30822 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30822
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDE.ISTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I l y ' m a 9 It-'�
OWNER'S NAME: PHONE: CONTRAC' 'S NAMEy s LIC NO;
is x//1111 GG N N/C CONTROLN
ARCHITECAINGINEER: LIC NO: AIllatfiss ❑
s44'
CONTACT PHONE: BUILDING PERMIT INFO
AB71 614)10' CL108)777-2Z!�3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am 1meBJ antro to and
Professions
Code. 9(commencing JOB DESCRIPTION
WO2 with Section]000)of Uivision3 of the Business and ihofessions Code.antro license is
QUO y PERMIT ISSUANCE RESIDENTIAL:
ge full fame and effect.
C m F to ❑SFDWL [I KITCHEN REMODEL
H4U License Class Contractor
2 Date—Cnmrunor APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
Z OZ I undersand my plans shall be used ns public records PANELS MODIFICATION
024-0 UI'TO 210 AMPS
FsLicensedF Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
Q Sdf� OWNER-BUILDER DECLARATION 201-Ig0AMP5 IMPROVEMENT
ad'at6 1 hereby affirm that 1 0m exempt from he Contractor's License Law for the OVER RXIDAMPS ❑BATH REMODEL/REPAIR C DEMOLITION
�6f 3,6U following¢anon.(Section 1031.5,Business and Prolbssiuns Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 m Na which requires a .it a:comwtl,ager,impmvc,demolish.or repair any structure
prior to its issuance,also requires the applicant for such pamitto file a signed smtenem SPECIAL CIRCULDMISC.
} that he is licensed pursuant to dw provisions of the Cmnractor's License Law(Chapter 9 �1 nnn
W (commencing with Section]tXN)of Divisiou 3 ofthe Business and Pmfcssinna Code)or EMI'.METER OR POLE INSI'. COMMERCIAL II�
a As p�1 Ibar he is exempt thmel'rsna and the naris bathe alleged exemptimi.Any vitilarion of C NEW BLDG/ADDITION C DEMOLITION
--y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES Is, ❑TENANT CFOQD SERVICE
F. f1ldoe ban five hundred dollars 6500). IMPROVEMENT
sof the pmpeny.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
�F=.� thework,and the strucwrc is not intended mufficred for sale(Sec.701 Business ❑OTHER .#t��W3fessions Code:The Contractors License Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES g�y who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvcmcros are not intended or offered for NEW RESIDENTIAL F.LECTR SQ FI'.
sale.If.however,the bmidarg or improvenuan is sold within one year ofcompletion,the S .OAR AREA 5/SQ.irn
cr-builder will have the burden ofproving that he did not build or improve for pur- /�J/8
pose of sale.). T' J(�
C 1,as owner of the property,am exclusively contracting with licensed cmnrsclors to TOTAL: /'
irshostarce,dam project(Sec.lDOU Best..and too Code:)The Commctors Li- Ur ('b&
1111/l�U
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Q
whocunaacts for such projects with a contract crud pursu0n rthc nry
C/ bb
License Law. t u a//� _ Inn s PERMIT ISSUANCE
am %
Uzte ALTER—DRAIN&VENT'—WATER UA) VALUATION
w
ER'S COMPENSATION Df eARATION' BACK FLOW PROTECT.DEVICE
ertb mmunder peeolV oeperjuryone oftheinsumfor deeWorkers Camper-
vee will
eaJfo by Se Certificate of Conunuo ase.for
Workers Ce of due #RAINS—FLOOR.ROOF ARP.A,COND.
ration,as provided for by Section 3100 of the Iabnr Code,for the performance of the STORIES TYPE CONSTRUCTION
wank for which this peon;,is issued. FIXTURES—PER TRAP
C 1 have and will maintain W..kcr's Compensation Insurance,az required by Section
3100nf Ne Labor Code,lin0r,perfmmanccuf the work for which thi r la+mid is issued. GAS—EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My Worker's Compensation hournnce carrier and Policy number arc:
Carrier: Policy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thizsection neeinutbecompleted ifthc t isforonehurWreddollars(SUND BUILDING DIVISION FEES
pc�, GREASF,TRAP
or less) YLANCHECK FEE
(certify thatinthe p.,unicancenfthework hn which this the Workers'
C,lshall SEWER—SANITARY—S'IURM EA.200 FT.
nm employ any person in any manner su ns m hcaomc uhjecuo the Wnrkcn'Compen- ENERGY FEE
C Z .radon Laws of CaliforniaDare WATER HEATER WNENT/ELF.CTR
z Applicant GRAVING FEE
N. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMU'REATING
> become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
fordwith comply with such provisions or this pstrait shall be deemed revoked. WATER SERVICE
0. 0
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
V O thereby aff a that there is a consuunion lending agency for the pcAnmance of Date Receipt#
U. H ,he work for which this permit is issued(Sec.3097.Ci,C.)
OLenders Name TOTAL:
V lender's Addfcxs TOTAL:
I certify dist l have read this application and state that the above informnion is BUILDING FEE
V) cored.l agree to comply with all city and county ordinances and state laws relating to Q'I'Y. MECHANICAL PERMIT FEE
U sZ bundingconswction,and Mrehyauthorize representatives ofthiscity menur upon the SEISMIC FEE
above-mentioned Prvpcdy for inspection purposes. PERMIT ISSUANCE
(we)agree ro save,indemnify and keep harmless the City of Captains,again, ELECTRIC FEE
liabilities.judgmen,s,costs and expenses which may in any way scans against said City ALI'ERORADDTOMECH.
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UND'('TO IglxO CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of Applicam/Commcmr Dae EXHAUSTHOODOMMUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle havrdous material HEATING UNIT(TO 100.000 BTU)
as defined by,he Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale.Section 25532(0)'1 HEATING UNIT(OVER 100,100 BTU)
❑Yes 7N PAID
' VEN'TILATION FAN(SINGLE RESID) Dau Receipt#
Will the applicant or future building occupant sea equipment sur devices which
emBhtrsdous sir contaminants as defined by the Buy Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU) -
TOTAL:
District?
E3 yes [IN. BOILER—COMP(OVER 100.000000 BTU)
I have most the hazaWnus materials requirements unJer Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
farm Realm&Safety Code,Sections 25505,25533 and 25534.1 undarsmnd that time NEW RESIDENTIAL MICA. SQ.IT.
building docs hist cunendy huvou tenon,,that i,is my respsmsi ality O notify the ocoapma
of the requirements which must he met prior In issuance of a Ceroficam of Occupancy.
Owner m authorized vgcar Date TOTAL: ISSUED BY:
OFFICE