30166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 30166 O���S
I6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING AU RESS: /D SANITARY NO. APPLICATION SUBMITTAL DATE
Q Q [�� r
OWNER'S 3N(ME: ` ^ERACTDR�'.SN Ni: O6/
CONTROLK
s�1RCHITECf/EN'GI sGR: LIC NO: V�ADURFSS: ,�� a /I ❑
BUILDING PERMIT INFO
"�\ ��/� �`1 / �I V ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1 ❑ O p<
LICENSED CONTRACTORS p DECLARATION QTY ELECTRIC PERMIT FEE �L
I hereby arfirnt that 1 am licensed anger provisions nr chapter 9(mntmrndng JOB DESCRIPTION
0o2 Whh SeenonL0gordfloiston Infthe Busmeasond ProfesdmnaC de,andmylicenses
l4 0 PERMIT ISSUANCE RESIDENTIAL,
�F S U ic.'eo¢e a tH«I.
UZV Licence Class Lica 4 ❑SPDWL [I KITCHEN RF.MODCI.
HQi Dna Cmnuaaor APPLIANCES—RESIDENTIAL ❑ADDITION GPLUMBING RE-PIPE
RCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z O;52 I undersand my plans shall be used as public recoNs ` MODIFICATION
OZ—q UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F-4 WLicensed Professional 201-1000AMPS IMPROVEMENT
�Y ,,j OWNER-BUILDER DECLARATION El BATH REMODEURF.PAIR ❑DEMOLITION
G C Q I hereby affirm Section'I am exempt Brands,Contractors license Law for the OVER)(X10 AMPS
X 34 F fallowing rca un.l5ection 70315.Business and P olessi m,Code:Any city or romm, SIGNS ELECTRICAL
prior
u1 4.y which requires a pcnNl w dimprove, my structure alter, demolish,or repair y scture
prior to its issuance,also requires one applicant for such penult to file o signed sammmt SPECIAL CIRCUIT/ IS .
S } dual he is licensed pursuant to the provisions ofthe Contractors License Law(Chaper9
�C) (eat he is ixempth Section and the basis for oftheegeBusiness xmpt Poson.Anyu i Code)orTEMP.Mit)ER OR P' F L:
d y o c that he is exempt IhereDom and IM1e basin for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
uXl 4• Section 7031.5 by any applicant for o permit subjects one applicant to a civil penalty of POW Eft DEVICES !,LENANT
F Z} not mom Nan five hundred dollars(S500y FOOD SERVICE
^�6 Q 1,as owner of the pmpcny.sur my employees wish wage as their sole campcnsatinn. SWIMMING POOL ELECTRIC IMPROVEMENT
�SyF� willdo lbework,and the structure is not intendedlroffered Btrsale(Sec.9044,Business ❑OTHER
413 w and Pmfessinm Cede:The Ci na,tun's License Law does not apply In an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such imp uscmenls arc not intended or offered Iia NEW RESIDENTIAL ELECTR SQ FT
sale,IL however.themilding or improvement issold whhinone yearofcampletion,the Q.FT FLOOR AREA S/SQ.ET.
owner-bander will have the burden of proving Nat he Nd not build or improve for pan r
"se of sale). QG i 1� 0'V k/J
❑1.as owner of the property,am exclusively contracting with licensed contractors In TOTAL: O/�,rod
construct the project(Sec.]64,4,Business and Professions Code.)The Contractor's Li- 1 y, �r
cents,Law does not apply loan owner of propcny who builds or improves Saimaa,and QTY. PLUMBING PERMIT FEE ren/re
who contracts forsuch projects with eontmerom(s)Incensed pursuant to IM1e Coo anion's
Licence Law. PERMIT ISSUANCE ;/ ,_t �*I�'Yf J•1 /�,nl 1
❑lam exempt under Sec. ,B&PCfor this reason
Owner Date ALTER-DRAIN&VENT-WATER SOG VALUATION
WORKER'S COMPENSATION DECLARATION So o
1 herch firm under BACK FLOW PRO'1'IiCr.DEVICE '
ya penally ul'perjuryn.,of Nefollmfor Worker's Co
)have and providlrwiby eicate37W of Con semirCadenmafor Worker's Cooper. DRAINS-FLOOR,ROOF,AREA,COND.
