30077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAL _ - PERMITNO. OO
BUILDING DIVISION .APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECTIDENTIFICA'T'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'Z o 4-pg . CLAY 5T GUPc2zi�o C�
OWNER'S NAME:_.. �O^,AP� NZ57 CONTRACTOR'S NAME: LICN
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NYC CONTROLN
ARCHITECDENGONEER: LIC NO ADDRESS: l-F Cl ❑
uk,o DOW aKlr+ G- �CG6A Bnaa�s ,i�c- G75,J.
t CONTACT: PHONE: BUILDING PERMIT INFO
G' / /3 ❑ Consultant Fees Paid by Applicant(initial) BLDG EO PLUMB MECH
CaM/!. 1J9 l�
LICENS.D CONTRA DECLARATION QTY ELECTRIC PERMIT FEE
I hereby amen mat 1 am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
QWZ with Second 70010)of Division 3 of the Business and Professions Code,and my license is RFSID NTIA
00 PERMIT ISSUANCE F�e
W in(case Clatrod effect. ❑SFOWL KITCHEN REMODEL
F�QU I.ieense Class LIc.M APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
N Q W Date Contunor
F,Oro5 ARCHITECTS DECLARATION PANELS ❑MULTLUNIT []STRUCTURAL
Z Ov�7, 1 undcmand my plain shall be used x pco
public rerds MODIFICATION
OZJ, UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-4I:rq LicensedProfessiaral 01-IIXNIAMPS IMPROVEMENT
PP44"�M•,.1 Oat I..exempt
fir DECLARATION Cumbr ON OVER IOpO AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
6 1 hereby affirm sen I am exempt from the Cssions Cos :Any c Law far he
O d V following rectum.(Section 7031.5,Business and Professions Code:Any city or counrySIGNS ELECTRICAL. ❑OTHER
B: FhF• O which requires u permit to cornwct,alter,improve,demolish m or,n any stmcture
p
prior o its issuance,also requires he applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
y2y y that he is licensed pursuant o the provisions ofthe Contractees License Law(Chalnerc)
Is70 (commencing with Section]f1110)Of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIA
0 L
dp,M C bar he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
'i� 4• Section]031,by any applicant forapplicant apermit subjects the applicano a civil penaltyof POWER DE'P,i S
IL�y ❑TENANT ❑FOODSERVICE
F•Z�• not mare than five hundred dollars(5500). "_'-t- IMPROVEMENT
6 O Las owner ofine property,or my employees wit wages as their sole compensation, SWIMM.tt- 7"TRIG
9p 0 will do termination,w.,k,andtermination,
re isnot intended truncated fnsale(Set.]U44,Business - = ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLE'.s' ' )EC-FIXTURES
y'3 r progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided!Nat such improvements a2 not imerbed or ORered for NEW REST -'.� _ SQ PT.
sale.IL however,he building or improvement is sold within One yemofcompldion,the SQ.PL FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving mat he did not build or improve for par- /
sof sale.).
❑1.as owner of the property,am exclusively contracting win licensed contractors to
construct the project(Sec.]BW,Business and Professions Cade:)The Contractors Li- "
cense Law does not apply to an owner of property who Inilds or improves income and QTY PLUMBINGPERMIT
who contracts for such projects with a dmntmetor(s)licensed pursmmt to the ComOomors
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C'for this reason �_
Owner Date VAN ALTER-DRAIN&VENT-OVATE R(EA) N _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby a(fien under penalty of perjury one of the following declarations: - oRr ttoliro°�Cti I Ad
❑I have and will maintain a Certificate ofConscnuo self-insure for Workers Compact- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Latex Code,for the performance of he K.3work for which this permit is issued. FIXTURES-PER TRAP �g
T71 have and will maintain Worker's Compensation IEmnc
rae,as required by Section ,{^
3100ofda Labor Code,for the performance of the wink for which his permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy Na, GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section need Out be completed But permit is for one hundred dollars(5100) BUILDING DIVISION FEES
GREASETRAP 7 n
or less.)(This
FEE
I certify that in the Performance Of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.201)Fr.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z ration laww(California.Dom WATER NEATER WNFNT/ELECTR
7�O Applicant GRADING FEE
q NOTICE TO APPLICANT.IL after making this Cenificate of Eiemption,you should WATER SYSTENU TREATING SOILS FEF.
�i become subject to the Workers Compensation provisions of the Labor Cade,you must
W forthwith comply with such provisions or this pcomishall be deemed revoked. WATER SERVICE
aQ
rs7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID Date Reeai,,#
L)0 0farw umrm that Onto is acunslO,.3nlendis.agency for the perlbrmance of
r•i hework for which this perosit is issued(Sec.309],Civ.CJ
Lenders Name - � TOTAL:
0 LUkI Lenders Address TOTAL: 3
1 certify that I have read this application and state that the above information is BUILDING FEE �,H
'LZ corder lagroemco.add wirsyantyar ceprnynrdiives ofand stem la enter
aping a MECHANICAL PERMIT FEE
V z building constmation,end hereby auhoriu represeniafives of this citymenter upon the 'SEISMIC IrEE
above-menOonW property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless he City of Cupenino agwnst ELECTRIC FEE
IiabiOities,judgmems,eastannd expenses which may many way accrue against said City ALTER OR ADD TO MECH.
in consequence Of he gtranting of this Permit.
- PLUMBING FEE Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 00,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. a /D
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature o(Applicam/Contrai Data EXHAUST HOOD(W/DUCO /.•f✓ HOUSING MTITGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will their licaramfuture buildingmmiximstareor handle hmardoms material HEATING UNIT(TO IW,W0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)'! HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID Data Receipt If
Will he applicant or future building occupant use equipment or devices which
'it haamdoas air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP LET OR 100,000 BTU) TOTAL'.
Incl] BOILER-COMP(OVER 100,000 BTU)
❑Yea C]No
I have read the bourbons materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
faro..Health&Safety Code,Stations 25505.M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have atermm;ohm it is my msponsibiloy to noddy the occupant
of th'a topen_�nos which must/y/R_ct pnonpy issuance ode CcniOcate oftheupawy.
Ow�authotixed agent Dom _ TOTAL: F ISSUED BY:
OFFICE