30076 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 7
CITY OF CUPERTINO BUILDING-ELECTRICAL. MRMITNO. 30076 O O 1 p/'-��N/
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OW ER:S NAME: PHONE: NTR LTOR'SN LICNO: rV 4e.
C!V _ WC CONE LN
ARCHITECDEN NENR: LIC NO:
ADDRESS ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Nt DR, '9 E3
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hemby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,n„3Z with Section 700o)o Division 3ofdm Bmisnotnd Probations Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
in full fame and eff
OO C�
W apo ❑SFDWL ❑KITCHEN REMODEI.
Contractor - ❑PLUMBING RE-PIPE
APPLIANCES-RESIDLNDAL ❑ADDITION
pry ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
(F... I'understand m I PANELS
Z O-7� y p ws shall be used as public records MODIFICATION
OZ- UP TO 2fN)AMPS
4.I']W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
ey+Y ,..I OWNER-BUILDER DECLARATION 20LI(kIf1AMP5 IMPROVEMENT
K j< 1 hereby affirm that 1 am exempt from to Contractors License Law for the OVER INV AMPS TH REMODEL/REPAIR ❑DEMOLITION
WQ a N.FV. following reumn.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
0 pj which recconsumer,ums a permit toconsumer,alter,improve,demolish,or repair any sanctum
gprior to its issuartt,also requires the applicant for such lemon to file national statement SPECIAL CIRCUIT/MISC.
yW} mat he is licensed pursuant to the provisions ofthe Contractors License Use Chapter
1q� (commencing with Section]ml0)af Division 3 afoha Buinessand Profersians Code)ar
TEMP.METER OR POL8INST. COMMERCIAL:
d Y
that he is exempt therefrom and the basis for the alleged exemption.Any violation of - (3 NEW BLDG/ADDITION ❑DEMOLITION
V• Section 7031.5 by any applicant fora permitsubjens the applicator o a civil Mary of POWER DEVICES ❑TENANT ❑FOODSERVICE
y of mora than fivr hundred dollars($500).
(,"owner ofma, IMPROVEMENTwil -.
❑ property,or my far trt.(Sol. 044.8 Business
SWIMMING POOL EL Cf RIC
and do Newark,and therectorsisnots Livens Lawdue,out art.(So.
to
war,of OGTHER
a and Professors Code;The Corwmoh Liana Law das not apply hi s if owner,of OUTLHTS-SWITCI S-FlXTU0.E5 N -
.. property who bails,nr improve.thereon,and who ntes such work himself or through
his awn employees,provided Net such improvements are not intended or oBemt for NEW RESIDE ECITt SQ FT.
sole.ILhuweveallhabuildingeburden of
ithsold hewithinione yenrofcompletionthe SQ.FL FLOOR AREA LSQ.PT.
Pa.of ale).will have to burden of proving that he did not build or improve for Pur-
Pau of sole - ,
❑1,as secttheowner of ct(Sm. 044,B sinus andely contracting with licensed mmoners-to AL:
construct the project(Ser.]064,Business end Professions CodeU'Ibe Contractors Li-
cense law does not apply to an owner of propeny who builds or improves thereon,and QTy. PLUMB E FEE
who contracts for such project,with Imument 01)licensed pursuantmthe Contractors ,
License Low. PERMIT ISSUANCE f
❑1 am exempt under Sec. ,B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WATER IEA) VALUATION -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarmion.s:
❑Ihxve Nod will meinmin uCeniOcam of Consent to self-insurt for Workelx Compen- DRAINS-FLOOR,RODE AREA,COND.
sation,as provided for by$.Nian 3]9)of the labor Code,for the performance of the 'STORIES TYPE CONSTRUCTION
work for which this permit is iemmd. FIXTURES-PER TRAP • }
❑I have and will maintain Worker's Conquest Insurance,as required by Section
3700of Ne Labor Coca,��firm.mp'eyr`fammntt ofthe work for which this permit is issacd, GAS-BA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
CuymerC.: Q L RaA+�e cartie PolicPolicy:number ons: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section rad no,becompletedaNe pmdt eis borons hundred dollars HIM) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performanceof to work for which this permit is issued,I shall
not employ any person in an manner u as to become subject flue Worker%Cam SEWER-SANITARY-STORM EA.200 FT. -
Y pen- ENERGY FEE
Z sation laws of California Dam
WATER HEALER WNL>NT/ELECfR
z C) Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenificatc of Exemption,you should WATER SYSTEM?REATING
(~ became subjat to the Worker's Compensation provisions of the Labor Cade,you must SOILS HE
forthwith comply withsuch provisions or this permit shall be deemed revoked. WATER SERVICE,
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FPAID -
Q ,(hercby affmm tat there iseronstmction lending agency for to performance of Date Receipt
[I.L-� the work for which this Femur is issued(Ser.309].Civ.C.) t -
01--� lender's Name TOTAL:
0. Lenders Address TOTAL:
1 certify that 1 have read this application and slam out Ne move information is BUILDING FEE e,
V1 carat I agree to comply with all city and,,holy ordinancesand xmm lawa misting m QTy. MECHANICAL PERMIT FEE
V Z building construction,and hereby authonse mpreunmtivcs ofthis city to enter upon the SEISMIC FEE
•�" shove-mentioned pmpeny for inspection purposes.. so All
(We)ago to Saye,indemnify and kap harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
inalmasN
ostsaodbspers which may in any way rector against said City ALTER ORADDTO MECH. PLUMBING FEE
in eomeqratingofthispermit.APPLICSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCEONS. MECHANICAL FEE
rs. Is AIR HANDLING UNIT(OVER In"CFM) CONSTRUCTIONTAX
Sign..—- teen mmctar Date E%HAUSTHOOD(WMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant store orhondle haaammus material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and But Health and Safety
Cade,Se9don 25532(x)7 HEATING UNIT(OVER 100.00(1 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID). PAIW f5mr Ra
Will the applicant or future building occupant use equipment or devices which rr DDe1l
Four harmdous or contaminants as dented by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) 2 ^�
TOTAL: i
District?
❑Yes 0 N BOILER-COMP(OVER IBLOW BTU)
'
1 beer rad the hazeNous mammals rc uimments urWer Cha AIR CONDITIONER
q pmr6.95ofthe Cuh- ISSUANCE DATE
fomla Health&Scurry Cade,Saunas 25505.25533 and 255]4.1 understand tat if r o NEW RESIDENTIAL MECH. SQ.FT.
ofthe g does requirements
rrentlywhich.have he met prior
isua responsibility mnotifydue ccuancy.
of the tequirettents wNcM1 run he met poor to issuance of a Ccnificme of Occupancy.
Owner or authorized agent Date TOTAL: SUED BY:
OFFICE