30486 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING•ELECTRICAL - - PERMIT NO. 30486 O as ^V8 VN/.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J( 4
BUILDING PROJECT IDENTIFICATION
—,BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
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24 (�NAME: �u NPHONE: D NTkeACfSIR'S AME: LIC NO:
,y N/C CONTROL N
ARCHITECT/ENGINEER: LIC NO:. DRESS: " - ❑ ,
}
CONTACT: PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ i' ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby mfr m that I nm fthe Bu under ndProona of chapter 9 dommeneing LOB DESCRIPTION
OR with Secrmand.affm Divisian3of the Business ani Professions Code,and my license is RESIDENTIAL -
� in full force and effect PERMIT ISSUANCE
CADWL C KITCHEPLUMBINREMODEL
�V License Class Contractor gppLIANCES-RESIDENTIAL []ADDITIGN - []PLDMBING RE-PIPE
yDate GOmracmr
Flmy ARCHITECTS DECLARATION PANELS 'C MULTI-UNIT CSTRHCTURAL
O Z N& 1 understand my plans shall IN used as public reeaNs MODIFICATION
UPTO 2W AMPS []INTERIOR []CHIMNEY REPAIR
r {Oil Licensed professional 2014"AMPS IMPROVEMENT
f5 •a OWNER-BUILDER DECLARATION OVER IOW AMPS C BATH REMODEUREPAIR []DEMOLITION
1 hereby affirm that 1 am exempt from the Contractors License Law far the
ip5t O0.V followingreason.permit
to
]1H 1.0.Business and,Pm,demolish,
hOde:Any city or county SIGNS ELECTRICAL C 0 —
su 3 u•NF¢ wh ch requires a permit to consw t atter.Improve,demahsh p y awewre - J
�O.i poor to't issuance,also req the applicant for such proof to filesignedstatement SPECIAL CIRCUIT/MISC-
thath licensedpursuant t fineprovisions of the Contractors License Le (Chapter9
pO (commencing withScti 7")ofDivision 3 of the Business andProfessions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
t, c K that he is exempt therefrom and the basis far the alleged exemption.Any violation of [INEW BLDG/ADDITION []DEMOLITION
r��rj Lt44 Section 101 Ll by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
"'..y not more than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
GIMPROVEMENT
Cl;as owner of the property,nr my employees wit wages as their sole compensation, SWIMMING POOL ELECTRIC . t
O wdldothcvmrl and the swaure is not intended mattered for sale(Sec. es
4,Busins
ProTHER
and fessions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
hsale,If,however the building or improvement is sold withinis own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
one year of completion,the - S.1.PL FLO REA V%Er.
caner-builder will have the burden of proving that he did not build or improve for per-
pose ofsaleJ. TOTAL:
❑I,as oe•am of the property,am exclusively contrucdng with licensed contractors to S
construct the project(Sec.7044,Business and Professions Cale)The Qmvertar's Li- 1x796
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE1
who contracts ch projects eontmaor(s)licensed pursuant tot Contract ' 11
Licen PERMIT ISSUANCE '+I It 'h' i.sjrr i a.191J
P rthis
illi 6:Owner Dm ALTER-DRAIN&VENT-WAT A) - VALUATION
WORKER'S COMPENSATION DECLARAT BACK FLOW PROTECT.DEVICE t
I hereby afrmm under penalty of perjury are of the following deet moons:
C [have and will maintain a Certificate of Comennn self-insure for Workers Compen-. DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
,moan,es provided far by Section 3700 of the Lubar Cade,for to performance of the
work for which thisp ermit is issued. FIXTURES-PER TRAP '
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
W
3] of the Labor Code,for performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4011TL OCC.GROUP APN
My Walker's Compensation Insolence comm and Policy number are:
Cartier: Policy Na: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
/I This ucti0nn dnol bo complaed if ep Itis crone bund ddollors($10E GREASE TRAP
or less.) PLANCHECK FEE
I caddy that in teperformarim.fthe work for wholidds permit is issued;l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as m become subject to the W gimme Compen- ENERGY FEE
OQ sullen Laws of California.Data WATER HEATER W/VENT/F.LECTR
Applicant GRADING FEE
�t NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should, WATER SYSTEM/BEATING
(•" 5 became subject to to Worker's Compensation provisions of the Lolmr Code,you must SOILS FEE
t..i forthwith comply wit such provisions or this permit shall Is,deemed revoked. - WATER SERVICE
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt
U.r� I for
rwhich rm that teraissued( econstruction lending agency for to performance of
U. [yt the Larmaek for which this permit is issued(Sec.3097.Co.CJ
Lenders Neme ._ - TOTAL:
Lender's Address TOTAL:
1 codify that 1 have read this application and state that the above information is BUILDING FEE
Ncorona.1 agree to comply with all city and county nNinances and state laws relating m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V building construction,and hereby authorize representatives0ftis city to animalism the
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hermless the City of Cupertino against ELECTRIC ME -
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. .
PLUMBING FEE•
in consequence of the granting ofthis permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicanVContrector - Data EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hemrdous material HEATING UNIT(TO I W."BTU)
as defined by,the Catarina Municipal Code,Chapter 9.12,end the Health and Safety
Cada,Section 25532(a)Y HEATING UNIT(OVER 100.000 BTU)
MYes ❑Na -
VENTILATION FAN(SINGLE GLE RESID) Date .ReceiptN
Will the applicant or future building oecupa d use equipment or devices which BOILER-COMP(UTP OR 100,000 BTU) -
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
District?
YeCNo BOILER-COMP(OVER 100,000 BTU)
❑ s - -
AIR CONDITIONER
I have read the hourphius nomenais requirements under Chapter 6.95 of the Cali. ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 tmdersuand tat if the NEW RESIDENTIAL MECH. SQ.FT.'
of
building does vents which
have IN met t.p tato is uxnm ofnsConiy to notify the Occupant 1
of the requirementswhich mast a tmetpriorit is myreofn Cmtyto notify
Occupancy. v jye//AY1^/Tli
Owner or authorized agent 'Date TOTAL: ISSUED BY:
V 1.
OFFICE