30287 �APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
HUILDINGADDRF_S5: SANITARY NO. APPLICATIONSUBMTITALDATI
11 c' 7
O:WNa N`,LPHONE
4
. C RACTOR' pAAME^x s N�
N❑/C
CONTROL
A HR C'VENGINEER: LICNO: ADDRESS:
6dyP7 n5�2, aJaL
CONTACT. PHONE:
BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LU MUCH
EJ ❑ 75ZZ7 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm,that 1 am licensed under Provisions of Chapter 9(commencing JOB DESCR]FIFICIN
{sO�00 with Sation]o00)of DivisionloDhe Business and Professions Code,amlmy license;, RESIDENTIAL:
FOO in full fame and effect. PERMIT ISSUANCE
❑SFDWL ❑t�- KITCHEN REMODEL
t UZ License Class Contractor
APPLIANCES-RESIDENTIAL []ADDITION CafLUrnBING RE-PIPE
�F�GL Dae Commctor
ZOOM ARCHITECTS DECLARATION PANELS []MULTI-UNIT ❑STRUCTURAL
t�Z I understand my plans shall be,used as public rteuNs MODIFICATION
OZ-- UPT0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 2B1-IWBAMPS IMPROVEMENT .
CApp OWNER-BUILDER DECLARATION C1VER 1000 AMPS BATH REMODEUREPAIR ❑DEMOLITION
I hereby affirm that 1 am exempt from the Contramors Licence Law for the O
MO y U following reason.(Section 7031.5,Business and Pmfessiore Code:Any city or county SIGNS ELECTRICAL Fl OTHER
F C F which regaims a Permit 0 emc met, he,,improve.demolish:of repair any swctere
rrsFF... poor 0 in issuance.also requires the applicant for such Permit to File a signed statement SPECIALCIRCUIT/M1SC.
,F, y that belscing it Secaant mthcP Division 3 the cousins liccme lawlChapmr9
Ya] p0 (commencing wit Section 7W0)uf Oivision3of the Business and PmfessionsCMe)or TEMP.METER OR LOLE.NST. COMMERCIAL:
la. a that he is exempt therefrom and the basis for the alleged exemption:Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
^t Section 7031.5 by any applicant for a Permit subjmts the applicant to a civil Penalty of POWE
not more than five hundred dollars(SSW). R DEVICES
.. []TENANT ❑FOODSERVICE
y
�ZY - IMPROVEMENT
❑❑❑❑Q' Loa owner of the pntpeny,or my employtts with wagesasthoutailcomrinnsation, SWIMMING POOL ELECTRIC
O wdl do the work.and the stmcture is not intended orofferedforsale(Sec.70Wq Business ❑OTHER
arM Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
�' .. progeny who builds or improves thereon,and who does such work himself or through
his own employes.,,provided that such improvements are oat intended or offered for NEW RESIDENTIAL ELECfR SQ FT. ti
sale.If,however the building or improvement is sold within one year of completion,the �- SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did net build or improve for put. r
pomof,rle.),
El 1,as wom'.1'the property,not c.,buively convening with licensed contractors to TIAL. jut QO
,construct the project(Sec.7044,Business and Pretensions Code:)The Contractor's Li- V f�
Li-
cerise Law does not apply to an owner ofprom
py who huilds orimproves Merton,and Q1-Y. PLUMBINGPERMIT FE (II/r'(�h 9s+UoQ�a
who contracts fnrsuch pointers with a cornmelo(s)licensed pursuant m the Contractor's
License Law. PERMIT ISSUANCE `urCl'(1Inu
❑lamaemprunder Sec. ',H&PCfordammeson
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WORKERS COMPENSATION of DECLARATION BACK FLOW PROTECT.DEVICE
1 hand waffirm under penalty of perjury one of the morin or declarations:
❑.have and Provided
bynection 37Micatc ofComwnt toLabor
Code far dam, Worker's Compeer- DRAINS-FLUOR,ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
.,mien,r provided for mi Section d. clam Lahr Cade,for the perfonwrce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I hew and will more,for Workers Compensation work
hi h required by Section -
3700oftheLabor Code.(ort the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC GROUP APN
My Work do InsyW��� artier and Policy numberiar2
Carier.�s sa c• Policy No.: r L� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE - BUILDING DIVISION FEES
(Thissationneed net be completed ifthe permit is furore hundred da1mrs(5100) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the Performance ofthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM G.200 IT.
not employ any Person in any manner so as to hem.subject m the Workers'Compen- ENERGY FEE
OZ a®ion LWs of Califomia.Date WATER HEATER W/VENTIELECTR GRADING FEE
Z Applicant -
ry NOTICE.TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMTREATING
l^ become subjano the Workers Compensation provisions of the Lahor Cale,you must SOILS HE
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
U' z CONSTRUCTION LENDING AGENCYagency NEW RESIDENTIAL PLMB. SQ.PI'. PAID Dem Rtee' tp
V r� .farhereby which
hi that isucomwc.inn lending agency for the perfomunce of
W. Ill..yrrr the work for which this pcnnit is issued(Sec.3097.Cie C)
Lenders Name TAL:
V Lender,Address TOTAL'
0. 1 certify that 1 have mad this application and state Nat the above information is BUILDING FEN
it ta
Ln center.I agree to comply with all city and county oninances and state laws miming to QTY, MECHANICAL PERMIT FEE
L)Z building convection,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
`r above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cupertino against ELECTRIC TLE
liabilities,judgments,costs and expenses whic ay in any way av,ouc,mma,aid City ALTER OR ADDTO MECH.
i nonounience of the granting oflhisK - PLUMBING FEE
PPL.CANT U R ANDS A If W CO A PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM) MECHANICAL FEE
. IURCE AT Ng,
AIR HANDLING UNIT(OVER 10,0(I0CFM) CONSTRUCf10NTAX
9igraMffofAppbvarVComtomDide EXHAUST HOOD(WMIJCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applawat or future building occupant store or handle hasNous material HEATING UNIT(TO 10(,(00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(07 HEATING UNIT(OVER IMMO BTU)
❑Yes [D No VENTILATION FAN(SINGLE RFSID) PAID
Data ReceiptM
Will the applicant or future building aecupant use impairmentm.devices which' BOILERCOMP(JHP OR 100.00(i
-
emit by us air contaminants as dcfinW by the Bay Area Air Quality Management
DtsmcTOTAL:
@
❑Yea ❑Nn BOILER-COMP(OVER 100,000 BTU)
1 have read the hmamdm mamruls requirements uraler Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 75505,25533 and 25534..innervated that if the NEW RESIDENTIAL MECH. SQ.FT.
building does an[currently have a tenant,that it is my responsibility to nmlfyrhe occupant _
of the rtquimo¢ms which must be met prior to issuance of a Certificate of Occupancy.
Owner or audariced agent - Dam TOTAL: ISSUED BY:
OFFICE