30875 APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30875
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 3
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
109-1 C61L. Alial S. 47
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LIC NO: ADDRESS3g': nQ El`l4 � �r LGN
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEF.
I hereby M.that I nm licensed under provisions of Choler 9( mm
coencing JOB DESCRIPTION
g"Z with Section 7000)of Division 3 ofthe Businessand Professions Cale.and my license is - R QIFyilITAU
oo PERMITISSUANCE
W fullfo lend effort.�. /p-G 'd I S ❑SFDWL III❑��KFI�T'''C����HENREMODEL
License Cl v Lte.p llIISLs'L-t¢'s'l gPPL1ANCCti-NESIDENTIAL ❑ADDITION BING R&PIPE
F rel more cammcmr
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
CZ4- Iundemm�J my plane shall be usW as puhlle remNs. PANELS MODICHIMNEY
OZ�p�' UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
(:s^fry-.E Licensed Professional 201-100UAMPS IMPROVEMENT.
C {, OWNER-BUILDER DECLARATION
0 I hereby affirm that 1 am exempt form the Cnmmcmr's License Law for the OVER] ❑BATH REMODEUREPAIR El DEMOLITION
3 O y U following reason.(Section 7031.5,Business and Professions Code:A,city or county SIGNS ELECTRICAL []OTHER
W which requires a permit to earshot,alcor,improve,demolish,m repair any structure
O prior w its issuance,also respires the applicant for such permit to file a.signed statement SPECIALCIRCUITNTSC.
ythat he is licensed pursuant o the provisions ofthe Conaacmfs Licenu Law(Chapter 9
Q� (commencing with Section 7")of Division 3ofthe Bnsinessand Professions Cede)or TEMR METER OR POLE INST. COMMERCIAL:
4 pt o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
a� Saban 7031.5 by any applicant for a permit subjects the applicant to v civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars(5500).
F Z IMPROVEMENT
f�taQ 6 ❑Lasownernfthepropcny,or my empinyae wish wages as theirsole cnmpcnsation, SWIMMING POOL ELECTRIC
O will duthe work,aml the smature is not intended oruffered for sale(See.7044,Business ❑OTHER
and Professions Cade:Tic Contractor's License Law docs nut apply to an owner of OUTLETS-SWITCHES-FIXTURES
ta'3 propeny who builds or improves thereon,and who does such work himself or through F1
his own employees,provided that such improvements ate not intended or offered for NEW RE OIWE TIAL ELECfit - SQ PT.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOORAREA $/SQ.FT.
owner-builder will have Ne burden of proving that he did not build or improve for par- Ile .
lac Oxide). - O r g REC''
❑h as owner of the property am exclusively contracting with licensed contmaurs to TOTAL"
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an ow,ner of property who builds or improves mention,and QTY, PLUMBING PERMIT FEE YUf IfNJ'
who
o contracts for such projects with a commusur s)Bcrnsed pursuant o the contractors Kt111N�!
Licenu Use PERMIT ISSUANCE
❑I was exempt under Sec. ,B&P C for this rcvum
ALTER-DRAIN&VENT-WATER(EAI VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby ill ai maintain
penalty of perjury one of me following declarations:Camper-
❑Ihave prowled main mi Sealnif7M of CanLabsor ode,samba Wadersce of thDRAINS-BOOR,ROOP,AREA.COND. STORIES TYPECONSTRUCTION
taboo,as provided for by Sretion 3700 of the lalror Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and well calejmaintain Worker's Compensmlon Insurance,nt required by Section
37110 ofthe Labor Cale,far the perfqq ace of the wad for which this permit is issued. GAS-EA.SYS'TPM-I INC.4OUTLETS OCC.GROUP APN
My Work _on wm=nxrMr eerier and Policy 9u�wyty�y p GAS-EA.SYSTEM OVER 4(EA)
Carrier: u Policy Nn: 13 /3b�T' /7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becompleted ifthe permit is forone hundred dollars($100) GREASETRAP
PLANCHECK FEE
or less.)
I cenifythm in the performance ofthc work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so vs m become sobjectto the Workcn'Co.,.-- ENERGY FEE
0 Z no.Laws w'Califamia.Dole
O Applicant Wq'TER HEATER W/VEN /ELECR GRADING FEE
7
q N NOTICE TO APPLICANT:If.after making this Certificate of Exemption,youshould WATER SYSTEM/BEATING
aF't become subject m the Workers Compensation provisions of the lalror Code,you must SOILS FEE
i� forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE
d Q
5 z CONSTRUCTION LENDING AGENCY NEW R
' ESIDEN IAL.PLMB. SQ.IIT. PAID Da Rzeiptp
V O lieubyaffirmthamhereisacanatmction lending a gemcy for the performance of
F the work for which this permit is issued(Sec,3NO,Civ.C.)
OLender's Name TOTAL:
Lender's Address
I certify that 1 have read this application and stem that the above information is BUILDING FEE
CIn correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
) Z building consrattiun,end hereby auth.dacwprcnentatives fthis city minmrupan the SEISMIC FEE
above-mein wad popery fur inspection puryous. PERMIT ISSUANCE
(We)agto save,indemnify and keep harmless the City rel'Capeoino against ELECTRIC IEE
ree
Iisbilmes,judgmentx.costs and expenses which may many wayaccrueagairco add City ALTERORAODTOMECH,
PLUMBING FEE
in conuyvence of the granting of this permit.
APPLICANT U [j(STANDS D WILL COMPLY WITH ALL O,POINT AIR HANDLING UNIT T 010,000 CFM)
SOURCE s ONS MECHANICAL FEE
O AIR HANDLING UNIT(OVER HIOW CFM) CONSTRUCTIONTAX
M a ea pplicanVCommctm 0Ua,a EXHAUST HOGG(W/)UC) HOUSING MITIGATION FEE
HAZARDOUS MA NIALS DISCLOSURE
Will the applicant mfuture boildi ccupant score or handle hamMnus mlmriel HEATING UNIT(DO 100,000 BTU)
as defined by the Cupertino Municipal Cale,CTaltt 9.1;atW the Health and Safety
Cale,Sceriun 25512(0)? HEATING UNIT(OVER 110,000 BTU)
❑Yes E]No VENTILATION PAN(SINGLE RESID) PAID
Will thea licom or Nmre building t use mem or devices which -Date Receipt q
pp g ytheDy equip y BOILER-COMPpHPOR IM.000BTU)
Omelet?Mous air contaminants vs definW b the Ra Area Air Quality Menagemem
DisvimE - BOILER-COMP(OVER 100,000 BTU)
❑Yea ❑
AIR CONDITIONER
I have aratd smaterids mrnts under Ch0pmr695 of the Call. ISSUANCE DATFi.
fomia Health YC .Sectio 50 25533 and 25534.1 renders ad that if Ne NEW RESIDENTIAL MECH. SQ.FT.
h ' n cat nant,t tit is my ms sibilirytonOil the upatn J
I the m rest aCenif
Owner orauthonud agent Date TOTAL' ISSUED BY:
OFFICE