30948 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY Q//�1
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO. O O V T H
BUILDING DIVISION APPLICATION/PEL. JRMIT PLUMBING
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHONE: CONTI1ACfOR' 9ME:
N/CCONTROL al
ARCHITEC'UENGINEER: V LIC ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
" ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
1 family affirm that I w,licensed under pmvixion,mf roamer 9 gommertcNg JOB DESCRIPTION
�aZ with Sation lalU)pfDivision3ofthe Business esti Professions Crile,onJ mylicenu is
�OO Ia PERMIT ISSUANCE RESIDENTIAL�
full force and effect _�, ❑SFDWL ❑KITCHENREMODEL�g.U((JJ License Cl x Lic.p •� APPLIANCES-RCSIDLNTIAL
yG6 Dem Convector ❑ADDITION ❑PLUMBING RE-PIPE
A CHITECT'S DECLARATION ❑MULTIUNIT ❑STRUCITIRAL
Z l-Dv1w l understand my plans shall be used as public recordv PANELS MODIFICATION
OZ�fO UPTO21XAMPS ❑INTERIOR El CHIMNEY REPAIR
�e4FpW Licensed Professional 201d1g1UAMPS IMPROVEMENT
�bd•L thatOWNER-BUILDER. exemptfrom
DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
!�p,CC LLM U 1 hereby affirm that 11. exempt from the Contractors Co :License., Law Entire
pd 06 U billowing ng urics.permit
103L&Business esti Professions Cale:Any city structure county SIGNS P.LECTRICAI. �O7HER
f{t[1l4O which it,mm permit raptures un,ufer.improve,demolish, fi repair o,1 mm.ent
Bar hePon,toi mcensul e,aluantto the Novisioso fur Contrach rmrOoicense Law(Chapter
SPECIAL CIRCUIT/MISC.
M marmorslicensmt S.n.rvu00).f Dirbimi(rhe Commie's .iicenulaw(Cbapmr9
M (cot he
exemiNSereman and of,basison3 ofthe eged01combon,Any
Cade)or TEMP.MfTF.R OR PoLE INST. COMMERCIAL:
a c a that he is exempt thercfmm end Ne basis rm the alleged exemption.Any violation of EI NEW BLDG/ADDITION [I DEMOLITION
Scamn]031.5 byanyapplicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
rn ❑TENANT ❑FOOD SERVICE
�6but not Nw five hundred dollars(55001. IMPROVEMENT
EDLasosawn.fthcproperly,of my employees with wages as theirsoleemapensation, SWIMMING POOL EIECfR
O will do the work,and the structum is not intended proffered for sale(Sec.]N4,Business ❑OTHER
W and ImEssinto Code:The Contractors License law does not apply 1.as owner of OUTLETS-SWITCH RES
L properly 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 NE W RESIDENTIAL ELECTR 5
pie.If,however,the building or improvement is sold within one year ofconipletion,the SQ.PT.ROORAREA VSQ.Fr.
er-builder will have the burden of proving that he did not build or improve for pur- A/?f
pose of owne gQA w o
1,as owner of the properly,ora exclusively contracting with licensed contmcmrs to TOTAL: /R
construct the forges,(Sec.7044,Business wd Profession,CWcO The Contractors U. e
mon,Low does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMITFEE /�y
whocoaUacu for such projects with s cpntmctons)licensed pursumua the Contractors (/h
License Low. PERMIT ISSUANCE L`
lam exempt under Sec. .B&P C forthis reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) ATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following Jeclorufirms:
❑ I have end will maintain a CertificmoxdConscnuo self-insure fur Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND.
smpro
iom,as sided for by Section 3100 of the Labor Cale,far the permnnurve of Be, STORIES TYPE CONSTRUCfION
work for which this permit is issued. FIXTURES-PER TRAP
I Save and will maintain Workers Compensation Insurance,as required by Section 11
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSIEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker tion race nmel.bd Polisyqugbyyf O1_�� GAS-FT.SYSTEM-OVER Cmrier: Policy No.:((ZZ��'-SS��
CERTIFICATE OF F.% MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thissectiw teal not hacompleted if the permit is(Drone hundred dollars($ilo) GREASE TRAP
or less.) PLANCNECK PEE
I cenifythat int he pc on ace ofth vo ;for vhlah this pertnitisisSow I"al l SEWER-SANITARY-STORM EA.200 FT.
nut employ any person i n ne n b' o the 011111 d Compen- _ ENERGY FEE
0 z sari..Luwsof Calif WATER HEATER WNENT/ELECTR
Applicant 5 GRADING FTSE
y NOTICE TOA LPA .IL after ranging this Ce c m of Exemption,you should WATER SYSTEMIfREATING
I—' become subject to the Workers Comp atectioq .,is of Na Labor Code,you must SOILS FEE
.aj fnnhwiN comply with such provisinne nr this permit all be dcemad revoked. WATER SERVICE
CLQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLvIB. SQ.FT. PAID
UZ I hereby affirm Nat there is a construction lending agency for the performance ofW. Dam ReceiptN
L) . the walk for which this permit is issued(Sec.3091,Civ.C.)
C) i" Leader'a No. TOTAL
UILender's Addreu T
GI certify that I have read Ni,application.ad smm that the above information is BUILDING FEF.
y coact,l agree to comply withall city and county ordinances and stare laws relating to QTY, MECHANICAL PERMIT FEE
U buildingcoolum,ism,and hereb,inamnze representatives pfthiscily toemer upon the SEISMIC FEE
r abov.-mentioned pmpeny for inspection puryoses.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments,costs and expenses which may in my way seem,against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence m the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,001i CONSTRUCTION TAX
Signature of ApplicanUConuactor Date EXHAUST GOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicwt.r future htilding«cupanutore or handle hevudous mamnal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(e)'1ZVx� HEATING UNIT(OVER 100.000 BTU)
❑ I
Yes _r 'o VENTILATION CAN(SINGLE RESID) PAID
Will the applicant or tumor building wcupmn use cquipment or devices which Date Receipt p
emit hazardous air contaminants us defined by the Bey Amu Air Quality Management BOILER-COMP(3HP OR 1(10.000BTU)
•District? TO AL:
❑Ya (�Jo BOILER-COMP(OVF.R 100,lXp BTU) `
AIR CONDITIONER
I. 1 hove read th sea rs mamrlmenty undo Chapter 6 95of theCali- ISSUANCE DATE
foMia Health& y Cc ,Sections33 and25534.1 bn erstaM that if Ne NEW RFSIDCNr1AL MF,CH. SQ.FTbraing bel, evenJa�ny nnsibilitymnaif hews pontt qtr' use&me nfaCcnifim( cel
Ow uNpnx tag t Dae TOTAL: ISSUED BY: V v—
OFFICE