ration,as provided for mi Section,i.. J]IJO of the LaMr Cale,for the perfonnana of the STORIES TWE CONSTRUCTION
work",zedwhich this mita is issued. FIXTURES-PER TRAP
uu,����,�''rr� d will maintain Worker's Cnmpensmimn Insumnec,m reyuir,J by Section
V"
sate Who Code,fmolt,performance of the work forwhich Nis pennilrsismed, GAS-EA.SYSTEM-1 INC.JOIfILETS OCC.GROUPs; � � pPN
My Walker'sC ape . alp suancecamcrmdPoli,,KutBbbenrW f1l
Cartier Policy lso,� m 7v_ GAS—EA.SYSTEM-OVER
CIiRTIPICATE OF E%IiMPI'ION FROM WORKERS' J
COMPENSATION INSURANCE GREASE/INDUSTRI,WASTE INTERCEPTOR
(This.section need not be completed ifthe permit is formic hundred dollars(SIM) r, �BI}R, (i"IV pa FEES
inlets). GREASE TRAPsa
PLANCHECKYgiE
I reunify do,in lhel<rlimaan.cofthe work nor which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to become subject to the Workers'Com
Z union Laws of California.Date an ENERGY FEE Vs l/llyu
7�Q Applicant WATER HEATER W/VENI'/ELECfR GRADING FEE
G , NOTICE TO APPLICANT:ll;aftennuking this Certificate of Exemption,you should WATER SYSTEN/TRfiATING
became subject to the Workers Compensation provisions of the Wbor Cale,you most SOILS FEE
lLl fnnhwido comply with such pmvisi.mo,this permitshall W deemed revoked. WATER SERVICE
0. 0
CONSTkUC'1'ION LENDING AGENCY
DZ NEW RESIUfNTiAh PLMB. SQ.FP. PAID
V I for by affirmwhich
thatthemi isacmat ec.30 lending agency for performance of Doe ReceiWN
f4, (, the work for which ths permit is issued(Sec.JW],Civ,CJ
Lenders Name
0 V TOTAL.:
LrnJcrI AdNeas TOTAL:
F y I certify o comply 1 have rued Nis y and court and state tht the above ws refor ms to BUILDING FEE
h bumeseL ilding agree mi ,and with inuth and countyordinancesesand state laws reforms to QTY.=ISSUANCE
CHANICAL PERMIT FEE
Uz abovengconswmoaand berchyauthorizerepresenatives of th;scity to enter upon theSEISMIC FEE
above-mentioned propene I'nr inspection keep m NCE(We)agree to cove,indemnify and keep hamdes Ne City of againsts againstELECTRIC FEE
incoiliequenceofthemanning fthis is it. may in any wee,cent,aguint said City D TO MECH.inconsequence Nthegaming tit he pcWIPLUMBING FEE
APP1, ANT UNDERSTANDS ANU WILL COMPLY WIT'!)ALL NON-POINTG UNIT(TO IB(XM)CFM)SOC REGULATIO SMECHANICAL FEE
IaG UNIT(OVER Io.oryd CFM) CONS]RUCTION TAX
Stgnturemfgppl¢am/C 'et/osr\ Date LD(W/DUCT)HAZARDOUS MATERIALS DISCLOSUREHOUSING MITIGATION FEE
Will the applicant or future building occupant pure or handle hazallous material HEATING UNIT GO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100.000 BTI))
❑Yes Fl No
VENTILATION FAN(SINGLE RESID) PAID
Will Ne applicant or future building occupant use equipment or devices which Dare Receipt a
rnit hazunlous it common asp as defined by the Buy Area At,Quality Management BOILER—COMP(3 HE OR 100,000 BTU)
District?
❑Yes 0 N BOILER-COMP(OVER IN."BTU)
I have read the hazardous materials requirements under Chapter 6,95 of the Cali. A 1R CONDITIONER
fmmia Health&Safety Calc.Sections 25505.M533 and Z 534.I understood that if the ISSUANCE DATE
building does not cmrendy have.mttaat.In.,11 is my respos,ibiInly lm notify the oecupanl NEW RESIDENTIAL MECH, SQ.FT.
of the replirtmems which moat be met pia to komaa,c of a Cemtonle of(kcupancy
Owner or authomed ager Dte TOTAL;
ISSUED BY:
OFFICE