30262 AOVLICPNT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY'
CITY Of,CUPERTINO "BUILDING ELECTRICAL I PERMITN030262
O ^^262/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL'
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - ,SANITARY NO. APPLICATION SUBMITTAL DATE
NER'S AME: PH N�'^. ` CO RAC MR'S NAM - C 0: 2h
,, n WJ O •'I NAC CONTROL#
RCHITECT/ GINEF.R: LIC NO: DR V ❑
CONTACT: PHONE: 22UNOM00AM
BUILDING PERMIT INFO
❑'Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
C� E ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 heresy affirm the]1 am❑eensed under promsions of cnapmr 9(commencing JOB DESCRIPTION
{l{Q�00 wllh Seelimla")of Uivlslon3ofthe Business and Profecrinns Code,and my license is
F W Oy iv full force and effect. PERMIT ISSUANCE RESIDENTIAL
�UF License Class Lic.is ❑SFDWL ❑KITCHEN REMODEL
to,
Data Contractor APPLIANCES-RESIDENTIAL -
to,pr/�rn ARCHITECT'S DECLARATION ADDITION ❑PLUMBING RE-PIPE
O 0 2 4 I understand my plans shall be used as public records - PANELS ❑MULTI-UNIT -]STRUCTURAL
MODIFICATION
UP T0200 AMPS ❑ ❑
INTERIOR ' CHIMNEY REPAIR
OWNER-BUILDER ON
¢FG�EC"W
Licensed Profesetenal ,201.1"AMPS IMPROVEMENT
C
cGa CCCC C 1 hereby affirm that 1 am exempt from the ContrCnntracmr's License Law far the OVERI000AMP$ ❑BATHREMODEVREPAIR 0 DEMOLITION
3 d U following reason:(Section 7031.5.Business and Pndessions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which req.iree a permirro construct,ahn6 improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit m file a signed statement
.] _
that he is licensed pursuant to the provisions of the Contractors Law(Chap¢r9 SPECIAL CIRCUIT/MISC. _
(commencing with Section]000)of Division 3 plane Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
P� WN
Section 7031.5 by any applicant for a perntiisubjects the applicant to a civil penaltyof POWER DEVICES
E, >, not more than rive hundred dollars($5W). ❑TENANT ❑FOOD SERVICE
`ZI D 1,asowneroftheproperty,m rsyemployces with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
ZI will do the work,and Ne structure is not intended proffered forsele(See.7044,Business ❑OTHER
and Professions Code:The Conuacmrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
d'3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTI I.ELr SQ ET -'
sale,If,however,the building.,improvement is sold within.neyeam"'mpinion,the SQ,FT.FLOOR AREA $/SQ.PT
m-builder will base the burden pfocusing that he did not build s improve for our-
pse of sale.). ,
❑1,as owner of the property,am exclusively contracting with licensed contractors 1. ollit, TOTAL: -I
onswn the project(Sec.7044,Business and Professions Code)The Contractor's Li-
tise Law Joos not apply man owner cf property who builds or improves thereon,and QTY, PLUMBING P FEE '
who contracts for such projects with a contractons)licensed pursuanLLo the Contractor's
License Law.
❑l am exempt under Sec. B&P C for this reason PERMIT ISSUANCRIln
lwnm — ALTER-DRAIN&V R( )
Date_ VALUATION
WORT R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI
Iherebyaffinoun eternally ofpejury one ofthe following declarations:
❑J have and will maintain a Cenifictae ofCamentin self-insure for Worker's C..I,a- DRAINS-FLOOR,ROOF,AREA,CO
a tion,as Provided for by Section 3700 of the Labor Code,for the performance of ane STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section `
3700 of the Labor Code,for the performance ofahe work for which this permit is issued. GAS-EA.SYSTEM-)INC.4 OUTLETS
My Workers Compensation Insurance carrier and Policy number urs: OCC GROUP qPN
Carrier Policy No.: - GAS-EA.SYSTEM-OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(Tbis seodom need not be completed Hope permit is falcon hundreddollars($1,00) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK FEE
Ioy say thainthe Peran,mneneeol1to orkbecome
m of rat to hepermitWose,'Corsued,I hull
opt employ any person in any nammr so as m hecpme suhject to he Workers'Cpmpen- SEWER-SANITARY-STORM EA.2W FT.
,* Applicata Laws of Cali forms.Date, ENERGY FEE
O Applicant Q - - WATER HGTER WNENT/[:LECTR GRADING FEE
7
.7 NO!ICE TO APPLICANT:If,attar making this Cisions of of Exemption,you should WATER SYSTEM/1'REATING
abecame subject m the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
131 forthwith comply with such provisions or this permit shall be Deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY
Z NEW RESIDENTIAL PLMB, SQ.FT. PAID
U� k for
thi thermic i Ls.oil(Sea.30 len ding agency for the performanw of Dam ReaetptN
4B F'the work for which this permit is isemed(Stu.309],Civ.CJ ,
C U Lenders Name
-
yy Lender's Address TOTALTOTAL: �0
L, 1 certify that I have lead this application an,[sure anal the above information is BUILDING FEE
,7
U V1 correct,l agree m comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U a. huilding conswetion,and hereby awhnrize representatives of this city mentor upon the SEISMIC FEE
above-mentioned property for inspection purpscs, 0
(We)agree to are,indemnify and keep hatmlaw Oe City of Chloride.armed PERMIT ISSUANCE ELECTRIC PEE
liabillties,judgmene,costs and expenses which may in any way tame against said City ALTER OR ADp TO MECH.^ gr
in consequence of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT PLUMBING FEE
HANDLING UNIT(TO 10,000 CFM)
URCE REGULATIONS. MECHA I E Y
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX ' O
ignanne ofAp ant/Comracmr Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant-,(inure building occupant store or handle hazardous material HEATING UNIT(TO 100,0!1(1 BTU) .�tgNQ
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ise Health and Safety _ N
Code,Section 25532m)? - - HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATIGN FAN(SINGLE RESID) PAID.
Will the applicant or future building occupant use equipment or devices which - Dateetre nal x
emit harmonicas air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CUP OR 100,000 BTU)
District? TOTAL:
❑Yes .ON. ' BOILER-COME(OVER 100,00013TU)
I have read the haeallous matedals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ", ISSUANCE DATE
bpmia Health no Safety currently
have.
Nasions 25505,25533 and 25534 1 understand that if the NEW RESIDENTIAL MECH. SQ.ET,
ofthergdoes uirimerm which have amnaopthao isoilua res of aCilitymnrnifOccupacupam
of the requi¢meius which most M met prior m issuance of a Certificate of Occupancy
, Owner or authonzeda ant a
B Date TOTAL: ISSUE
OFFICE
B F
Y
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PLA KING DEPT.
BLDG. INSPECTION DEPARi'NIENT
CITY OF CUPERTINO
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