30753 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMITNO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL {`+!
BUILDING PROJRCF IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
%b-tVs It`tl!LAw\Ifl paMa&)a Q•16I.'l(a0
OWNER'S NAME: yHONE: CONTRAC'IOR'SNAML': LIC NO:
Seo(Cvs NIC ccONTROLe
TCIIITECI'/F.NGINEER: LIC N0: ADDRESS: (JZ
g.v0.1«wrtA. MICOC. C.' ��o4 C q`\� QWt 31L106L' {)ll. 5.�! 7
In CUNTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGELF, PLUMB MECH
WLuMv'tA P< ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE
1 hereby affirm Nal 1.m licemed under pm.isions of Chapter 9(armmercirg JOB DESCRIPTION
{O{yCZ with Section 70W)of UivisionJof Ne Business and Professions Cale,and mylicense is RESIDENTIAL:
F02 in full force and effect PERMIT ISSUANCE,
CWF �L 0 9.'7t.(. O 0 SFDWL - El KITCHEN REMODEL
QUO Licerae Class Lic.M
� W Date k• s Contractor tY4N\O tktraM. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPF,
1F.. p' ARCHITECT'S DECLARATION OMULTbUNIT STRUCTURAL
Optn� I understand my plans shall N used as public records PANELS _ ❑
MODIFICATION
Ill'TO 200 AMPS
Fss4.f.W Licensed Professional
El INTERIOR ❑CHIMNF,Y REPAIR
0g4�3 OWNER-BUILDER DECLARATION OVER
IMPROVEMENT
C Q I hemby nffrm Nut 1 vm exempt from he Comractor's License law for the OVER IUg1AMP5 ❑BATH REMODEURBPAIR DEMOLITION
sG L U following rwson.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL OOTHER
Fy which rtquires a permit m co ommi.alter,improve,demolish,or repair any structure
pnmm its issumce,also requires the appliemn furwch peorat to tile.signedstwemem SPCCIAI.CIRCUIT/MISC.
that he is licensed Pa...,1.the provisions mthe Contractors License Law(Chapter Y
W COQ (commencing with Section 7000j of Div Ill.Sof the Business.ad Professions Cude)ar TEMP.METER OR POLE INST. COMMERCIAL,
a a c that he is exempt therefrom and the hesis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Section 703 L5 by any np,lieaa,fora permitmbmets theapplirmat to.civil penahy of POWER DEVICES
FZY not more Nan five hundred dollars($500). rr�.'�l'�ANT q ❑FOODSERVICE
O L as owner of Ne property,or my employees wilt wages as their sole compensation, SWIMMING POOL ELECTRIC OTHERVEMENT
y will do the work,and the swcwre is not intended mothered for aide(See 7(A,I.Business ❑OTHER
W via and Professions Cale:The Contractor's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
6 3 pmpeny who builds or improves thereon,and who does such work himself or Nmugh
his own employees,provided merriest in,m vermad.are not imcnded or offered for NEW RESIDENTIAL ELELTR SQ Ff.
aale.lf.however.Are huilJing or impmvemem is sold within ancycarofcomphnion.Ne SQ.FI'.nARAREA ESQ.FT,
bui'c'r will have the burdeaaf proving that he did not build or improve for put- W A '®
❑Lu�wner of the propene am exclusively cammctin8 with licensed con vectors to Jq "1
construct the project(Sec.ily o an Business and rte who
i builds
ut Cade:)Tho Contractors Li- O Iv
censeenwdoeorsuchs not forme an with
SCrwner fpmpcny wmemseddsramrat ocheves Contra.and QTY PLUMBING PERMIT FEE
who..Law.for Hoch projects with a conuacmgs)licensed pursumn m the Contractors
Limns law. PERMIT ISSUANCE' F(.
