30400 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT NO. JK^ 0 4 0 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
0 -Wi r �Zpt�D S-n- ro
\ OW R'S NAME PHONE a ONT AMOR'SNAME: LIC NO: /
NC CONTROL
ICHITE rNG %ER: i;CNO:� DURESS:• ,414/4,-1141% ❑
CONTACT. VVPHONE: Y an
�j
Toe" 2)1-o-1
�� ❑ Consultt Feev Paid by Applicant(initial) 1k_*4 BUILDING PERMIT INFO
64� 4 BLDG EL CT P
r LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I heachy affirmmat 1 am licensed wader provisions of chapter 9(commencing JOB DESCRIPTION
Z with Section 70DO)of Division 3 of the Business and Professions Cade,and my license is RESIDE IAL
�� in fall force and eft PERMIT ISSUANCE
aU��] ameCl4 Lic.q
Li � - ❑SFDWL ❑KETCH REMODEL
1� Date Canwao APPLIANCES-RESIDENDAI. ❑ADDITION [I PLUMBING RE-PIPE
F- B' ARCHITECTS DECLARATION PANELS CMULT6UNIT El STRUCTURAL
Z 0�Z understand my plans shall be used as public records _ .MODIFICATION
0z-,Q UP TO 20)AMPS El INTERIOR E3 CHIMNEY REPAIR
Licensed Professional - - 201.)(MAMPS IMPROVEMENT
•J that I a �exempt fr DECLARATION
Contractors
ON OVER load AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
1 hereby affirm OW 1
OWNER-BUILDER
from me RATIOOf6 License Law for the
U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
W which requires a permit m enmauct,alter,improve,demolish,or repair any structure
priorm its issuance,also requires the applicantfor such permit to file a signed statement SPECIAL CIRCUR/MISC.
thatheiscing itpunuant mmeprovisionsof the Business
and
Proflaw(shorter9
a0� (rommencing wins Section]DWIof Division?ofthe Business and Professions Code)nr TEMP.METER OR POLE(NST COMMERCIAL:
6 y y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wlw Section 7031.5 by any applicant for a pem subjects the applicant to a civil penalty of POWER DEVICES
of marc man five hundred dnlmrs(S5W). TENANT ❑FOOD SERVICE
F pma
Cl,as owner of me property.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the inane,is not intended mattered for sale(Sm.7044,Business
W �_ and Professions Cale:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
properly who huilds or improves thereon,and who does such work himself or through
his own employees,providedthin such improvements in nm intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.IL however,the building or improvement is sold within one ycarmfoompiction,the SQ. . -,REA $/SQ.FT.
ser-builder will have the burden effacing that he did not build or improve for pur. N T. V
po a of sols.)
C 1,as owner of the properly,am exclusively contracting with licensed contractors to A
emenruet the project(Sec.70,14,Business and Professions Code)The Contractors Li-
censeLawdoesnotapplytoanownerof properly who builds or impmves thereon,and QTY, PLUMBING PERMIT PIFEEOF
Who contracts forsuch projects with a conmectons)licensed pursuant to the Contmmors f
License law. PERMIT ISSUANCE
C't am exempt under Sec. ,B&P C far this reason
Owner Data
ALTER-DRAIN&VENT-WATER IEA) VALUATION
11 WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1hand amrm under penaltyof penuryoneto mefollowingdorkers m:
(have and idea!ll far by etion nale37M of Com cm mCode,far the
Workersen of the
DRAINS-MOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCf10N
ishan,r providhi for by Sermon 3]W of the[shot Cade,far the perfamance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will ode,for
Worker's Compensation Insurance,h required by Satins
J]W of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTF,M-1 INC.4OUTLETS OCC.GROUP APN
My K' s's Co pens roc Insum�n(r}v�emier and Policy no
CarticcS%� p$( Policy No.: I GAS-EA.SYSTP.M.OVER4(EA)
CERTIRCATROF , EMP IONFROIN KERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE.INTERCEPTOR
Ubis action mast not he completed ifthe Permit is forone hundred dollars($100) BUILD G VIS NFEES
m 1cio. GREASETRAP
PLANCHECK PEE �
(certify tha.the pcHvnnvnceo(thewnrk for whichthispermitisissuW,lahall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner w us to become subject m the Workers'Ctsmpcn- ENERGY FEF.
0Z a bort laweaf Celifomia.Date WA7 ER HEATER W/VENT/BLECB
In
Z 0 Applicant GRADING F -
fA NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SVSTLM/1'REATING
ai
have.subject to the Worker's Compprovisions
Corsair you of me Labor Code, most SOILS Eli
{17
forthwith comply with such provisions or this permit shall be Jamed revoked. WATER SERVICE
CONSTRUCTION LENDING ng ager NEW RESIDENTIAL PLMB. SQ.FT. - PAID
V Q (hereby affirm that there isacanswction lending agencyfarmeperformenecof Da¢ RCceiptM
w (•+ the work for which this permit is issued(Sa.3097,Civ.C.)
Q , Lender's Name TOTAL:
LUk1 Lenders Address TOTAL:
1 certify that 1 have read Nis application and imte that the No.ofom town is - BUILDING FE r
In corral.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building constmnion,and herehymahmise ox resenativcaofthis city m enter vponthe SEISMIC ME
above-memiaoed propcny for inspection purpoas.
(We)agme m save.indemnify and keep harmless the City M Cupertino againstPERMIT ISSUANCE ELECTRIC E
liabilities,judgments.cups and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL FE
$)I1R U S. ;I/ k _
AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TA
Signature of ApplicpnVContmctor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATE) E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hourdous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Coda Chapter 9.12,vnd the Hcalm and Safety
Cada Section 25532(a)7 HEATING UNIT(OVER IW,(IW BTU)
E)Yet E]No VENTILATION FAN(SINGLE RESID) PAID
Date Recei g
Will the applicant orfuwre building by ueBumequipmentor Management
BOILER-COMP OHP OR IWAW BTU)
mit hazardous air conmmirmnm as defnW by me Bey Area Air Quality Manegcment T AL:
District] BOILER-COMP(OVER 100.00)BTU)
C Yes []No
AIR CONDITIONER
I have tend the hazardous materials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
forma Health&'Safety Code,Sections 25505,25533 and 25534.1 undermost that if me NEW RESIDENTIAL MECH. SQ.PT. -
building does not cortically have a tcrunt,that it is my responsibility to notify the occupant
of me requiremena which must be met prior to issuance of a Certificate of Occupancy.
Owner m mithi rued agcnt Data TOTAL: ISSUED BY:
OFFICE