30807 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING:ETR
LECICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT • - PLUMB'D MECHANICAL
BUILDINGADDRESS O o Q O
BUILDING PROJECT IDENTIFICATION: t -
' a . SANITARY NO. APPLICATION SUBMITTAL DAT 5oi o
OWNER'S NAME: Q.a
PHONB� ONTRA R'S NA LIC NO: p
2S '— CONTROL#
ARCHITECT/ENGINEER: ,LIC NO: ADDRESS: ❑ -
CONTAC`P.. PHONE:
BUILDING PERMIT INFO
s ❑ ConsultantFees Paid by Applicant(initial) BLDG ELECT P UMB MECH
,�. LICENSED CONTRACTOR'S DECLARATION QT y ELECTRIC PERMIT FEE ❑
I hereby a1Brm mat f am Raenaed ander pronLs;dna.f Chapter 9(commencing JOB DESCRIPTION
�CZO with Sation]OW)of Division3of,heBminess and Professions Code,and my license is ,T
m tali lose and a ec PERMIT ISSUANCE"
IwZE UceneeC . G Lic.# SFDWL ❑KITCHEN REMODEL
FZaI Dae Comracmr' APPLIANC&S-
RESIDENTIAL
rn6y ❑ADDITION r❑PLUMBING R&PIPE
O�„pra ARCHITEmatin LAR PANELS ❑MULTbUNIT, ❑STRUCTURAL.
tp1 Z 1 understand my plans shall be matins ods MODIFICATION
� UP T02W AMPS [I INTERIOR - ❑CHIMNEY REPAIR
�gww ''sl Lensed Professional 201-IOMAMPS IMPROVEMENT-'
`1 OWNER-BUILDER DECLARATION
—04 !'hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 10f10AMPS ❑BATH RE��O•��D••��E.. EP}}aa''���uu-- ❑DEM{n-'r(TION
3 d F following reason.(Section 9U3L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL �,�yy l3VL� O�'C?Yx rTl (.L
4N which resl.ircs a pumh m oonswct,ober.im p y s p¢OTHER C I IPI 11
FI'„O¢ prove,demolish,ore air signed ware - 'tQPoor 'F��REYRDy E}�L`-p
shm.] that he,l c ensed p.. requires thovisio,of far such Candoormiuo Ele a ow(statement
y that he isliaensedpursuamtome provision,of SPECIALCIRCUIT/M1SC.
{{yy provision (Chapter
(commencing with Section]WU)uf Division 3o17the Businessand Professions Code)or TIME.METER OR POLE INST. COMMERCIAL-
66i5�n W that he is exempt therefrom and the basis for the alleged exemption.Any violation of I
NEW BLDG/ADDITION El DEMOLITION
a4�rn
Scene.7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
El n t more man five hundred dollars($500). - ❑TENANT
❑FOOD SERVICE
� 0 (]I,as owner of the property, IMPROVEMENT
p, y my compensation, SWIMMING POOL ELECTRIC
�e will dome work,and theama.reis not intended or offeredforsale(Sec.7044,Business ❑OTHER
0.,3 an and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
property,who builds or improves me con,and who does such work himself or through
his own employees,provided that such improvements are not intended or offeredPor NEW RESIDENTIAL ELECTR SQ
sale If,however,me buddingorimprovemem is sold within one yearofcnmpletion,the SQ.PT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sola.). -
❑I,ac ownerof the proper,ran exclusively contracting with licensed comrec, to r L: �y
onsu irl the project(Sec.9044on
,Business and Professions Code:)]me Convauor'e LI= r AID
cense Law does not ripply i......er of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pjects with a.."plans)licensed pursuer,m the Comment,,, `
License Law,.
C] am PERMIT ISSUANCE OCT 24 RECIB
1 exempt under Sec. - � .B&P C for this reason PERMIT
((f
Owner Date _ ALTER-DRAIN&VENT-WATER(EA)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEr QUrtkA'110N
1herebyaffirmunder penalty ofperjuryone ofthe following orker''s Co �-
❑l Invests]will for b in a Cion 37 eof the Labor
Craft,
6r Worker's ce of the
DRAINS-FLOOR,ROOF.AREA,COND,
radon,r provided for by Section 3]W of the LaM1nr Code,for the Performance of the STORIES TYPE CONSTRUCTION
work have
this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as his prequired t i Section
'37 of me Labor Code,for me,perfomianeeofthework for which this permit is issued. GAS-EA.SYSTEM IUNC.4OUTLETS OCC.GROUP APN
My Wor Companion u aei and Pmicy^yn1
.Cartier
Policy ROM ORKEtlt 7`A�b� 'GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OMPE POMON WORKERS'COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
Otis sectio.need not be completed lfthe permit is for one hundred delta,,($I W) - BUILDING DIVISION FEES
or less.) • GREASETRAP PLANCHECK FEE
really that in me perf ncroma a of the work for which this permit is ismad,l shall
.notemploy anyp miry mann¢ bcome sui the Workers'Com pen- SEWER-SANITARY-STORM EA.2W IT.
0 Z 'radon Laws of Ca oro a Date - ENERGY FEE
O Applicant Oxw�A WATER HEATER W/VENT/ELECIR
GRADING FEE
h NOTICE TO PLI ,aft¢ ma ung this rtifcate of Exemption,you should 'WATER SYSTEM?REAPING
ti baome mbjat ie Worl pensatien proaisions of the Labor Code,yan mum !SOILS FEE .
WRj faahwith comply with suchprovisionsor ihispermitshall hedeemedreyoked. WATER SERVICE,
Z CONSTRUCTION LENDING AGENCY' NEW RESIDENTIAL PLMU SQ,FT, PAID '
U 0 !hereby affirm that them is a construction lending agency for the Performance of ' Date Receipt#
{is !P the work for which this permit Is issued(Seo.3097,Civ.C.) r
Q U Lenders Name - TOTAL:
>� W Lender's Address TOTAL: ,
alBUILDING PEE
1 certify that 1 have read this application and slate that the above information is -
ims ti) comet 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building ennsunction,and hereby authndre representatives of miscity to enter upon me SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may I.any way,acerae eg.a.,,said City ALTER OR ADD TO MECH.
I.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALC'NON-POINT AIR HANDLING UNIT(TO 10.0(10 CFM)
SOURCE REGULATIONS, n MECHANICALFEE
I AIR HANDLING UNIT(OVER 10."CFM) CONSTRUCTION TAX
Signature of Apphcan✓Convmtor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE r HOUSING MITIGATION FEE
Will me spidcen,or name building oecupan,smre or handle h...Won,mammal HEATING UNIT(TO I Of,"BTU)
ns defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safety
Cale,Section 25532(a)7 1 _ HEATING UNIT(OVER 1 W,UOo BTU)
❑Yes ❑No
Will mea applicant or future building VENTILATION FAN(SINGLE RESID) PAID Dace Retain,#
pP g occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR I00,000 BTU)
District? ,TOTAL:
❑Yes1 E3 No BOILER-COMP(OVER 10100 BTU) -
I have read the hazardous materials requirements under Chapter 6.95 of r Culi- AIR CONDITIONER 5 -
Rome Health&Safety Code,Seniors 25505,25533 and 25534,L understoodunderstoodmISSUANCE DATEut if the NEW.RESIDENTIAL MECH. SQ.FT.
of;h,ca upom currently notave Ineenet now on
isua responsibility of aCto careofymeacapant
" of me requirements wmeM1 must ire met prior to iasuenea o(u CertiOeme.[Oecupancy.
Owner or authoneed agent
Data TOTAL: ISSUED BY:
OFFICE