30775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING 0G-MECHANICAL 5
BUILDING PRIydECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATIONSUBMITTALDATI
`_P-06(o C�i-ri-rc:eCz_ 4f_d—' /_ / 4--57 '
OWNERVSrP-lAM': PHONE: CO RACfOR'S NNAMME: / LIC NO:
IJ of 'N/C - CONTROL#
lop RCHI'rECI'/ENGINEER: LIC NO: ADDRESS: �a ❑
CONTACT: PHONE: _ l/.LCIf BUILDING PERMIT INFO
73—6)89 O ❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONQ
(commencing ter 9( '� ELECTRIC PERMIT FEE
r ❑ ❑ ❑
I hereby affirm that I um licensed under provisions of Chapter 6 JOB DESCRIPTION
qa'R with Section]IX111)ofpivisionJofthe Businesnvnd Pmfessians Cade,and mylicense is RESIDENTIAL:
00 PERMIT ISSUANCE
in full forces eRed.
�FUzICt,] License Cines Can ❑SFDWL ❑PLUMBIN RF,PIPE NQS Dura Commcmr APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
Fpy ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
,x O[O 7, I understand my plans shall be used as public records MODIFICATION
pZ C UPT02MAMPS El INTERIOR ❑CHIMNEY REPAIR
rattts1 Licensed Professional - 201-1000AMPS IMPROVEMENT
OWNER-BUILDER m Ce CommeON
nces
OVER I"AMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
O U I hereby.Scar that I am exempt from the assioncmrs License Law for the
G�yS following reason.Permit
OoM.d,Business, Iw. andove.demolish,
h,or Any city o countyowar. SIGNS ELECTRICAL ❑OTHER
which requires a permit re construct,otter,improve,demolish,or repair any suanum
this heist lensed palsomquires provisions of batsman pormaiLiceno,Law(sutemem SPECIALCIRCUI]'/MISC.
II��iy+
(commencing
it Section?ummt 0)of Division 3 the Cnnusinss nd Proo Loons Code)at
p�GC (commencing wiN Senior]II(lo)ofpivisianJnf the Business and Pmfessiom Cade)orTEMP.METER OR POLE INST. COMMERCIAL:
6
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
+ � Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
y []TENANT ❑FOOD SERVICE
p. not mom than five hundred propenyl or myrs
MPROVEMENT
a6I]Lm ework,the proptrty,or isomplendedwith wages eredasthei(Sec.compensation, SWIMMING POOL ELECTRICiis.
Q will Bothe work,and the s o Com is noes License La dos not apply to an RosinessNOTHER
andpro Pmfessiom Code The oms do License Low does not apply w lf owner of OUTLETS-SWITCHES-FIXTURES 10,
property who builds or improves thsuch i and who does such work himself or through
his own employeese provided that such improvements me not intended or offered for NEW RESIDENTIAL ELECI'R SQ PI'.
sale.If,however the building or improvement is sold within one yea ofcumpledon.the SQ.Ff.FLOOR AREA 5/SQ.
thrdFT.
owner-builder will have e buen of proving that he did not build or improve far par r^ d I' D
pose of sale,?.
I,as owner of she property,am exclusively contracting with licensed contractors to TOTAL:
construct he project(See.7014,Business and Professions CWc:)'I'he Conuunors enm m A Li- p I nt- sD
cse Law does napply an owner of property who builds or improve dmaran,and Q1W. PLUMBING PERMIT FEE ISL
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Low. PP.RMIT ISSUANCE CII Y Ur
I um exempt under Sec. ,B&P C for this reason �urcM Gl 0-
ALTER-DRAIN&VENT-WATER BEA) - VALUATION
Owner nam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affimt ander penally of pedury one of the fallowing declnretiom:
❑I haveand will automation CenldcmeofComeat msel&Insure for Workers Couper- DRAINS-FLOOR,ROOF,AREA.COND. - STORIES TYPE CONSTRUCTION
saoio r as provided for by Senion 37W of the Labor Code,for the perfommmce of Ne
work far which Nis permit is issued. FIXTURES-PER TRAP #
❑1 have and will mainwin Workers Compensation Insurance,as required by Scelion '
3700 of the Labor Coda.for the performance ofthe week far whichthis panni,is issued. GAS-HA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wo sC mpem tiglnsurnme wrtier and Policy GYM D 13-51, )
or- GAS-EA.SYSTEM-OVER 4(EA)
Carri9� u Policy No.:
CRTIFlCA'IE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEONDUSTRLWASTEINTERCEPGIR
BUILDING DIVISION FEES
This saction need not be completed ifthe perran is for onehundreddollars($100) GREASETRAP
or Ian,.) PLANCHECK FEE
Toy any that in the performance ofthean
t becomeork for subjecch t
to tPermit he Wisissuedlshall SEWER-SANITARY-STORM EA. FT.
' not employ any person in any manner et as m became suhjen to the Workerr;Compen- ENERGY FEE
Z
award Laws of Celifomia.Data WATER HEATER W/VENT/ELECTR
O Applicant GRADING FEE
V) NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,N g p ion,you should WATER SYSTEM?REATING SOILS FEE
lYi 5
become sumthe Workers Compensation provisions of the Inbar Code,you run
forthwith comply with such provisions or this permit shall be deem#revoked WA'T'ER SERVECG
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
U O Date Receipt 0 ,
I herby affirm that from is construction lending agency for the performance of
the work for which this permit is issued(Sec.301 Civ.CJ
Lenders Name TOTAL:
O V Leader's Address TOTAL:
GI certify that 1 have read this application and slate that the above information is ,O� UILDING FEE a
N correct.l spree to comply with all city and county maliruncesaml sure laws telating to QTY. MECHANICAL PERMIT FEE
(.)Z building construction,and hereby authmirs representatives wilds city to enter upon the SEISMIC FEE
above-mentioned property for inspection puryoses. PERMIT ISSUANCE
(We)agree to cave,indemnify and keep hvmless the City of Coped la,against ELECTRIC FEE
liabilides,judgmems,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in countenance of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applan.00muaaor s Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wlltheapplicaulor future building recupantssorcor handle harallommananid HEATING UNIT(TO 100,0011 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cale,Senion 25532(a)? HEATING UNIT(OVER 100,00#1 BTU)
❑Yes ON. PAID -
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(JHP OR 100.0(10 BTU)
emir hazardous it contaminants m definW by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,(X0 BTU) _
❑Yes ❑Na _/
I have reed the mourelus tsuterials requirements under Chapter 6.95 ofine Cali- AIR CONDITIONER ISSUANCE DATE -
Boom Health&Safety Code,Sections 25505.25533 and 25Si4.1 understand thin if the NEW RESIDENTIAL MECH. SQ.FT.
building does not commonly have v tempt,that it is my re,pawlibillty to notify the oaupant
of the requirements which must be met prior to issuance of a Certificate of Occupntey.
Owner ro wthodz<d agent Dole TOTAL: ISSUED BY:
OFFICE