30302 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
- CITY OF CUPERTINO r � '1 r' BUILDING-ELECTRICAL PERMIT NO. O/N JK^ 0^
BUILDING DIVISION ' APPLICATION/PERMIT, PLUMBING-MECHANICAL. 3 L
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRESS: r SANITARY NO. APPLICATION SUBMITTAL DATI
/D/810dax
nbel-lev _a-n e�
PCl
OWryI+Jt'S ,LS - 182' CGN c�RG�-u rr,ctr,.) LI�975 .
NIC CONTROL N
ARCHO CT/ENGINEER: LICNO: ADDRESS
CONTACT: ., - PHONE BUILDING PERMIT INFO
• y!/ a ❑ Consultant Fees Paid by'Applicant(Initial) r BLDG ELECT PLUMB•. MECH
' LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
O Z 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commercinK SOB DESCRIPTION '
with Section'81fgb Of Division 3 of the Business and Professions Code and my license is
F Or in full fume an ffec q�..+ PF,RMIT ISSUANCE
�WF 20 / J FDWL ❑KITCHEN REMODEL
LeiDUO License Class o r ' APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
y am- /.{� IMCTS Contractor ran A HITECTe DECLARATION _ [I MULTI-UNIT El STRUCTURAL
IL O'/a�j 1 understand my plans shall be used as public records PANELS - MODIFICATION
OZ-
Licensed
UP TO 200 AMPS '
D ' - ❑INTERIOR .(]CHIMNEY REPAIR
Licensed Professional 201-1000 AMPS IMPROVEMENT.
OWNER-BUILDERDECLARATION
ON OVER Hall AMPS C1 BATH REMODEUREPAIR [1DEMOLI1g4
GG CCCC mm 1 hereby affirm That I am rapt fromm thee Cammemrs Ciccone Law for the �^{`.—
ippi55��O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL [-]OTHER .^aA7 o!
which requires a permit to construct,alter,improve,demolish,or repair any structure
fryn priorro he lssuana,eLno reyuires the applicam for such pahmluo Bleosigned emoement SPECIAL CIRCUIT/MISC. ,
< that 1111 licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
GO that he
engwith Sereind.told of Divisi for oft he Businessand Professions Code)of TEMP,METER OR POLE INST. COMMERCIAL:
a❑q o e'
that he is exempt Therefrom and the basis for the alleged exemption.Any violation of EINE W BLDG/ADDITION ❑DEMOLITION
X tL Section]031.5 by any applicant fora permit subjects the applicant o,a civil penalty of POWER DEVICES
❑TENANT El FOOD SERVICE
z not more than five ie por pJ dollars y employees
IMPROVEMENT
Q ❑Laeowner Of the pro party.rmyemntended with w.dfmthei(Sa 7044,engine ,SWIMMING POOL ELECTRIC
anddo the wofk,and the he Cont a not intended or offered s net apply to an Business - OTHER
pro Professions Code:The Contractor's License Law does not apply to if owner of OUTLETS-SWITCHES-FIXTURES FE
property who employees.
or improves Hereon,and who doer such work
te himself or through ^•
his own employeese provided that such improvements thin not intended or offered for NEW RESIDENTIAL ELECTR SQ'
safe.ILhoweverllhave Ile larng or en.1prmenl isoldhe
aneyear ofildori improve
ion,theor put, .FT.FLOORAREA $/SQ.FT.
owner-builder will have ore huNen of proving that he did not build or improve for par- t
• pose made.).
'
I,res ow r of the property,am exclusively contracting with licensed comments to TOTAL: 1��P 1
construct the project(Seo.7044,Business and Professions Code)The Contractors U- • �T• �91,[`
Li-
cense Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE _ 'f�_ V
who contracts for such projects with a contractors)licensed pursuant to the Camr4cmrs 4tI i�gl y`
License Law. PERMIT ISSUANCE - ^
❑I am exempt under Sec. ,B&P C for this reason _ ..
