATER SYSTEM/IREATING
become subject m the Worker's Compensation provisions of me Lata,Code,you must SOILS HE
{✓a forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE ,
UO CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.LE PAID '
1 hereby effort that them is a construction lending agency for the performance of Date Receipt is
Hthe work for which this permit is issued(Sec.3097,Civ.C.) ,
OLeadef,Name TOTAL:
[D�] Lender's Address TOTAL:
y 1 really that I have read this application and smote that the above information is BUILDING FEE
V7] correct,I agree te comply with all city and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE
U G building construction,and hereby authorize reprocomouises of this city m enter upon the 'SEISMIC FEE
abom
ve- entioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC ME "
liabilities,judgments,cats and expenses which may in any way accme against said City ALTER OR ADU TO MECH.
in consequent.of the granting of cols permit. PLUMBING FEE
APPLIC IT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR EGULAT - MECHANICAL FEE
�L.-� AIR HANDLING UNIT(OVEB 10,"CFM) CONSTRUCTION TAX'
Sig amre of ApplicantlCnntmtlor _ CCCJJJ /Date' EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZAREGGS MATERIA 'DISCLOSURE
Will the applicant or future building pamstne,or handle hazardous material HEATING UNIT(TO 100,000 BTU) x
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Can Section 25532(a)? ❑Na- HEATING UNIT(OVER 1(0,000 BTU)
VENTILATION FAN(SINGLE RESID) PAID -
Will the upplice I or future building occupant use equipment or devices which Data . Receipt it
❑Yee
emit hazardous it conaminants as defined by the Bay Area Air Quality Management BOILER-COMP ETW OR 100,0000TU) `
District? TOTAL:
❑Yen FI No BOILER-, COMP(OVER100,000 BTG)
have rend the hazardous materials r AIR CONDITIONER ISSUANCE DATE
requirements under Chapar 6.95 of the Cali- -
Farm.Health At Safety Code,Sections 25505,25533 tad 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.FT. '
building does not currently have a tenant,that it is my responsibility humidify the dccup.,
'
of the requirements which must be met prior to issuance of a Cenifcd,of Occupancy. go- r
Owner or submitted agent Data - TOTAL: ISSUED BY:
OFFICE