30577 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN.ONLY '
CITY OF CUPERTINO . BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT r PLUMBING-MECHANICAL _
BUILDING PROJECT IDENTIFICATION
UILDING ADDRESS:. - SANITARY NO. APPLICATION
_
APLICATION SUBBMITTA
L DATE
la fALq .6
E PHONE: CONTRA%?NAME: LIC NO: N/C CONTROL is L a
1C ECT/HNGINI2� LIC NO: r ADDRESS: El� N '
mNTncm PHONE: BUILDING PERMIT INFO
,airy,p'_� Consultant Fees Paid by Applicant(Initial) BLDG PW MB M C
d/ LIC17NSED CONTRACTOR'S DECLAARA` 1TION QTY ELECTRIC PERMIT FEE .
1 hereby affirm mat 1 am licensed under provisions of Chapter 9(commencing B DESCRIPTION
0Z with Section 700(piif Division Jorma Business and Proficssians Code,and my license is RESIDENTIAL,
O PERMIT ISSUANCE
W in full force and effar. WL ❑KITCHEN REMODEL
FaV
License Class Lic.p APPLIANCES-RESIDENTIAL (TION ❑PLUMBING RE-PIPE
N a b Dale Cm tractor
I„Dtn ARCHITECT-S DECLARATION' PA S MUTT
❑STRUCTURAL.
Z p ern 7zp I understand my plans shell he used i s public accords MODIFICATION
cz-W UP TO 200 AMPS ❑INTERIQI; ,gy_ El CHIMNEY REPAIR
Oita 1-wesaW Professional 201-ft"AMPS IMPRO�VEEAMA 1 D
Oat I an exempt
fir DECLARATION
Contractor
ON OVER I"AMPS ❑BATH REMODEURFPAIR ❑DEMOLITION
yy I hereby affirm that 1
OWNER-BUILDER
form me RATION License Law lie the
x36V following ressan.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0O�L
which requitss a permit an construct,alter,improve,demolish,or repair any swmure 6s
priorwitsixsuancialxo requires the applicant kasuch permit In fileaaignedsammmt SPECIAL CIRCUIT/MISC.
�ya } mut he is licensed pursuant to the Provisions of the Conhutures License Law(Chapati)
W Qf (commencing with Section 70110)of Division 3 ofrhe Business and Professions Code)or TEMP.METER OR POLE INST. -EH FIN
mm �
he is exempt therefrom and the basis for the alleged exemption.Any violution of ❑NEW BLDG/ADDITION DEMOLITION
iC Y. Section 7031.5 by any applicant for a permit mhjecrs me epplicam to u civil perahy of POWER DEVICES
u]—m ❑TENANT ❑FOOD SERVICE
zzz i.
net more than five hundred or (empl. IMPROVEMENT
Crl� OLo the
of the property,mmyempinyas wimwred for le(Sm.compensation.
ess tiWIMMING PO(11.P.LECfRIC
FF
will Pr mewons Lord the re Com err.tended License Law does rsale(ply ad a Business ❑OTHER
and Professions Code:Ten Contractors and w Law does Lou apply to owner of OUTLETS-SWIT'CHFS-FIXTURES -
�' properly who builds or improves thereon,and who does such conte dedohimself or thnmgh
his own employeese Provided thnt such improvements thin nm intended m offered for NEW RESIDENTIAL ELECTR SQ FT.
owdeChowev will
have
he bur improvement issoldhewithinoneyemof completfar the SQ.FT FLOOR AREA SJSQ.FT.
