30766APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING - MECHANICAL
O 766
BUILDING PROJECT IDENTIFICATION
BUILDING ApD : ��
111111
SANITARY NO.
APPLICATION SUBMITTAL DATE
1 r>q
OW�ER,S P
CONTRACffJR'S MP LIC NO:
NIC -
❑
CONTROLN
N i
ARCHITECTTNGINEER: LIC NO; ADDRESS:
CONTACT: PHONE: -
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT P UMB MI CH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
QTY ELECTRIC PERMIT
FEE
JOB DESCRIPTION
I hereby a1Rra that 1 as licensed under provisions of Chapter fromrnomr,
with Sectioal")of Division 3 ofthe Business and Professions Code, and my license is
RESIDENTIAL,
in full fame,and effect.
PERMIT ISSUANCE
❑SFDWL❑ CHEN REMODEL
License Class Lic.Y
Dae Contactor
APPLIANCES —RESIDENTIAL
❑ADDITION L ING RE -PIPE
❑S RUCTURAL.
ARCHITECTS DECLARATION PANELS❑MULTI-UNIT
1 undersand N
my plans all be used w public accruals
MODIFICATION
IP'TO HIO AMPS
❑INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT
Licensed Professional - 201.1000AMPS
OW fr
OWNER-BUILDERON
Ce
Oat RATION
OVER I" AMPS
❑ BATH REMODEDREPAIR ❑ DEMOLITION
1 hereby affirm 1 E m
I in exempt from the Counsel.,'. License Law for Ne
following mesion. (Section 7031.5. Business and Professions Cade: Any city or county
SIGNS ELECTRICAL
❑ OTHER
which rtquim a Permit in amstact, alter, improve, demolish, or repair any structure
prior to its issuance, also mquires the applicant for such Permit no file a signed statement
SPECIAL CIRCUIT/MISC.
that he is licenaedpurs antro the primaistaxisof the Contractor's License Law(Chapter9
COMMERCIAL:
(commencing with Section Alga of Division 3 ofthe Business and Professions Code)or TEMP. METER OR POLE INST.
Net he is exempt therefrom and the basis for the alleged exemption. Any violation of
-
El NEW BLDG/ADDITION [J DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to B civil penalty of
POWER DEVICES
[]TENANT ❑ FOOD SERVICE
not more than five hundred dollars ($500).
IMPROVEMENT
01, aaownerofthepropeny, army employces with wages as their solecompensation,
SWIMMING POOL ELECTRIC
will do the work.oad the simulate is not intended proffered fill sale (Sec. 70W, Business
❑OTHER
and professinm Code: The Convectors License Law does not apply to an owner of
OUTLETS—SWITCHES—FIXTURES
progeny who builds or improves thereon, and who does such work himself or through
his own employ,., provided but such tmprovemems are not intended or offerW for
NEW RESIDENTIAL ELECTR SQ FT.
S EO�
LSQ F.
sale.ILhowever. Ne building or improvement is sold within one year ofompleti.ddme
eobuilder will have the burden of proving that he did not budJ ter improve for par-
b
pose of side.),
CI7
❑ 1, as owner of the property, as exdusively cantracting wird licensed cmd.0 , to
TOTAL:
N y ut. UUYLj j I INO
conswet the,raped (Sec. 7004, Business and Psafes mm ColeO The Camramoms Li-,
cense Law does not apply to an owner of property who builds or improves nonce, and
QTY. PLUMBING PERMIT
FEE
who contacts far such pro va,a with a contractors) licensed p osuamuo the Contrucam's
License Law,
PERMIT ISSUANCE
❑lam simF under Sec. ,B&P C for this rennin
'
Date
ALTER — DRAIN & VENT — WATER (EA)
VALUATION
W(fAERSCOMPENSATIONDECLARATIOSI BACK FLOW PROTECT. DEVICE
I hereby aRrm under Penalty of perjury tine of the following declarations:
❑ I baveand will ramuminaCertiEcate of Consenrto self -insure for Worker's Compen-
DRAINS— FLOOR, BOOR AREA. GOND.
STORIES
TYPE CONSTRUCTION
sation, ss provided for by Section 37M of the labor Cok, for the performance of the
it
work far which this permit is issued.
igXTURES — PER IMP
1 have aad will maintain Workers Compensation In.m. as requimd by Section
3700 ofthe Labor Code, for the performance ofthe work for which this permit is issued.
GAS — EA. SYSTEM -1 INC. 4 OUTLETS
OCC, GROUP
APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrie,. Policy No.:
GAS—EA. SYSTEM -OVER 4HEA)
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This vection neW oat he complemddthe t is foranehundrtddollarOSIM)
,,.rare
,
PLANCHECK FEE
or less.) GREASETRAP
(certify thatNe ofthe forwhich Nis Permit is issued,( shall
SEWER—SANITARY—STORM LA. 20o FT.
ENERGY FEE
penin
say twi
rot employ any person in any manner so asmbecome subjecrin the Workers Compen-
sedan Laws of California. Dote
Applicant
WATER HEATER WNE NTT LECIB
GRADING FEE
NOTICH TO APPLICANT. If. aft" building this Cenificvte of Exemption, you should
WATER SYSTEMNREATING
SOILS FEE
become subject to the Worker's Compensation provisions ofthe Labor Cole, you must
forthwith comply wiNstich provisiomor this permitshell he deemed revoked.
WATERSERVICE
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PIMB, SQ. FL
PAID
I hereby affirm that there is a construction lending agency for the performance of
Date Receipt»
Ne work for which this,,.remit is issued (Sec. 3097, Civ. C.) '
Undei s Name
TOTAL:
Lender's Address
BUILDING FEE
1 certify that 1 have mad this application and sate that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
QTY, MECHANICAL PERMIT
FEE
building construction, and hereby mahorize representatives clods city to enter upon the
SEISMIC FEE
alcove -mentioned property for inspection purposes.
PERMIT ISSUANCE
ELECTRIC FEE
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
ALTER ORADD TO MECH.
PLUMBING FEE
in consequence of Ne gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10.0110 CFM7
MECHANICAL FEE
SOURCE REGULATIONS. '
CONSTRUCTION TAX
AIR HANDLING UNIT(OVER to," CFM)
Stormont of ApplarintlContsacmr - Date
EXHAUST HOLD OVMUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous material
HEATING UNIT (TO 100.000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
"
Code, Section 255321x)? - HEATING UNIT (OVER 100,000 BTU)
❑Yes []NO
VENTILATION PAN (SINGLE REEID) -
PAID r '
Will no applicant or future building occupant use equipsaem or devices which
Data Receipt#
emit hazardous drennlaminants as defined by fie Bay And Air Quality Management
BOILER— COMP(3HP OR 100,00alI BTU)
District?
❑Yes E] No
BOILER — COMP (OVER 100,0110 BTU)
TA
I have mad the heurdoas mmerials te3uimmente under Chapter 6.95 of the Cali.
AIR CONDITIONER
ISSUANCE DATE
fomite Health & Safety Cade, Sections 255115, 25533 end 25534. I understand that if the
NEW RESIDENTIAL MECH. SQ. FT.
building does nm currently have a tritium, that it is my reappa
oroddlity to notify the occunt
of the aquimemmena which must be met prior to issunEe of a Certificate of Occupancy.
ISSUED BY:
Owner or authorized agent Date TOTAL
OFFICE