❑lam exempt under Sec. ,B&PCfa Nis reason
Owner
ALTER-DRAIN&VENT-WATER EA) VA 11Z10N
Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I lerebyaffrmr under penalty of perjury one ofthe following declarations: �t7 r
I have and will maintain a Certificate ofConsam to self-insure for Workers Crimper. DRAINS-FLOOR,ROOF,AREA,COND. STORMS TYPE CONSTRUCTION
don,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
0 1 have and will mainmin Worker's Compemalm.Insurance,as squired by Section
37Waf Nc labor Code,for the performance.fthe work for which this Foram is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN
orkers Compensation Insurance carter and Policy number am:
orrice Policy Na.: GAS-IiA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS ANDUSTRL WASTE IM'ERCEPTOR
(This sectiunneedmt lie completed ifNc permit is forms hundreddoll.PHB) - BUILDING DIVISION FEES
or less.) OREASETRAP PLANCHECK FEE
lay sayChain the any mrnanceof the work for which this thePermitshall SEWER-SANITARY-STORM EA,2W IT. r
not employ any petwn in my manner w nv to become subjecuo the Workeri Compete ENERGY PCC
O Z sation laws yfCyIO'omia.Dat WATER HEATER WNENTMLF.CTR
Z 0 Applicun GRADING FEE
NOTICE M APPLICANT IE after making this Ccnifi a o 'on,you should WATER SYSTEMII'REAfING
a become subject m rhe Warker's Cnm,croam nn pro.Won,of the Labor Cade,you must SOILS FEE
forthwith comply with such Provisions or this permit shall be doomed revoked. WATER SERVICE
Q
UZ CONSTRUCTION LENDING AGENCY NEW RESIUIiNT1Al.YLMB. SQ.FT PAID
U. 0 I hereby a h this
Nauhes is sued(Sec.
30 l7.Cmg agency fur the performance of Date Receipt p
U. F Newark for which Nis permit is issued l$ec.3pl"l.Civ.CJ
0 U Lender's Name _ TOTAL:
LendeYI Address TOTAL:
1 mrd agree that 1 have read Misll ty and coun and stem that the above iws relatian is BUILDING LYE 'L
In burring construction,
and with yaurb rii countyordinancesstem mwarimsmt a QTY. MECHANICAL PERMIT FEE
above-gconwcdonert bombs amhonprposes. moves ofthis to enterupon the SEISMIC FEE
shove-(We)are propene for inspection an purposes' PERMIT ISSUANCE
-csju agree to save,indemnify and kmp harmless the City of against s against ELECTRIC LYE
incoide,ttenc ofth,costs and expenses thispormit. may in any way eccrmte against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE EGULATIO S. MECHANICAL LYE
'�yL AIR HANDLING UNIT(OVER IIL(I(IO CFM) CONSTRULTIONTAX
ig fe l'ApplicanUComractor . I Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
HA]ARDOUS MAPF. E
Will the applicant or future building necupmt store or handle hazardous mammal HEATING ON IT ITO 100."BTU) Aer
u defined hY the Cupertino Municipal Cale.Chapter 9.12,and the IIcahn and Safety
Calc.Section 25532(n)P HEATING UNIT(OVER 100,000 BTU)
p Ye. ❑No \
' VENTILATION FAN(SINGLE RISID) PAID
Dam ReceiptM
Will Ne air concomitants
it furore building by the Dt use equipment or devices which HOILER-COMP(3HP OR 1 W,OIIB BTU)
- r .'t haza�Aam air conmminunts as defined by the Bay Area Air Quality Management TOTAL:
Won? BOILER-COMP(OVER 100,000 BTU)
OYea [I No -
I have read de haaeNnus nownalsrcgairemenn under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA ;
fomia health&Safety Cods,Sadao 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does notcurad,have.teram,that it is my responsibility 1. fit,Neuccupum
of he requirememms which mus,be mm prion.issuance of a Certificate of Occupancy.
Owner ar aumorized.gear Date TOTAL: ISSUED BY:
OFFICE