30248 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OFCUPERTINO - - BUILDING-ELECTRICAL^ - - PERMIT NO.,,30248 O /N p
4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J( L VX
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DATE
• 0 2D me t✓P � '
OW 'S NAME: P O C CTOR'S NAME: LIC NO: NIC CONTROL#
Dn un 3 3v9 lxrurnahn.P/b ) ?5a9
ARCHITECT GINEER:. LIC NO: AO REBS: ` - 2 ,❑ ,
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w/owri
C ACT: TSO PpyO/NE: S, BUILDING PERMIT INFO
//f� 3 O f0^D�3 3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB n
WIIJ .X�FWC(/N�-•tea ❑
LICENSED CONTRACTORS DECLARATION, QTY. ELECTRIC PERMIT PEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing J09 DESCRIPTION '
OZ with Section]000)of Division 3 tome Business and Professions Contained any license is
r in full force a Iffect PERMIT ISSUANCE
�U J License Cl ass Lto. S� SFDWL El KITCHEN REMODEL
rFaU� APPLIANCES
6 DnteH�Contmcmr .. ❑ DDITION El PLUMBING RE-PIPE
,Doti ARCHITECT'S DECLA ATION ❑MULTI-UNIT ❑STRUCTURAL
I understand m leas shall be used as public records PANELS
x OrRfr.� YP p � - MODIFICATION '
Ox— s UP TO 200 AMPS. [:J INTERIOR ❑CHIMNEY REPAIR
Licensed Pmfessional 201-11"AMPS -IMPROVEMENT
�09
OWNER-BUILDERexemptman CLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
a W I hereby affirm that 1 am exempt from the Contractor's License Law for the
iipp55,� 0.0 following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
s't i3 C)v11 which requires a permit on
to construct,alter,improve,demolish,or repair any structure.
�N; P17 7-
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITNISC.
} thahe'slicenaed ,t
p...ano theprevisions of the Connector's License Law(Chapter 9
0)o _
OC (commencing with Secdon]00f Division 3 ofthe Business and Professions Code) TEMP.MITER OR POLE REST COMMERCIAL: '
d
ca that he is exempt therefrom end the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
^la, -
Section l031.5 by any applicant for v permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
p. not more Nan five hundred dollars(SSW). IMPROVEMENT
0 ❑Lasmmerofthe property,.,my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will tlo the work,and the swa'..is not intendcd.foRered for sale(Sec.]044,Business ❑OTHER
3 and Professions Code:The Contractors License Law deer not apply to an owner of OUTLETS-SWITCHES-FIXTURE
property who builds or improves there..,and who 3cea such work himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
salufco
e.If,however,the building or improvement is sold within oneyeafmplediat the SQ.FT.FLOOR AREA $ISQ,FT.
owner-builder will have the burden of proving that he did not build or improve for put. -
pose of sale.). -
❑1,as owner of the properly,um exclusively cnmecting with licensed conwcmts to TOTAL: "
construct the project(Sec.7044,Business and Professions CodcJ The Contractor's
Li-- t
cense Law docs nm apply to an owner of property who builds or improve thereon;and QTY, PLUMBING PERMIT FEE e SEP
8 '�0�1
who contracts far such projects with a contrnmoKs)licensed pursuant the Contractor's -' x7ld
License Law. rf
❑I am exempt under Sea ,B&P C for this reason PERMITISSUANCE Ilt L`l
ALTER-DRAIN&VENT-WATER(EA)
Ower - DateVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE at 6 (906.
I hereby affirm under penalty of po Jry uone of the following declarations:
❑I have and will maintain a Cenificam of Comentto self-insum for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES -TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which ansperenit is issued. ' FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of due Labor Code,for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS ' OCC.GROUP APN
My War n d Policy n )V Cartier. / policy bm.� ��2�'! GAS-EA.SYSTEM-OVER 4(EA)
CBRIT CATE F MOM WORKERS' -
COMP NSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
less)
(This section need not ba GREASmpleted ifthe Permit is for one hundred dollars t$100) -E TRAP EBBUILDING DIVISION HIS
ur
I certify that in the performance of the work for which this permit is issued,l shall - PLANCHECK FEE
'
not employ any person in any manner so as to become subject to the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
cation Laws of Califomia.Date
O A lacmt WATER HEATER WNENTIELECfR
DD - GRADING FEE
y NOTICE TO APPLICANT:If,atom making this Certificate of Exemption,you should WATER SYSTBM/1'REATING
become subject y the Workers Compensation aparprovisions.f the Labor Cade,you must SOILS PEE
Lkl forthwith comply with such provisions.,this pcnnit shall be deemed revoked. WA'F'ER SERVICE
aQ
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.Pf. PAID
U p work Cal
that issued(Section lending agency for certormance of Date ReceiptN
L1r H the Werk for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name TOTAL:
Ill. Lender s Address TOTAL:
Ill., '
, I certify that 1 have read this and application sato that the stove law.on noun,
is BUILDING FEE '
p1 building
I agree to en, ad with all city end county ordinances and state laws relating m QTY, MECHANICAL PERMIT FEE
G building constmction,and hereby amh.riu.,restoratives of this city to ewer upon the SEISMIC FEE
above.mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of CuNnam against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the starting of this permit 'PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
S BCE REGULATIONS ,r - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,Tq CFM) CONSTRUCTION TAX
.are of Appli:antl Ymurrit"or � ~ Date'L.J EXHAUST HOOD(W/DUC) �' HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(M 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532hol HEATING UNIT(OVER Hat"BTU)
❑Yes �yNo ^ PAID -
VENTILATION FAN(SINGLE REBID) Dao Receipt# -
Will the applicant or building occupant use equipment.,levies which
emit hazardous air contaminantsnts as defined by the Bay luta Air Quality Management BOILER-COMP(THE OR 100,0010 BTU) -
District? t - TOTAL:
❑Yee _ `F' . - BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials re momicats under Cha or 6.95 of the Cel'. AIR CONDITIONER
9 P ISSUANCE DATE
fom'a Health If Safety Code,Section 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Et.
buiWingdces n.tcurently haveatenanp that it is my responsibility to notify the occupant, - -
' the mFmantsw ch
amest be met prior to issuance of?ni! of Oc Gcy.
no,or e.th.nzed agentate: TOTAL: ISSUED BY:
OFFICE