owner-builder will hove the burden of proving that he did not build or improve fur at. t Oylis. � JIM
pos tf oaten). "JI �
us owner of the properly,am exclusively contracting with licensed contractors m L
con et the project(Sec.70004.Business end Professions Code.)STe Cmancedr's Li- Q
cense law does not upply to an owner ofpropeny who builds or interests demon.eM TY. PLUMBING ERMIT FEE - L
who contracts for such projects with a mountains)licensed pursuant to the Commences
License Law. PERMIT ISSUANCE -
Olson In U2 Sec. ,B&PC for this mason
-
"hilim, LTAER-DRAIN&VE - HA) �, VALUATION
WORT ER'S COMPHN� TIO ECLARATION BACK FLOW PROTECT.DEVIC �� 01(00.�
_ hcrcby effort under penalty of)ferjury t e of the following declared um:
,] I have and will maintain a Cettifcate of Con. Lamself-insurefor Worker's Compen- a DRAINS- O OP,AREA,CON
snide,as pmvidcd far by Section 37M of the Leber Code,for the perfnmwce of the STORIES TYPE CONSTRUCfION
work for which this permit is issued, FTXTUREs
I have and will maintain Worker's Compensation Insurance,ea required by Section
3700 ofine Labor Codi forte perfordsom ofthe work for which this Permit is issued. GAS-FA. STEM-]IN GULLETS OCC.GROUPAPN
My Workersm
Compensation Insurance carrier and Policy number e: -
Cartier: Policy No.: GAS-EA.SYSTE 4(E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSINTER
RUI D ISIONFLES
(This section need not becompleted ifthe permit is fnrnnc hundred dollars(8100) ORGSETRAP
or IexsJ PLANCHECK FE' %A lsstZWJ�
I omi fy that in the performance of the work for which this permit is issued,I shall V
nor employ anWER-SANITARY-STORMC ITT. A
p y y person in my manner sec ss to hccome subject nt the Workers'Co.,,.-Compen- ENERGY FE i. Ljto
Z .tion laws cf California.Dale WATER HEATER WNENT/ELECIR
O Applicant >< GRADING FEIIJ
NOTICE TO APPLICANT.If,after making this Cer ilicata of Exemption,you.should WATER SYSTEM/(BEATING v
a , become subject o the Workers Compensation provisions of the Labor Code,you must SOILS FEE ,
(11 forthwith comply with such provisions or this Permit shall be deemedrevoked. WATER SERVICE. -
Ot
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V O l hereby affirm that hem is a construction lending agency for the performance of Dam eipI# -
�� the weak far which this permit is issued(Sce.3097,Civ.C.)
O V lender's Nan. - TAL:
Lenders Address
yI rectify that I have read this application and state that the above information is BUILDING E
In correct,lagsec to comply with all city and county ordinances and sate laws reining to QTY, MECHANICAL PERMIT FEE
V building concoction,and hereby aumorize representatives of this city to enter upon the SEISMIC E
above-mentioned praperry for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton against ELE -EE
liabilities,judgments,costs and expenses which may in any way accmeugainst said City ALTER OR ADD'1'6 MIiCII. PLUMBI FEC
in consequence of the training of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0(N1 CFM) MECHANICAL E
SOURCER GULATI S:
'AIR HANDLING UNIT(OVER 10.000 CFM7
�� CONSTRULTI NTAX
nam pplicanl/Com cmrJ Date EXHAUST HOOD OVIDUCT) HOUSING M IGATION FEE
H DOUSMATERIA DISC SURE
Will the upplicint or future building sec antat ur handle hazuNous maaoial HEATING UNIT(TO 10(1.000BTU)
-
as defined by me Cupertino Municipal Code,Chapter .12,tad the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,0101 BTU)
E]yes []No VENTILATION PAN(SINGLE.RESID) PAID
s Date Nee pt pas
Will the applicant or forum building by the Bt use equipment or lily Macesnagement
which BOILER-COMP OHP OR 100,(100 BTU). t
miteell ux air cnnaminants as defined by the Bay Area Air Quality Management L'TL
�Dixtrict?
❑Yes ❑No BOILER-COMP(OVER I100,0008iU)
I have read me humorous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE .
(omit Health&Safety Code.Sections 25505.25533 and 25534.1 undersenrd that if me NEW RESIDENTIAL MECH. SQ.FT.
building cuarenif Ift Inunl mat itismy rtslnn ihility to notify mcacupant _
of the renGimmems it
must Mmnpfrnn issuance o C ifcateor Occupancy.
Owner urhoriuJ agent
Dote T �, ISSUEDBy 'I
OFFICE