30544 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - s BUILDING-ELECTRICAL -PERMIT NO. O
f BUILDING DIVISION APPLICATION/PERMIT PI.UnIBING-MECHANICAL. "3
BUILDING PROJECT IDFMIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
l to GCAAJWRIOS e
WNE NAM PHONE: TRACT 'gN E: LIC NO:
CONTROL#
ARCHI LT/ENGINEER: V LIC NO: wk RESS: bb ❑
G
CONTACT: - PHONE: BIIILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)' T� ELECT PLUMB MECH
7z71.yg ❑ ❑ ❑ .
LICENSED CONTRACTOW, DECOMATION QTY ELECTRIC PERMIT FEE
I hereby affirm Ohm 1 am licensed under provisions nLChapter 9(commencing JOB DESCRIPTION
{�{411aZ will Section 7000)of Division 3 of the Businnsand Professions Cade,and my license is
FOO in full force end effort. PERMIT ISSUANCE RESIDENTIAL:
W I:, ❑SFDWL ❑KITCHEN REMODEL
EMLicence Class C.oh APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
EM Dote Commcmr
Z8ay . ARCHITECTS DECLARATION PANELS El MULTI-UNIT El STRUCTURAL
2 [understand my#loos shall he u.ed as public reatN. MODIFICATION
OZ—, UPTO 200 AMPS
p 11 INTERIOR HIMNEY REPAIR
Licensed Professional - 201.1000AMPS IMPROVEMENT
that I a -exempt fr m the RATION OVER 1000 AMPS ❑BATH REMODEUREPAIR []DEMOLITION
a 1 hereby affirm that 1 um exempt from the Commcmrs License Law for the
3 06 U following reason.(Section 7031.5,Business maul Professions Cade:Any cityor county SIGNS ELECTRICAL ❑OTHER
LL F which rcmuims a permit to construct,alma improve,demolish,or repair any strucmre
pdmnoity issuance,also require.Ne applicant for such perminn Rleasigned eta¢mem SPECIAL CIRCUITIMISC.
} that beislicensed punuummthe provisions of Ne Contractors License Law Chubut
�1 p0 (commencing with Section]OW)of Division3of Ne Business and Professions Code)a, TEMP.METER OR POLE INST. COMMERCIAL:
e pf
not he is exempt therafmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
mry Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES
Nan five hundred dollars($500). ❑TENANT ❑FOODSERVICE
6 I,as owner of the property,or my employees with%ages as iheirxole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O will do the work,and the structure is not intended oroffemd hustle(Sec.7044,Business ❑OTHER
a and Professions Code:The Commcmrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ Fi
sale.If.h.wevegthebuilding.,Improvement is sold within one yearofcomplemm.dic _ SQ.FT.FLOORAREA $/SQ.FT.
owner-builder will have the burden of proving Net he did not build.,improve for poo
pose of owner
a
Last the p of the property,am exclusively contracting will licensed)Ihecoast is i- TOTAL:
or.La the project(Sec..im Business and Professions Code.)The Commcmrs Li-
whocoawdoesnmapplyman.wnaof property who
oacdporlmt Loth Continues QTy, PLUMBING PERMIT FEE
who contracts for such projects wiNacomnamrts)licenced punuammthe Cnmmmors EP '1 2
License Law. PERMIT ISSUANCE' SEP O(IC
❑1 am exempt under Sec. ,B&P C for this reason w7a7{�
Owner Data ALTER-DN
RAIN&VET-WATER(EA) i (,i tLUVAIUfTION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE .
1 hereby affirm under penalty of perjury one of the following dedamtiom:
❑Ihave end will mainaine Cenificneof C.numto wlGinsurc fm Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUC ION
ration,as provided for by Section 37M 01 the LnMn Code,for the pndm name,of the
work for which this pema,is issued. FIXTURES-PER TRAP
❑I nave and will maintain workers Compensation Insurance.as remained by Section
370)o Inbor Co ,forth erformaratt of On work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wor sC ape mtinnI mace tamer and Policy number am:
Carrier. ey No.: GAS-EA.SYSTEM-GVHR 4(EA)
CERTIFICTEOFFXEMFROMWORKERS'
COMI'ENSAt'1 INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BNLDING DIVISION FC:ES
(Thissecti.n naJ not becomplemd ifNepermit is(Drone hundred Millan(5100) GREASE TRAP
or less.) PLANCHECK HE
I certify that in Ne Performance ofthe work forwhich this permit is issued,l shall SHWHR-SANITARY-STORM EA.200Ff.
not employ any person in any manner so as R,became subject to the Worked Comae.- ENERGY FEE
OZ ..tion Laws of C.1ifumm.Data WATER HEATER WNENT/HLECfR
O Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenifican of Exemption,you should WATER SYSTEMITREATING
a , become subject to the Workcrs Compensation provisions of the Labor Code,you most SOILS FEE
W .. fonhwitheomply widames provisions or this perom shall M deemed revoked. WATER SERVICE
Q
�Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Dam Receipt V r1 I hereby vffrn that ismissued
construction30 lending agency for performance of P
{k. lF:•'t Le work for which Nls#aortia is issued(Sea.309],Civ.C.)
Lenders Name TOTAL:
L) LendcrI crony t TOTAL:
i Yt 0. BUILDING PER
F I certify that 1 have reed Nis application untl antro that the vMrve information is
pJ toren.I agree to comply with all city and county ordinances and state laws relating in QTY. MECHANICAL PERMIT FEE
(,) building construction,and hereby vmhorize representatives of this city to enter upon the SEISM IC FEE
above-memioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to suor,indemnify and keep hamiless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way seems against mid City ALTER ORADDTO MECH.
I.cionars mea of the gaoling of Nis permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10'"CFM)
SOi EREGVLA NS. MECHANICAL FEE
IS /f`• / AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sign roof Applicant/Contmcwr r Date v EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS D SCLOSURE
Will the applicant or future Imitating mcupant stem or handle hazardous material II EATING UNIT(TO IM."BTU) ,
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,000 BI U)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt
Will Itsdrus to,coamemacant or uture building becupamy Am.use pm entity or evices which
Management
BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bey Area Air Quality Management TOTAL:
District?
Yes N.
BOILER-COMP(OVER 100,000 BTU)
❑ ❑
1 have mad be hvradons matedms acquirements uMe,Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Rupia Health&Safety Cole,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a annual.that it is my responsibility m notify the occupant
.f the requirements which must be met prior o kauamc of a Certifiwan of Occupancy.
Owner or mahmiacd agent Dare TOTAL: ISSUED BY:
OFFICE