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
'
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty m perjury one ofthe following Workers Co
�� d�
I have and provided
for eCion 37 m of Qe Labor Code,self-insurethe Workers ce of the
DRAINS-FLOOR,ROOF,AREA,COND.' - STORIES � TYPE CONSTRUCTION
sation, ,apmvidhi far mi Section 3]00 of the Labor Code,for the performance of ore
work have and this permit is issued. FIXTURES-PF.R TRAP
❑I of and will maintain Workers ante 6flhew Insurance,as his Permit
by Section � -
3]00 ftheLabor Code,fnnhe performance oflhe work for which this [rcissued. GAS-EA.SYSTF.M-1 INC.40UTLETS
MyW r d Policy t� OCC.GROUP - _ AIN
�F dyt�IyfylSgyo o �.vvLL//u'�
Cern I��Pclicy No', OAS-EA.SYSTP,M-OVBR4(P.A) s
CE CAT O of
FROM WORKERS
COMPENSATION INSURANCE - GREASBIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PL?ES
(This section need not be completed if the permit is forone hundred dollars(8100)
or lees) 11 GREASETRAP - PLANCHECK FEE
I certify thatin the performance ofthe work for which this permit is issued,[shall SEWER-SANITARY-STORM EA.200 FT.
oat employ any person is ony manner po us In M1elnme subjwl Ira the Workers'Cbmpen- ENERGY FEE '-
OZ station Laws of California.DateWgTER HEATER W/VENT/ELECfR .
7.O Applicant GRADING FEE
Lay NOTICE TO APPLICANT If,after making this Certificate Of Exemption,you should '
WATER SYSTEMITREATING aOILS FEE become subject to the Worker's Compensation provisions of the Labor Code,you must
LkI forthwith comply with such provisions or Ibis permit shall Nabe deemed mankind. WATER SERVICE
Q
CONSTRUCTION LENDINGACENCY r .NEW RESIDENTIAL PCMB. •SQ,FT ' PAID
U O I for which
this
that there is sued(See.30 lending agency fonbe performance of Date Receipt M
W the work for which this permit Is issued(Sec.309],Civ.CJ
O U Lenders Name - TOTAL:
LkI Lender s Address 'TOTAL:
f certify that l have read this epplicelion and pwm thin the abdvo information Is BUILDING PEC
i.+.Wcorrect.1 agree to comply with all city and county Ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
7
U G building construction,and herery authorizereprematatives,Ofthis city to amerupon the SEISMIC FEE
above-mentioned properly for inspection purposes. I
PERMIT ISSUANCE
I - (We)agree to save,Indemnify and keep harmless the City Of Cuperdim against ELECTRIC ME
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of Nis permit. PLUMBING FEE,
APPLICANT UNDERSTAND.1 AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
URCE REGULATIO S. !/—QG
AIR HANDLING UNIT(OVER I0.IXk'1 CFM) CONSTRUCTION TAX,
&JIlignature of ApplicamUContmebr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE s
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous mamnal HEATING UNIT(M 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)'IHEATING UNIT(OVER 100,000 BTU) -
E]Yes %XNo . VENTILATION FAN(SINGLE RESID) PAID _
Data ReceiplM
Will the applicam or future building Occupant use equipment or devices which
emit hazardous aiccomaminants as defined by the Bay Area Air Quality Management BOILERBOI -
COMP(3HP OR 100,(100 BTU) ,
UislncB - `' - "TOTAL'
Yea Ip Na AIR CONDITIONER
OVER Ifq,00I1 BTU) ,
I have read the hazmdaus mumnals AIR CONDITIONER
requirements undo Chapter 195 of Cali- - ' ISSUANCE DATE
fomia Health&Safely Code,Sections 25505,25533 and 25534.1 nnderimnd hot, the NEW RESIDENTIAL MECH. SQ.FT. * -
building does net currently have a tenant,tat it is my responsibility til notify Ne mcupam _
the inquire ante whic cost a met pdonoisauance ofaC ificale of Ors ancy.
mors, nzed agem Date I TOTAL: ISSUED BY:
OFFICE