30040 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30040 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
0X5Z1 DQs6res QVA -
OWNERS NAME. PHONE: CONTt�gTJR'S NAME: LIC NO
T —1—✓I Ir) 0- �/Q21 ZSS 994 nes IH4sn n. $9435 NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS. 'l� // 1/Q ❑
CONTACT. ' ' - PHONE: / BUILDING PERMIT INFO
J1/ I c.7-O1 ,•Z —7 �/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Vl ❑ ❑ ❑
LICENSED CONTRACTORS
DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alarm that I am licensed under provisions of Chapter 9 my license
JOB DESCRIPTION
'n�Z with Sedion]UW)of Division lofthc Business and Profcssinns Code.and my license is RESIDENTIAL:
OO in full force and effect p p < PERMIT ISSUANCE
FzTFUJ Licen a Z tic.# 13 OD� - - ❑SFDWL KITCHEN REMODEL
y6y
Data "I-
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
1„py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z o' 1 understand my plans shall be teed as public records MODIFICATION
OZ UPTO200AMPS C1 INTERIOR [I CHIMNEY REPAIR
r4k Licensed Professional 201-II011AMPS IMPROVEMENT
gyed OWNER-BUILDER DECLARATION OVER IWO AMPS ❑BATH REMODEUREPAIR �D[MOLITIN
W C) 6 I hereby affirm that I am exempt from the Conrranor's License Inco for the �-
C),
d U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL R
rLL.C which mutates a permit to construct,alter,improve,demolish,or repair any structurestructurestructureo 6, prior to its issuance,also requires the applicant for such permit m File a signed statement SPECIAL CIRCUIT/IHISC. �� -
yWyW'j that he is licensed pursuantto the provisions of the Contractors License Law(Chapter 9
CQO (commencing with Section]IK10)of Division 3 of the Business and Profession,Code)., TEMP.METER OR POLE INST. COMMERCIAL:
q y that he is exempt therefrom unit the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y y at more than five handed dollars($500s IMPROVEMENT
G C)1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
O will dothe work,and the structure is not intended oroffered formic(Sec.]044,Business []OTHER
4aI and Professions Code:The Conoactors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES a
-. property who builds or improves Hereon,and who does such work himself m lhnmgh
his own employees,pmvided that such improvements ore not intended or offered for NEW RESIDENTIAL ELEM FT.
sale If.however.Ne building or improvement issoldwittim oneyearofcompletion,the SAI R EA MCI.PT.
wrur-builder ve will hathe burden approving that he did not build or improve torpor. _
poaeafsale.).' OCT .
I] 1,as owner of.i s,property,am exclusively contracting with licensed convectors to TDI 4 1996
consmtct the project(See.7D44,Business and Profession,Code:)The Ousrsetors Li-
camelawit. or apply ro an ownernf property who builds ars impns.them...xad QTY. PLUMBING PERMIT CITY
x 11�
who commaproje
s forsuch cts with a contraeons)licensed pursuant to the Contractors OF LUf CTi l lIYl,J
License Law. PERMIT ISSUANCE.
❑lamexeguilmder Sea ,B&PCfm Nis rtssan
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date 9 .VALUATION
oV
WORKER'S COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
1e and will
oder penalty ofperjury
one of the following dalmatians:
❑Ihave and will forbimeCertificate ofCommat the Labor
Cod,for the Workers Camper. DRAINS-FT.00R,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sminn,as provided for by Section 3]On of the Labor Cude,for the performance of the
or which this pemulis arks. FIXTUNFS-PER TRAP
ave and will maintain Worker's ante ofste w rk for ce,n,required by Section'
' ]00o(the Labor Code.for the performance of the work for which this permit is issued. GAS-F.A.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Wmgeaa Cum naulion firsarpnce comer olicy y mher
Carrier.Lxil" A14}e a��B11Ky No.: LJGY4�l03 OC GAS-IiA.SYSTEM-OVER4 TA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FF.FS
(This section need not No completed ifthe permit is forom hundred dolluss(S IW) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the perfmmance of the work forwhich this permit is issued,l shall
not employ any Person in any manner so as to become subject to the Wmkera Compete- SEWER-SANITARY-S'TORM EA.200 IT. FNERGY FEE
Q z sation laws of California.Date WATER HEATER WNENT/ELECTR
z 0- Applicant GRADING FEE
H NOTICE TO APPLICANT:If.after making this Centfteme of Exemption,you should WATER SYSTEMORHATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEL
W forthwith comply withsuch provisions or this per it shall be dttmd revoked. WATER SERVICE
0
CONSTRUCTION
LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.IT. PAID
V 0 l for
rwhichvm hot them iaaed(Ses.onlendis,xgeney for the performance of Date Receipt#
the wok for which Nis permit is issued(Sec.3097.Civ.C.)
`r•'� Lender's Name TOTAL:
Wlarder's Address TOTAL:
a, 1 ccnify thin 1 have read this application and ..,hat the eMve information is BUILDING FEE
Vi carat l agree to comply with all city and county outhouses and shim lows reining to QTg MECHANICALPF.RMIT FEE
U 7 building concoction.and hereby amhodu representatives of Nis city to enter upon the SEISMIC FEE
tri above-mentioned property,for inspection purposes.
1 (We)agree to save,indemnify and keep harmless the City of Capetian against PERMIT ISSUANCE ELECTRIC FEE
r• Iiabilitinajudgmems,costsad expenses which tray many wayaecrueagmnst said City ALTERORADDTOMECH.
/ in consequence of the grunting of Ibis permit. - PLUMBING FEE
Lt APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO I10.0100CFSD MECHANICAL FEE
SOURCES UILpT10N
/��,,((^^ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Amtni
Signature of Applicant/Contrumur Data EXHAUST HOOD(W/UUCO HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stun or handle hamrdom material HEATING UNIT(TO I W00D BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectio 25532(u)') _ HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RES ID) PAID
Data plaintiff Will the air comm or nomas building by the B use equipment or devices which
emit hmardnus air emtuminnms as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I00.U011 BTU)
TOTAL:
District?
E]Yes Fl No BOILER-COMP(OVER 100,000 BTU) -
I have read the hmalloux maremal,reforettmms under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sermons 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MEC".
building does not currently have u union,flat it is my responsibility,to notify the occupant
of the which must he mer priormismxnce of.Cc ton Qcupua .
2 t 1a-Mcupa4
• Own or authorized agent - - - Date TOTAL: ISSUED BY:
OFFICE