30719 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECP[Dp1 IF'ICATION
HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/U l Lfo �2'LG Q a
PHONE: CONTRACTOR'S NAME: LIC NO:
&DOVIC IPA 8P6739-LiLNq
NIC CON�gT�RyO�LN
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RCHITECf/F9-►5-L. E]F,R: LIC NO: _ ADDRESS:
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CONTACT: PHONE: - BUILDING PERMIT INFO
0ld10S14;gAE2. �S1e7)�lq-p�1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION herEl ElQTY. � ELECTRIC PERMIT FEE
I eby uffira Nut I em littnsed under pravisians of Chapter 9(comms ting JOB DESCRIPTION
{�{�s��Z with Senion]f1t11p of Uivision3oftheBusinessand Professions CeMe,und my liccnseis RESIDENTIAL,
FCC in full force and effect.
PERMIT ISSUANCE t =
yeyu ❑SFDWL ❑KITCHEN REMODEL
aZ W Lt.so Clens Coma
APPLIANCES-µES ID SIAL y6i Dute Cnnvunor ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-0NIT ❑STRUCTURAL.
ZFbg= I understand my plim,Mall beusWaspublic recntds PANELS MODIFICATION
CZ Z UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
;M t al Licensed Pmfusionul - - 201-I"AMPS IMPROVEMENT
' OWNFR-BUILDER DECLARATION
66 6 1 hcreby affirm that 1 em exemfromthCountermenWfa
pt Countermen License IN r the OVER Palo AMPS C3 BATH REMODEUREPAIR ❑DEMOLITION
x3�U followin,ciatan.(Section 7031.5.Easiness end Professions Code:Anycitynr county SIGNS ELECTRICAL ❑OTHER _
LLLL - which requires a permit m construct.alter,improve,demolish,or repair any stmcmre
t�0 prior to its iedwin0.uknrequites the applicant fmmeh pc coal m lileasigued statement SPECIAL CIRCUITIMISC.
i+ that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapeau OC (commencing wiOt Secdan lOLYQ of Divixion3of the casinos and Professions Cale)or TEMP.METER OR POLE INST COMMERCIAL:
d c oC that he is exempt therefrom and the hank fon the alleged exemptionAr,violatine of ❑NEW BLDG/ADDITION ❑DEMOLITION
-^,m Section 10315 by any applicant fora permit subjects the opplicem m a cin 11 penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more than Eve hundreJ dollars($SOLE.
pqp ❑ ro
1,as owner ofthe property,or my employees with wages an their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT '
22G❑GC will do Ne work.and the structure is not intended croffcred for sale(Sec 9044,1tnsincss ❑OTHER
Irl and Professions Code:The Contractors License Law dote not apply to an owner of - OUTLETS-SWITCHES-FIXTURES
0. ^ property, ro
who builds or impves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended nr offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building or improvement is sold wiNin one year ofcompleow.the SQ.FC FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving roar he did not build or improve for pur-
poseofsnleJ.
Cl1,os owner of the psopaco,am exclusively contracting with licensed conwctma to TOTAL T
consumer the project(Sec.1044,Business and Professions Coda:)The Contractor's Li-
waveLowdoesnotapplytoanownerofpmperywhobuildsorimpruventhereon,and QTy. PLUMBING PERMIT FEL'
who coutmcu Ibr such projects with a comfa aunt)licensed parsaant to the Commmor's
License Co. PERMIT ISSUANCE
❑1 amt exempt under Sec. ,B&1'C for can reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
ffiWORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DEVICE! 4) OT ON
I hereby arm under penalty ofperjury one of the fallowing deomti
leonx: J V
O l have and will maintain a Cerificamof Cunmm to self Insure for Worker's Caution- DRAINS-FLOOR,RIX3P,AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 37W of the Labor Code,for the performance of the
work Me which this pemtit is issued. FIXTURES-PIER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Lobar Code,for the performance ofthe work for which this permit is issued. GAS-EA.Sys TEM. INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insumme,carrier and Policy number we::
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
C13RTIFICXM OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need act be completedcompletedif Ne permit is foronchundrN dollars($100)U) f (VISION marsGREASETRAp
m less.) PLANCN F —�
(certify Perhatson
nthein anymanncc ro ffic astoarkfof which0o theperandWorkers
C,Isha11 SEWER-SANITARY-STORM RA.2W19L '
not employLaw any person is any manner no tae m heconm subject the Workers'Cuntpero - G
OZ moon LawsnfCalifomia.Date WATER HEATER WIVENT/ELEC11
z Q Applicant GRADING FEE
r.t y NOTICE TO APPLICANT:IL after staking this Certificate of Exemption,you should WATER SYSTEMITREATING, C lasso,Cry,dO
a � become subject to the Workers Compensation provisions of the Lothar Code you most '.YMS FEE
Gk1 forthwith comply with such provisions or permit shall be deemed revoked WATER SERVICE
aQ
z M.Mcce
CONSTRUCTION leading
NEW RESIDIiNTIALPLMB. SQ.14. PAID Uure 1-can
esti Op
U 0 (hereby affirm rhauhere in construction lending agency for the performaae of P
Ne work for which this .it is issued(Sec.3091.Civ.C.)
0 Lender's Name TOTAL:
WLender's Address 'TOTAL: -
I certify that 1 have red m this application and sa that the strove information is BUILDING FEE
hacorrect l agree to complywith all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE
U building construction.and hereby schema,representatives of this city to enter upon the SEISMIC FEE
rRwo
above-mentioned property for Iasp:ction purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep hardens the City of Cupertino against ELECTRIC FEE
Iiahilities,judgmems,costs and expenses which may In any way accrue ugaimlsuid City ALTER OR A DO TO MECH.
in consequence of the gaming of Nis instant. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT GO PROBE CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.00iM) CONSTRUCTIONT
Signature of Aphemic Commcam Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle htuadous material HEATING UNIT(TO I00.000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 2,5532(a)9 ^' HEATING UNIT(OVER 101"BTU)
Yes �'p-[fi\
• VENTILATION FAN(SINGLE RFSID) PAID -
WiII the applicant or future building occup rt use equipment or devices which - :Dam l Receipt M
mit hamrdmen air recriminations as defined b the Ba Area Ab Quality Management BOILER-COMP(3HPOR 10,B"BTU)
Y Y Y 6 TOTAL.:
Dixtrim4
[I Yen BOILER-COMP(OVER 100,000 BTU)
o
AIR CONDITIONER
1 have read the hmaudous materials requirements under Chapter 6,95 of Ne Cali- I ISSUANCE DATE
forma Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant that it in my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
III Owner or amhorixed urgent Date TOTAL: o ISSUED BY:
OFFICE