30876 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM],No 30876
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
I'llUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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N 'S NAM : I HONI?'. CONTRACfOff'S NAMI!: LIC NO:
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CONTACT: - - PHONE: BUILDING PERMIT INFO
��_��// -O Consultant Fees Paid by Applicant(Initial) BLDO ELECT PLUMB ' MECH
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LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 of licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ• th Section 7Uro)of Division 3 ofthe Business and Professions Code.and my license is RESIDENTIAL:
yIs��oO w, PERMIT ISSUANCE
FkdC in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Cmc APPLIANCES—RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
' Z to Date Cnnvucmr
[[--��<Pm ARCHITECTS DECLARATION PANELS ❑MULTIANII' [:1 STRUCTURAL
Z pv1 7J. 1 understand my plans shall he used as public records MODIFICATION
p,z - UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-•,F' Licensed Professional 201-1010 AMPS IMPROVEMENT
< OWNER-BUILDER DECLARATION
OVER ICU AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
,6 1 hereby affirm that I am exempt from the Contractor's License Law for the
aCt U following reason.(Section]031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL []OTHER
4Fa which requires a permit to con.swct.mbar,imp..e.demolish,or repair tiny surrome t
primm fix issuance,nlsn requires the npplicam for such permino lilac signed statement SPECIALCIRCUIT/MISC.
pN.. that he is licensed purnermto the presisionsnf he Contractor's license Low(Chapter 9
I CC mommencing all Section 7")of Division 3 of the Business and Pn+fc.mm Code)or TEMP.METER OR POLE INST. COMMERCIAL:
g. e K that he is exempt therefrom and the basis let the alleged exemption.Any violation of [3NEW BLDG/ADDrrION ❑DEMOLITION
deg, la• Section]031.5 bapplicant fora nsubjects the nt applicam o civil penalty of POWER DEVICES
u1=y y any pmit ❑TT:NANT FOOD SERVICE
not mart Nan Bve hundred dollars lfSW).
Q ❑I,Off a 'fthe pr,eny.ormyemwith compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
and dothework,andthea actuatorintended e La.dofarsale(Sea to aBusiness []OTHER
µa7 and Professions Calc:imp Conweols License Law saes not apply s lfo owner of OUTLETS—SWITCHES—PI -
r progeny who boilss or improves tM1inch amusements
who aces such work himself or through
salown employee,provided Nat such improvements thin not intended or offered for NEW RESIDENTIAL ELECTR SQ
sde.ILhiline the building orimprovement is sold within one year of completion,the SISQ.FI'.
nwncr-builder will have the burden of fimving thin he did not build or improve for par.
pose mf selene A In�
❑Lasowner of the propcny.am exclusively contracting with licensed contractors to TO './
construct the tiniest(Sec.7M4,Business and Professions Code:)Me Contractors Li. µ.A�
cense tawdoes not upply foam owner ofpmpeny who builds or Improve thereon,and QTY. PLUMBING PERMIT' FEa C� ,N.00
who contracts fmrsuch pmjecls with a contimetor(s)licensed pursuant to the Contractor's Ur
License Law. PERMIT ISSUANCE CVrCNI'Jry(�
❑ m
IaexcmfunderSee. ,B&PCfon
orlhisreas
��Owner
Data ALTER—DRAIN&VENT—WATE 1 VALUATION
( :R'. ON DECLARATIO BACK FLOW PROTECT.DEVICEOO�
1 hereby affirm under penalty of perjury one of the following declarations:
Ski Ihave and will muinminaCenifem of Cnnsemmself-Insure fnr Workers Compen- DRAINS—FLUOR;ROOF.AREA,GOND. STORIES TYPF.CONSTRUCHON
safion,as pmvided for by Section 3700 of the Lthm Code,for the performance ol'the
work for which this permit is issued. FIXTURES—PER TRAP ,
1 have and will maintain Workers Compimrtion Insurance,as required by Sermon
37M ofthe labor Cede,for the perfmmancrof the work far which this permit is issued, GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
I Cartier: Policy No.: I GAS—EA.SYSTEM-OVER 4 FA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed if Tho permit is fomite hundred dollars(SI00) BUILDING DIVISION FEES
nr les.) GREASETRAP PLANCHECK PEE 0--
I certify that in the performanceof the work forwhich this permit is issued,l shall SEWER—SANITARY—STORM EA.2nd FT.
not employ any person in any manner so os to become subject a the Workers'Compen- ENERGY FCB
Z
sation Laws of California.Date WATER HEATER WNENMELECTR
7�Q Applicant GRADING FEE
G (,q NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTEM/TREATING SOIfS FEE
h �^ become subject m the Worker's Compensation provisions ufine IaMn Cede,you roux,
Wry forthwith comply with such provisions orchis Permit.shall be counted revoked. WATERSERVICii -
U -
z z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID Dam Receipt#
U P for
which this
thatthno isaco (Sec.30 len ding agency for Nc performance of
the work for which this pemtit is issued(Sec.309],Civ.CJ
U. U Lenders Name TOTAL:
U Lenders Address - TOTAL:
I� d I certify that I have read this application and state that the above information is BUILDING ME
�^ ZI correct.Io Fore to comply with all city and county ordinances and surto lows trading to QTY, MECHANICAL PERMIT FEE
U 4 building construction.and hereby authorize representatives of this city it)enter upon the SEISMIC IEH
.Inose-mentioned propcny,for inspection purposes. PERMIT ISSUANCE(We)agree m sere.indemnify and keep harmles the City of Cupertino not ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
n conesquence,of the granting of this permit, PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
., SOUR REGUI 1710 MECHANICAL FEE
���/'�e� ' y0_f� AIR HANDLING UNITRIVER IO.WIICFM) CONSTRUCTION TAX
aignmure of AppicantcanntA-moractor 7r Data / EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theippiicantoh future building oecipanduareor handle laminators materid HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chaser 9.12,and the Health and Safety
Code,Section 2"32(1 HEATING UNIT(OVER Haff"BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Uvm Receipt p
Will the epplic.m ar future building apam us
roue ctimpmen or devices which
Pill hazardous air contaminants as delined h the Ba Area Air Quality Management BOILER—COMP(3HP OR 100,01X)BTU)
Y Y Y. 8 TOTAL,:
tsmcIT '
❑Yes ❑Na BOILER—COMP(OVER 101,000 BTU)
I have end the ha]nrdous materials requirements under Chapter 6.95 of use Cali. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cede,Sections 25505,25533 and 25534.I understand that If the NEW RESIDENTIAL MECH. SQ.FT.
building A not currently have a tenant,that it is my responsibility tit notify the occupant
ofthe oust. hich t met orio Nsu -of.Cenit1. 'f ccu nc
net orTimlioniRd agent Date TOTAL: ISSUED BY:
OFFICE