30556 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
EERMIT NO. 30556
BUILDING DIVISION APPLICATIONT(PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
ItUILDINGADDRPS �� �� Tj /v .2SAyITA� 0.
APPLICATION MALAIf
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\RCHITECT/EIJGINE[R: LIC NO: ADDRESS:
CoreHACCT. PHONE: BUILDING PERMIT INFO
yy6,ya9-\- ❑ Consultant Pecs Paid by Applicant(Initial) BLDG GEC PLUM MCH
1 LICENSED CONTRACTOR'S DECLARATION
❑ QTY ELECTRIC PERMIT FE
I hereby a01nn thin I am licensed under provisions Of Chapter 9(commencing JOB DESCRIPTION
OZO with Section]000)of Division 3ofthe Business and Professions Code,and my license is
in full foroeanJ effca -. PERMI'TISSUANCE R ID NTIA
,,Wt: License Cla, Limp WL G KITCHEN REMODEL
hQL
contractor) Coctor APPLIANCES–RESIDEM'IAL (TION
To ARCHITECTS DECLARATION ❑PLUMBING RE-PIPE
OZyZ I Understand my tomo,hnll be used ai,ablle records PANELS (LI ❑STRUCTURAL
UPT02(p AMPS MODIFICATION
F.N.F7W Licensed Professional [IINT17RIOR GCHIMNEY REPAIR
201-I0W AMPS IMPROVEMENT
u s j IO
A
OWNER-BUILDER DECLARATION
y C 6 1 hereby affirm thin I ten exempt R E the TIOmr'(License haw for the OVER I"AMPS G BATH REMODEUREPAIR G DEMOLITION
x 3LLFU following reason.(Section 1031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
N which requires a permit To consumer,alter improve,demolish,er repair any smteme,
I"'��j prior n)its issuance.also requires the applicant for such Permiuo file a ognedsmtcmem SPECIAL CIRCUIT/MISC.
} that he is licensed pursand to the provisions of the Contractors License Law(Chopter9
yG� frnmmeneing with tieminn]1MM11 of Uivision3 of rhe Business and Pmlessirns Crde)or �y(�---
pp TEMP.METER OR POLE INST. COMMERCIAL° Vfs
6 2 e that he is exempt therefrom and the basis for Rte alleged exemption.Any violation sky of
X^ lection 7031.5 by any red dmn for a pemtir subjeca the applicant m u civil pewlty Of POWER DEVICES G NEW BLDG/ADDITION ❑FOOD LITION
SERVICE W r N nm mort than five hundred dollars(5500). ❑TENANT FOOD SERVICE
fS� ❑I,as owner of the proleny,or my employees with wages as their sole cmnperomicn. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work.and the structure is not intended or offered ferxvle(See JDbL BusinessTHER
W3..eo and Pmessiens Code,The Commctor's License law does net apply ns an owner of OUTLE'I;S-SWITCHES-FIXTORES
property who builds or improves Thereon,and who d«s such weak himself or through
his own employees,provided that such improvements aro not intended Or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however the building or improvement is sold within one year orcompletion,the SQ.FT.BOOR AREA 8/SQ.FT.
Owner-builder will have the burden of proving that he did not build or improve for par-
,in of sale.).
❑I.as owner of the properly,am exclusively contracting with licensed contractors to T
mswn the project(Sec.]f44,Business and Pmfessinnx Code)The ConuacmGs Li-
nse law does not apply To an owner of property who builds or improves themon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a commends)licensed pursuant TO the Conranors
Li«nm Law. PERMIT ISSUANCE
❑I 11 u ,l)&P C for this reason
ynA A 1ER-DRAIN&VENT-WATER GIA) /1 VALUATION
W R :R'S COMPI'iYN-SVATION DECIARATIOIt BACK FLOW PROTE(TE DEVICE
I hereby affirm under penalty Ofparqury one of The following declaration,
ave and will maintain a Cenificateof Caravan m wif Unsure for Worker's Compen- DRAINS-FLOOR.ROOF AREA,CONE.
anon.as provided for by Section 3701 of the Labor Code,for rho per ocivaice of the StORIES TYPE C0NS'1'RUCf10N
work for which This permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37700 ofine Labor Code,for the parfonrnerof the work for vehichthis permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP
My Worker's Compensation Insurance currier and Policy number art: AP
Carrier: policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'I'RL WASTE INTERCEPTOR
less.)
(Thisuction need not he completed if the pcmdt is for one hundred dollars CS l no GREASETRAP BUIL G VIS FEES
or
I cenity that in the perfomunce urine wink for which this permit is issued,Isha11 PLANCHECK FE 1\
not employ any person in any manner so as to Mcoon subject it)the Workers Contpen- SEWER-SANITARY-STORM EA.200 IT. ENERGY FE V
0 Z cation laws of California.Date WATER HEATER WNENT/ELEC R
Z 2 Applicant GRADING Ft
y NOTICE TO APPLICAN'E If.after making this Certificate of Escmprion,you should WATER SYSTEMaREATING
> become subject a the Workers Compensation provisions of the Labor Code,you nmst SOUS FEE
D] forthwith comply evithoveh pmvixmns Or this permiuhall he deemed revoked. WATER SERVICE
0. Q
CONSTRUCTION LENDING AGENCY
D Z NEW RESIDENTIAL PLMH. SQ.FT. PAID
U0 I for whihhi thanhcrt isacd(Set,097.Cingagency Grnhc performance of Do Receiptp
W. j= the wick for which his pcnnit i,,,,.cd(Sea.11l9].Civ.C.)
Lenders Name
U Lenders Address L. 'TOTAL:
F0. I certify drat I have read this application and stare that the above information is BUILDING FE �•
h correct 1 agree m comply with all city and county oc inonccx and amts laws relmmg m QTY. MECHANICAL PERMIT FEE
C„)Z buildingconstruction,and hereby audience espssenmtives of This city to enter upon the SEISMIC FEE
shove-mentioned property for inspection purposes.
Wcle to use.indemnify p YO PERMIT ISSUANCE
( gree yandhic harmless Cit of ELECTRIC FE
incoisequnce of ossto grstsandor this ermit.hmayinany way aceraeagam.a said City ALTER OR ADDTOMECH.
consequence Of the graining of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ACI,NON-POINT AIR HANDLING UND'(TO IB.DIH CFM)
SOURCE REGULATIONS. MECHANICAL E
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION X
Signaturrol'Applicant/Contmetor Date EXHAUST GOOD DVDUC) HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thcapplicam or future buildingcecupant store orhandlchacanlousmatenal HEATING UNIT CTO 10RON BTU)
as defined by the Cupertino Municipal Code.Chapter 9,12.and the Health and Safety
Code.Section 25532(x)'! HEATING UNIT(OVER 130,90)BTU)
ED Yet, CNO
VENTILATION FAN(SINGLE RESID) PAID Date Be ipta
WII the applicant Or future building Occupant use equipment or devices which
%it..hmmdcus air exmamiams as defined by the Buy Area Air Quality Management BOILER-COMP GINE OR 100.000 BTU)
n1 TOTAL:
❑Yes C]No BOILER-COMP(OVER 100.0001111)
I have read the hmamous materials requiecmcros under Chapterb.95 of The Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 25505.25533 and 25534.1 Understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building dues not curen0y h or a mot,th
unat it is my resporomility m nutify the cecupant
of the requimmenrs which must be,met prim to issuance of a Certificate of Occupancy.
4 Owner or vuthonud egcm pate
ISSUED BY:
OFFICE
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