30804 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMITNO. a] QO
BUILDING DIVISION APPLICATION/PERMIT'- PLUMBING-MECHANICAL _ J o
BUILDING PROJECT IDENTIFICATION
ILDINGADDRESS: �� C,011ie
��, '� SANITARY NO. APPLICATION SUBMITTAL DATE
HER' NAME: PHONE: ONTRACTOR'S NAME: LIC NO: ^�
��! NIC CONTROL b
ARCHITECTIENGINMR. LICNO: DRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
All-
TENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herchy offiim that I am licensed under provisions of Chapter 9(commtenciag JOB DESCRIPTION
q0p with Senior 700fpof Division 3 ofthe Business and Prnfessiore Code,on�my license is RESIDENTIAL
WF in full force and effaL�J / PERMIT ISSUANCE
/t/ - ❑SFDWL [3 KITCHEN REMODEL
V Lrttnse Cl s Lic.a
Dames Convamnr t APPLIANCIS-RESII3ENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FF.. ARCHITECTS DECLA A I N ❑MULTI-UNIT ❑STRUCTURAL
F.=w w PANELS
Z O t2 2 1 umlersy�d my)1yn e shd a u>e s public recoNs MODIFICATION
OZ �- y / Qf/�� UPTO 2W AMPS, ❑INTERIOR ❑CHIMNEY REPAIR
�-y,F'ad u c oastunal'7 201-I"AMPS IMPROVEMENT
s pp�j,.1 OWNER-BUILDER mDECLARATION OVER I"AMPS H REM�IKPtIbE1 DEMOLITION
pOp, W 6 1 hereby affirm that I am exempt from the Cessions Co License Law for the //11 11 ly/
Sd a U.V following reason.(Section constrain,
Business and Professions Code;Any can or county SIGNS ELECTRICAL OTHER
Ya11
U. which requires a permit m cunswc6 nlmr,improve,demolish,or repair any swcwrc
0 prior to its issuance,also requires the applicant for such permit to file a signedem¢mem SPECIAL CIRCUIT/MISC.
Y that he is licemed puzoanuo the provisions of the Contmcmes License Law(Chapter9
00 (commencing with Section 700(Bof DNision 3ofthe Business and Professions Code)or TEMP.METER OR POLE INST. TJAL
a q y out he is exempt themfmm and the basis fur to alleged exemption.Any violation of ❑ ,1/ gppl'1'IQN- p�rOLITION
iaCl 0. Section 703L5 by any applicant fora Permit subjects the applicant to a civil penally of POWER DEVICES Vuf Crlf(�
m ' NANT DSERVICE
ZZy not mo thanfive hundred dollars($SIX). MPROVEMENT
60 ❑1,as owner oftheprism,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended oroffcied for sale(Sea 7044,Business OTHER
4 �_ and Professions Cods:The Convector's License Law does nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.IL however,the building or improvement is sold within one year ofcompleuon,the SQ.FT.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden ofproving that he did not build or improve for put- Qg 'A 0
pmt,ofade.). r• N
(-1 1,as owner of the propsny,am exclusively contracting with licensed contractors to TOTAL:
meet the project(Sec.7044,Business and Professions Cale)The Ciumacmrs U.
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE J
who cnmrace for such projects with a contmaon(s)Iizensed parmintto the ARS Commetols A
License Low. PERMIT ISSUANCE L
C]I am exempt under Sec. ,B&P C far this reasunilly 'uHLONO
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
/�
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE. / N
I hereby am under penalty of perjury one of the following decdeclaration,ion
vl/ slsis--
❑I have and will maintain a Certificate ofConseot to self-insure for WmkcYa Camper- DRAINS-FIAOR.ROOR AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the labor Cade,for the performance oldie
work for which this pcmdt is issued. FIXTURES-PER TRAP
❑1 love and will nummain Worker's Compensation Tnsarwce.as required by Se,tion
37Wof the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Cameorker�Comyensetin�unynce rartie Paley No.Y numbe.d Pull,r, GAS-
EA.SYSTEM-OVER4(EA)
�SbCERTIFICATE OF EXEMPTION FRO W R RS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION
(This section need not M completed if ihepermit is Income hundred dollar($100) FEES
I or lets) GREASETRAP PLANCHECK FEE
I unify that in the performance ofthe work for which this permit is issued,I shallSEWER-SANITARY-STORM EA
.1 FT
rot empldy any person in any manner so av 1.become subject to the Workers Compen- ENERGY FEE
O z sation Laws of California.Date WATER HEATER WNENT/ELECTR
Z O Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this Cenifcute of Exemption,you should WATER SYISTEMTREATING
FF++ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS ME
LaLt� faMwith comply with such provisions or this permit shall be deemed rooked.
WATER SERVICE
CONSTRUCTION LENDlNGAGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID
Ll O T herebyaffirm that proms, issconstmc.3097.lending
s,agency fonhe Perfommnce of Dam a ptM
w tr me work for which this permit is issued(Sec.3097,Civ.CJ -
O (~ Lender's Name TOTAL:
Leader Address TOTAL:
0. 1 certify that 1 have read this application and state that the above information is BUILDING E Z /e
yc.I.l agree to comply with all city and county ominances and state laws rclmingm QTg MECHANICAL PERMIT FEE
V building convection,and hereby authorize representatives of this city to enter upon the SEISMI LID
above-mentioned Property for inspection punPoses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamtless the City of Cancan.against ELECIR FRE
liabilities,judgments,costs and expenses which may loony way scerm,ainst said City ALTERORADDTOMECH.
in asequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1MM)CFM)
SOURCE{REGULA�TI(/�S. M[Ct{pNICAL E
'� AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRU NTAX
Sign ure of ApplNmant/Contenter Date EXHAUST HOOD(W/DUCT) r HOUSING IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamorfumrt building axunant store orhandle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined'by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Cede,Section 25532(x1? HEATING UNIT(OVER 1011,000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant or future building ceenpaut use equipment or devices which Date Renee k ll)M
mit hazardous.irconmmia.m.,as defined by the Bay Ate.Air Quality Management BOILER-COMP OHP OR 100,000,BTU)
Disvim7 TOTAL:
❑Yes No BOILER-COMP(OVER I00,01M BTU)
1 have read the hazardous materials requimmcne under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomin Heakh&Safety Code,Sections 25515,M533 aM 25534.1 understand tem if the NEW RESIDENTIAL MUCH. SQ.FnIn ildingdocc not currently love a tenant that it is my responsibility to notify Ne occupant
of the is,immems which must be met prior m issuance of o Certificate of Occupancy.
I Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE