30798 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 3O I QH
7
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. J
BUILDING DIVISION AppmcATIONIPERMIT PLUMBIL. JNG.MECHANICA
NUILDING PROJECT IDEN'TIFICA'TION
BUILDINFiAgRE �� �� - , SANITARY NO. APPLICATION SUBMITTAL DATE
pik
OWNER PHONE:M' PHONE: v OgSN h]F��� / LIC NO:
• /W/ N L NIC CUMAOL X
10,
ARCHITECT/ENGINEER: LIC NO: DRESS:/
CONTACT , PHONE: BUILDING PERMIT INFO
0 Consultant Fee's Paid by Applicant(Initial) BLDG ELECT PLUMB MEfIA
LICENSED CONTRACTOR'S DECLARATIONQTy ELECTRIC PERMIT FEE 05s. X ❑
I hereby affirm Nns
et I am liceed undvi
er provisions of Chapter 9(commencing JOB DESCRIPTION
MOZO with Stttion]0011)ofDivisionJ Ofthe Business and Professions Cale,and mylicense is PERMIT ISSUANCE RESIDENTIAL:
in full force an/d offer.
FaUla! - ❑SFOWL El KITCHEN REMODEL
U,7 License Clan Lic.p --r�--�—f—
sZ Date 1 9 Comreo�. / / /11'/�w�-� APPLIANCES-RGSIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
E, ARCHITECTS DECLARATL N PANELS ❑MULTI-UNIT ❑STRUCTURAL
Ovv��_ I understand my plans shall he used es public records MODIFICATION
Z CI UPT0 200AMPS
O Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
s OWNER-BUILDER DECLARATION
20[4000AMPS IMPROVEMENT '
y❑� 1 hereby affirm Nr I am oomph from the Commcmr's license Lew forte OVER 1000 AMPS ❑BATH REMODE/REPAIR ❑DEMOLITION
x36Ufollowing reason.(Section]031.5,Business and Professions Code:Any city or county ❑OTHER
rt
which requires a t construct,alter,int SIGNS ELECTRICAL
F,a.O q Mnrh m wprove,demolish,or repair any swdurc .
11 pretty its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
<� that he is licensed pursuantto the provisions of Ne Contractor's License Law lChapter9 '
CO (commencing with Section 7000)of Division 3 of the Business and Professions Code) TIME METIER OR POLE I ST COMMERCIAL:
Q.p,M q that he is exempt Ncmfrom and he basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
PG 4. Section]031.S by say vpplicare fora pennitsubjects the applicant to v civil penalty of POWER DEVICES
uF]z not more Nen five hundred dollars(8500). - SANT ❑FOOD SERVICE
C6� ❑l,as owner of the propcny,nr my employees with wages es th<irmlecompensainn, SWIMMING POOL ELECTRIC IMPROVEMENT'
fC. willdo the work,and are swdwe is not intended orofred fireside(Sec.]014,Business ❑OTHER
6a$ and Professions Code:The Contrucmr's License law does not apply to an owner or )UTLHTS-SWITCHES-FIXTURES -
propeny who builds of improves thereon,and who dues such work himselror through
his Own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however,the building or improvement is sold within oneycarafcompleam the SQ. .FL R $/SQ.Fr.
owner-builder will have are burden of proving that he did not build or improve for put.
pose of acus). �AAREC'D
I,as owner of the property,am exclusively contracting with licensed camecmrs to
construct Ne project(Sec.](kN,Business and Professions CWc:)The Connerom's U.
cense Low does not apply to an owner of property who builds or improves Hereon,and QTY. PLUMBING RMIT FEF. CITY UUP LKINO
who contracts for such projccts wllh a contradur(s)licensed pursuant the Gmtrucmr's C�11 Ur V LIl 1'
License Law. PERMIT ISSUANCE
❑I am exempt under Sm. ,B&P C for this reason
Owner Dae ALTER-DRAIN&VENT-WATE VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CP.DE C VO O�aA.,�•
Ihercby affirm under penalty ofperjury one of the following declarations: V a�ST
FlI have and will maintain a Ceniftcam of Consent to self-maure for Workct's ,ROOF Comped- DRAINS-FLWRAREA.0 STORIES TYPE CONSTRUCTION
section,as provided for by Section 37X1 of the Labor Code,for the peRorrtrnce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
3700 ofthe labor Cale.forthe performance niche work for which this permit is issued. GAS-EA.SYSTEM.]INC.4 OUTLETS Or
OCC.GROUP APN
My Wtker'sflgah ,,Ion Inmmncecaoier and Policy numberarc.
Carrier: V'G.J Policy No.: GAS-EA.SYSTEM-OVER CERTIFl� CATS OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMIsIDUSTRI,WASTE INTERCEPTOR
(This section decd roc be Completed if thepermit is for dna hundred dnliom BUIL ISIONEF.ES
(E100) GREASETRAP
or less.) YLANCHEC I,.t ..
(certify that in tm perfnmmance ofthe wah for which this permit is issued,Ishdi SEWER-SANITARY-STORM EA.200FT.
not employ any person u any manner so m to become subject m Ne WorkeM Comped- ENERGY T,
0 2 action Laws of Califomia.Date WATER HEATER W/VEM/L•L[CTR
z 0 Applicant - GRADIN
u NOTICE TO APPLICANT:If,offer making this Cerificete of Exemption.you should WATER SYSTEM?REATING
abec oro,subject m the Worker's Compensation provisions of the Labor Code,you roust SOILS FEV
LhfonhwidreomPly wiNsuchro
pvisioerNispermitshdoked.l hedoemedfcvWATER SERVICE
Ms
Q
CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.1T. PAID
.0 0 Iherehyaffns Natthere ear onstrudior Ictimngagency for the pe,fomma.cr ate Receipt
P Ne work for which this permit is issued(See 3047,Civ.C.) -
0U Lender's Name - TOTAL:
Lender's Address TOTAL:
I certify that I have read this application and state Nat the above acro iniumn is BUILDING FEE
H correct,l agree to conoply with all city and county ordinances and state laws rtlaing to QTY. MECHANICAL PERMIT FEE
U building connection,and hereby authorize representatives of Nis city to enter upon Ne SEISMIC FEE
aMvementioned propeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless lie City or Cupertino against ELECTRIC FEE
liabilities,judgments,costsund expenses whichinny inany way nccroeagvinst said City ALTER OR ADD TO MECH.
in consequence of the goring of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
���SOUR EREGULATIONS. MECHANICAL FEE
// �� AIR HANDLING UNIT(OVER IO.tIIp CFM) CONSTRUCTION TAX
Signature ofppp ican/Comredor Dam EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant same or handle hazvNws material HEATING UNIT GO 100.000 BTU)as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety .
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU
❑Yes ❑Nn
VENTILATION FAN(SINGLE RESID) PAID
Will the ep,fcam or future building occupant use equipment or devices which Date Receipt X
emit hesaNsms airmnmminams as defined by the Bay Arca Air Quality Management BOILER-COMP PHP OR 100,000 BTU)
District? , TOTAL:
❑Ye C]NO BOILER-COMP(OVER 100,000 BTU
I have aid Nchvorro,materials requirements under Chapter 6.95 of he Coli- AIRCONDMONER ISSUANCE DATE
(cede Health&Safety Cade,Sections 25505,25533 end 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ 17.
building does not currently have a mown,Nut it is my«sponsibi dy to notify the occupant
of Ne rs,imments which must be met poor to issuantt Of a Certificate of Occupancy
Owner or auNorizcd agent- Date I_ ISSUED BY:
OFFICE