30403 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY " •'
CITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMIT NO. ^ A
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL K O /1T.0
BUILDING PROJECT IDENTIFICATION N
BUILDING ADDRESS'`' SANITARY NO. APPLICATION SUBMITTALDATE
+ OWNER'S NAME: /�� Z1 PHONE: CONTRACTOR'S NAME: - LIC NO:
/w-\ `P^[rVOGSL�I/�``L1`u��`//t � NIC CONTROL k
}. CHITECIRNGINEER: I.IC NO: ADDRESS:
CONTACT: ' PHONE: - t ' BUILDING PERMIT INFO .
�` ❑ Consnitant Fees Paid by Applicant(Initial) BLDG ELECT "PLUMB MECH.
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
�yl�. IL-C�I
I hereby affirm tbai I am licensed under previsions of Chapter 9(commencing I JOB DESCRIPTION
'a:4Z whh Section]tlOfl)of Ot sion3nf the Business and Pmfessiona Code,and mylicense is -
k�00 PERMIT ISSUANCE RESIDENTIAL:
W r in full force anB effecLl ElSFDWL ❑KITCHEN REMODEL
�Vz(U,,) License Class Lic.k APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
In 6 0. Dole Contractor
-
,zip, ARCHITECTS DECLARATION ❑MULTI-UNIT 'STRUCTURAL
y pVj I understand my plans shall be used as public records PANELS MODIFICATION .y
OIZJ UPT02W AMPS
�'N-SFqqW - 21H]cM,O AMPS MODIFICATION
0Z OCHIMNEY REPAIR
1�- Licensed Pm(eeslonel- I,
¢y�W OWNER-BUILDER DECLARATION OVER I"AMPS C BATH REMODEUREPAIR CDEMOLITION
+a st 6 I herehy affirm that I am exempt from the Contractor's License Law for the u
iq5 O d V ❑OTHER
following reason.(Section 7031.5,Business and Professions Codc:Any city or coumy SIGNS ELECTRICAL
as a IL F which requires a permit m construct,alter,improve,demolish,or repair any svucmre h'
FSO prior to its Issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC. -
'F. } Nat he in licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
GC (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or 1 TEMP.METER OR POLE INS
d y e of that be is exempt therefrom and the basis for the alleged exemption.Any violation of _ NEW BLDG/ADDITION El DEMOLITION
iC V. Section]031.5 by any applicant for a permiisubjects the applicant to a civil Iry of POWER DEVICES
PP Penalty TENANT El FOOD SERVICE
y rat more Nan6vehondreddollas, S5W). - IMPROVEMENT
D 1,as owner of the property,or my employees with wages as their sole compensation. 'SWIMMING POOL ELECTRIC
O will do the work,and the svucmre is not intended or offered for 40.at sale(Sec.70Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES'EIXTU
property who builds or improves thereon,and who does such work himself or through
'
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECTRS
sale.If,however the building or improvement is sold within one year ofcompletion,the SQ.PT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving than he did not build or improve for pur-
p�s�
❑1,asownerof thepropeny, exclusively bomradinwithlicensednmmoTOTAL: ..
=
construct the project(Seo.]044,,Business and Professionss Cada)The Contractor v i-'s Li-
se Law does not apply to an owner of propeny who builds or improves thereon,and QTY, PL G P,ER
who contracts for such projects with a contramons)licensed pursuant to the Contractors
License Lew. IPERMIT ISSUANCEt�yf. , 1„
x ❑I am exempt under Sea .B&P C far this,
_
Owner Dore ALTER-DRAIN&VENT WA (9A) v VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.D� ET\
66 1 hereby affirm under penalty of perjury one of the following declarations ��
/�Q l have and will maintain a Certificate of Consent to self-insure for Workers Cumpen- DRAINS-FLOOR,ROOF,AREA, D., STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3]00 of the Labor Code,for the performance of the - ; f' ,
..,it for which this permit is issued. I I FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section -
3700ofineLabor Care,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP AIN
My Workers Compensation Insurance earlier and Policy number are:
Cartier Policy No.: GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS' `
COMPENSATION INSURANCE 'GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This semionneednm he completed ifthe permit is butane hundreddollso, SHy) GREASETRAP
or less.) PLANCHECK HE
(certify that in the performance nfrhe work for which this permit is issued,l@hall SEWER-SANITARY-STORM EA.200 FT.- '
Inot employ any person in any manner so as to income subjecfro the Workers'Compen- ENERGY FEE
sation Laws of California.Date WATER HEATER WNENT/ELECTR " GRADING FEE 6
,Applicant
q V5 me NOTICE TO APPLICANT:IL after making this Cuttificate of Exemption,you should WATER SYSTEMOREATING
aF) becosubject to the Workefs Campenaation provisions of the Labor Code,you most SOILS FEE
W forthwith comply with such provisions or this Permit shall b,deemed revoked. WATER SERVICE' ,
a0.
CONSTRUCTIONwitolmLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PT. - PAID
U O Date Receipt M
I hereby affirm But there is s ed(See.30 lending agency for the performance of "
Ne work for whiaM1 phis permit is issued(Sec.3p9],Civ.CJ
Lender's Name - � OTAL:
U Lender's Address TOTAL
Y� W� BUILDINGFEE,
[.+. I certify Non 1 have read this application and state than the above information is
Ir CA correct.l agree to comply with nil city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby authorize representatives of Nis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit, PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REG L NS. MECHANICAL FEE
�)i AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRULTIONTAX s
Signature ob ApplicaMContract Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) �
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely -
Code,Section 2553200? HEATING UNIT(OVER IW,"BTU)
` ❑Yes Fl No 3 VENTILATION PAN(SINGLE RESID) PAID
Date Receipt If
Will the applicant or future building occupant use equipment in devices which BOILER-COMP(3HP OR I W,000 BTU) r r
mrit hazardous air conwminems as defined by the gay Arca Air Quality Management TOTAL: .
- District] BOILER-COME 100,000 BTU)
❑Yes a ON. t '
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER 1 ISSUANCE DATE _
'fomia Health&Safety Cade,Sections 25505,M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Pli
building does not currently have a tenant,Nat it is my responsibility to notify the occupant
of the requirements which must IS,met prior to issuance of a Certificate of CoraPaacy. - t
Ownermauthorizedagent - Date TOTAL: ISSUED BY: XP
OFFICE