31342 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEMONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDINGER ISION ` APPLICATION/PERMIT PLUMBING-MECHANICAL '
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRES I SANITARY NO. APPLICATIONSU BMITTALDATE
60 73
OWNE 'S NAME: - PHONE: - CONTRACTOR'S NAME: ', - LIC NO'.
C� N/C CONTROL M
ARCHITE NGINEER I LIC NO:
;DRESS: ❑'
CONTA( :7_7_6 h WV PHONE:/sem 8 . S BUILDING PERMIT INFO
_'00 e �❑ Consultant Fees Paid by Applicant(Initial) BLDG, ELECT_ PLUMB MECIfj ;
r+LICENSED/CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE 4mQ/ IrIrA✓ IIQ
1 hereby affirm that 1 am licensed under provisions of Chapter 9(wmmencing JOB DESCRIPTION
u❑7CZp with Section]000)of Division3ofthe Business and Pmfexsionx Code,amdmyliceewis PERMIT ISSUANCE RESIDENTIAL:
F in full force and effect/ / .3
Id� -kens Cats M d s OSFDWL ❑KITCHEN REMODEL
pp APPLIANCES-RESIDENTIAL
an Date "Comraaor - ❑ADDITION ❑PLUMBING RE-PIPE
[�'Dtei ARCHITECT'SDE ATION PANELS - Ll MULTI-UNIT 3STRUCTURAL
Z O y ZJ I understand my plans shall be used as tic records
y MODIFICATION
O Z^^C UP-' OAAMPS [J INTERIOR t El CHIMNEY REPAIR_
Licensed Professional .� 201I WOAMPS IMPROVEMENT `
OWNEwBU1LDEfrmthe O
RATION OVER]"AMPS El BATH REMODEUREPAIR [I DEMOLITION
1 hereby affirm That 1 am exempt from the Conacmr's License Law for the
aj 3 a U following reason(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
Cwhich requires a permit to consumer,alter,improve,demolish,or repair any structure prior 1,it,issuance,alsorequires the applicant formeh mi
pert to Ole a an adstatement SPECIAL CIRCUIT/MI$G.
p, thot he is licensed pureuammthe provisions of the Cammemr's License Law(Chapmr9
tip (summarizing with Section mend of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMME
a p,a e*`that he is exempt therefrom end the basis for the alleged exemption.Any violntion.of ❑NEW BLDG/ADDITION ❑DEMOLITION
fiRC W
- Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
zz"� not more 11five hundred dollars($500). - ❑TENANT 'El FOOD SERVICE
F 4 ❑I,as mourofthe property.ofmy employees with wages exist,sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will Bothe wnrk.and the structure is not pleadedor offered for sale(Ser.70a4,Business OUTLIER
and Professions Code The Continuities License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeity who Budde or improves thereon,sad who does such work himself or through _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ Pr.
sale.If,howevem the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ,ET.
owner-builder will have the burden of proving that he did not build or improve for purl I - - 1
,,cut sale.).
❑L as owner of the property,am exclusively contracting with licensed rogt' mxs to TOTAL: ,
construct the project(Sac.9044,Business and Pmfessioaa Code:)The Comtrucmr'a Li- O
cense Law does not apply to an owner of property who hui Ids or improves thereon,and QTY. PLUMBING PERMIT FEE Nov 91i{��
who contracts for such projects with a emanations)nons)licensed pursuam nt the Contractortl s X41
License Law. PERMIT ISSUANCE -
❑I am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EAJ VAWATION
Owner Dote
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby,affirm under Penalty offer,Of one of the following declarationa:
❑.l have and will meinmina Certificate of Comentm self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
STORIES 'TYPE CONSTRUCTION
tion,as provided for mi Section 3]00 of the LeMn Code,for the performance of the
which this permit is issued. FISTORESTRAP 32,' t
wort have and will maintain Worker's Compensation Insurance,as required by radian
3]00 of the Lebdi Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-IINC.40UTLETSOCC GROUP APN
My Workees Cho tpe�e I mer and Policy nu her
Carrier: 7�6 _Policy No.: 6 &,Mffia,
GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OFEXEMPTION FROM WORKERS' S'T`0 '•
+ COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR'
BUILDING DIVISION FEES
(This section need not be completed lithe Permit is fomnehundred dollars(SIM) GREASETRAP �.
or less) CHECK FEE
Ioy any that intilein perany mnance nerof the work for subjectch to
perthe it Wrkesued,I shall
'Compn- SEWER-SANITARY=STORM EA.200 FT.
not employ any Person in any manner so as m become subject to the Workers'Compen- GY FEE
Z cation Caws of California.Date'O O Applicant WATER HEATER WNENT/ELECTRING FEE
q y NOTICE TO APPLICANT:If,lifter making this Certificate of Exemption,you should WATER SYSTEM/IREATING
F+ become subject w the Workers Com FEE 1-
a ) ns or this provisions of the Lobar Code,you must
LlI ry
Forthwith comply wilhpuch Provisions or this permit shell be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.
Thereby affirm thauhereis aeonswuiion lending agency for the performance of Date Receipt
�+ the work for which this permit is issued(Sec.3097,Co.C.)
Q (~�IxUt der,Name (' TOTAL:
w l Leader's Address TOTAL: o
I certify that 1 have read this application and stare that the above information is a BUILDING FEE
r
(1) correct.l agree to comply with all city and county ordinances and state laws minting In QTY. MECHANICAL PERMIT FEE Ar
(,) '& building construction,and hereby authtirize representatives ofthis city to emu upon the SEISMIC FEE
above-mentioned prmpery for inspection purposes. : PERMIT ISSUANCE IELECTRIC FEE
(Wt.)agree to save,Indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTGR OR ADD TO MECH.
in consequence of the golufing of this permit. - PLUMBING FEE 0
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.110 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTION TAX
Signature of Applosnt/Comractor Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant tar future building occupant store orhandle hazardous material HEATING UNIT(TO 100,(MO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I,.
Cilie,Sermon 25532(a)P HEATING UNIT(OVER I WBM BTU)
- .Yes ON. / VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices whieh Date Receipt is
emit hazardous air conmminants as defined by the Bay Area Air Quality Management BOILER--COMP(3HP OR 100,000 BTU)
TOTAL:
Disvict9 No
Fly. BOILER-COMP(OVER 100,000 BTU)
❑
1 have read the hazardous matenals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
9 u ISSUANCE DATE
fo llid Health&Safety Cede,Section 25505,25533 my and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ell
build' does not coronary a eemnant,that it is my responsibility to notify the rxcupant i
of auks whit est be me to tot efa Cvmficme fOCC ancy.
��
O e rnmbonzedogentDat - TOTAL: ISSUED BY:
OFFICE
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Home Owner: Jon and Linda Goldsworthy Contractor: Showcase Kitchens, Inc
Address: 10731 Castine Avenue 12333 Saratoga-Sunnyvale Road
City:Cupertino Zip:95014 Sarataoga, CA. 95070
Project: Hall bath remodel. New cabinets, California Contractors License # 665395-B
counters, shower and fixtures. No
structural work being done