30321 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL 30321
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAD
!0'500 o
OWN S �� //�� PHONE: C RACT R'g NAME: LIC NO:
�13/a • /-� �t./ NIC CONI'R(lLM
ARCHITECT/ENGINEER; LIC NO: AILD SS O S 0
CONTACT PHONE: BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ' MECH
LICENSED CONTRACTOR'S DECLARATION
QTY. ELECTRIC PERMIT
C 1 hereby amfm that ia am licensed under provisions mChapter 9(commencing JOB DESCRIPTION
Z withf firlo n7W0)o(DlvisionJof the Business end Pndessions Cade,and my license is RESIDENTIAL r+
00
wait
force and df PERMIT ISSUANCE d 11 A
�WE, kit ��. Z L ❑SFDWL hUMENREMODEL
tot"' Dme Com amor APPLIANCCS-RESIDENTIAL OADDRION 'PLUMBING RE-PIPE
UCTURAL
i,.;)on ARCHITF,CTS DECLARATION PANELS ❑MULTI-L4tjG 12 /S�QIFICATION
Z O 1 understand my plans shall be uaed ns public rwords v /,,,,/yy��
On, - UP TO 2W AMPS ❑INTERIOR L`1 GG NEY REPAIR
fs•�` Licensed Professional 201-1001DAMPS IMPROVEMENTV
C OWNER-BUILDER DECLARATION OVER IfgI(IAMPS - 13 BATH REMODEL/REPAIR''tOr DEMOLITION
GG 1 hereby wrion Not I am exempt fimw thu Contrudnr's License Law for the
y(06 U following onsawn.(Section 7031.5.Business and Professions Code:Any lily or cony SIGNS ELECTRICAL ❑OTHER
uu7i LLO(� which acquires a Permit to construct,alter,improve,demolish or repair any ewetme
.a7 prior to its issuance,also requires the applicant for Such permit an Glea signed statement SPECIALCIRC MISC.
} am,he is licensed pursuant to the provisions ofthe Commctofs License Law(Chapter 9
aOC (commencing with Section 700())of Division 3 ofthe Business and Professions Cade)or TEMP. OR POLE INST COMMERCIAL:
!6yx o a' that he is exempt thercfmm and the basis for the alleged exemption.Any violation if
EW BLDG/ADDITION Cl DEMOLITION
W^ Section 0031.5 byany applicant for.plasm subjects theapplicunua u civil pewlty of POWER ANT [I FOOD SERVICE
=Z� not more than five hundred dollars(SSW). IMPROVEMENT
C6 DI,ee ownerof the property.or my employeeswith xvgesustheirsnlecompensutinn, SWIM POOLE kl
f m will dothe we&,and the suucmac is not intended or offered for gale(See,TOO,Business ❑OTHER
u0j m and Professions Code:The Contmemr's License law does not apply 0)ua owner of OUTLETS-SWITCHES- R
d 3.. property who builds m improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR FT.
sale.IL howr,are building or improvement is sold within one year ofcompletion,the SQ.PT.pLOOR 5 SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put- /l
page ofsale.). b Co //
❑1,ea ownerof the property,am eidusivdy convucting with IiecnseJ mnvacmrs mfe
on.nmctthe praised(Sec.0014,Business and Professions Code:)no Contractor's Li- ,
x law does not apply to an owner of property who builds or improves thereon,unit QTY. PLUMBING PERMIT FEE
who contracts for such projects with a communing)licensed pregnant o the Contractors
Licenu Law. PERMIT ISSUANCE
El I am exempt under See. ,B&P C for this reason
Owner Uale
ALT17R-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby union under Penalty of perjury,one of the following declarations: .--�
❑I haveand will maintain a Certificate of Consent to self-Insure for Waxers Compern- DRAINS-FLOOR.ROOE AREA,COND. PE CONSTRUCTION
satlo..as provided for by Section 37M of the labor Cale,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I haw and will maintain Workers Compensation Insurance,ss required by Section
37M of the Labor Code,for the PeRormance of the work for which this permit is failed GAS-PA.SYSTF,M-I INC.4 OUTLETS APN
My WorVj�s�pmpF{Jinn lmury ce anter and Policy nyy�yc�q1g
Carricr. I�/I�rIf /A/A M P.Hcy Nn:SL.,3Y*!&0j GAS-EA.SYSTEM OVER d(EA)
a—
CERTIFICATEOF COMPENSATION
I EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASFIINDUSTRL WASTE I RCEPTOR ODIVfSION PEES
(This section need not be completed ifthe permit is forone handbell drilling P1100) GREASETRAP
or less.) PL-q&n
a/'
Icmify that in the pertnnnanee nfthe wo&forwhich this permit is issued,)shall SEWER-SANTTAR -STORM FA.200 FT.
not employ any Person in.ny manner so us m become subject do the Wo&en'Compen-0Z salonLawsofCalifomiu.Date WATER HEA WNENT/ELECI'RGRZ Q ApplicantNOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER S' TEMOREATING
; become subject to the Workers Compensminn provisions of the labor Cads you must SO
forthwith comply will,such p..skions m this permit shall be deemed revoked. WATE SERVICE _
�Z CONSTRUCTION LENDING AGENCY NE RESIDENTIALPLMB. SQ:PT. PAID w ReceiptM
V O l hereby affirm that is a construction lending agency forteperformance of1 0.
the work for which this permit is issued(Sec.3097,Civ.C.)
Lks E~ Lenders Name ir TOTAL:
L) Lenders Address TOTAL:
1 cenify that I have read this upplication and state that the nbwe information is BUILDIN FEE giaaa�
f�A eoeacm.l agree to comply with Wl ciry and count'ordinances and sorra laws rclming to QTY. MECHANICAL PERMIT FEE
V building construction.and hereby authorize representatives ofthis city to enteruponthe SEISMIC FEE
sia-in .0
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree tosave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE'
liabilitieajudgmenu,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH. PLUMBING FE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(1 CFM) MECHANICAL I G
SOURCE RECHILVONS.
AIR HANDLING UNIT(OVER III.000CFM) CONSTRUCTIO TAX
omm of p 'cant/Contreetal ate EXHAUST HOOD(W/DUCT) 'HOUSING MITI ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoocupam store or handle hazardous material HEATING UNIT(TO 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,and to,Health and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 1100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building oeeupxm use equipment or devices which Uate Receipt p
emit haxmdous are contaminants as definN by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) 'TOTAL:
District? BOILER-COMP(OVER 100.600 BTU)
❑Yes ❑No _
I have read thc hmardaus materials mquircmends maker Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safely Code,Sections n505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH.
building does not currently have a tenant,that it is my responsibility to notify Ne occupant
of the requiremcnb which must be met prior to issuance of a Certificate of Ottvperncy. aL
0.
Owner or authorized agent Date SUED BY: IIIA!/-
OFFICE'