21797 a
APPLICANTTO FILL IN INFORMATION WITHIN RED I_INFS-VSE 9A'_L POINT PEN ONLY
Cy i Y OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 30984
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
'IIUILUING,\UDRESS: SANITARY NO. APPLICATION 5UBMI'I-I'AL DATE
IV 20 .7 u
TT�� q
y�PN 'SNAME: �q \� P fNJ E�:q�� ONTRACTOR'S SAM1I''I LIC NO'. SIC CONTROL vI_ T�'tU-hA'h '� YYIe�'E Ir'yr1 ❑
%RCHITECl/FNC.INLLR VCa f ll�ay _ ADDRESS'
IrCONTACr PHONE: L/IO BUWDING PRRirU'C INFO
❑ Cmuultent Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ .� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
„
11eby afrrm mat I am we^aw and,,pmvismm of Chapter 9(commencing JOB DESCRIPTION
wonlwith Sect na 70500ofDlvlaom 3 of the Business and Profe,eio^s Codea^dmy license is PERMIT ISSUANCE RESIDENTIAL:
�ktCVl License Qlaustdclfml Lich ❑SPDWL ❑KITCHEN REMODEL
C V APPLIANCES-RESIDENTIAL C1 ADDITION ❑PLUMBING RE-PIPE
y 7j a DaR Conuacmr
44 ARCHITECT'S DECLARATION ❑MULTI-UNIT [I STRUCTURAL
pt2 Z I I understand my plans shall h used as public records PANELS MODIFICATION
Z- 0 )'PTO 200 AMPS [I INTERIOR Ll CHIMNEY REPAIR
F I'"Ial Licensed Professional 201 ONDAMPS IMPROVEMENT
•]
OWNER-BUILDER DECLARATION OVER IOIN)AMPS ❑BATH REMODEUREPAIR El DEMOLITION
p, Q I hereby affirm that I m exempt f the C t l L L for the
X d V following (Section 7031.5,B d Professions Cod A t county El OTHER
Y ^Y SIGNS ELECTRICAL.
OF' wit ch <y a perm t to c n truer It reprod I';h p y tor cture
y1 prio � [ aL req [h ppl' tf hPe tt fl g d t temenl SPECIALCIRCUI'T/MISC.
{V�jy that m I with
puma a th pro Division
of
C tiaeter aL er. La Is Code)r9
ifcommennngwith Section 70001 of Division3of[he Business and Professions Code)or TEMP METER OR POLE INET. COMMERCIAL:
m�po
6 C as that he is exempt therefrom and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑FOODDEMOLITION
SERV)
{c Scol 9031 9 by any apPf a I f pe t bj �I the ppl' I I � 1 penalty of POWER DEVICES
�m ❑TENANT ❑FOODSERVICE
} tot m m f huIt 0ndred d t II .(empl IMPROVEMENT
6 [] 1 �� n of the property. Y employees litwages .their' I pens ion, SWIMMING POOL ELECTRIC
wtllJ m k Jlh :w t Y t d d Re df f. 1 ISE 70,14 Bak es ❑OTHER
and P f ssions Cade.The Contractors L cense Law does n t pply t own r of OUTLETS-SW ITCHES-FI%TURES 5
R' r,property who builds or improves thereon,and who does such work himself or through
his on employees,provided dratmeth improvemems are ma intended m offered f NEW RESIDENTIAL ELECTR SQ IT.
sale If.however,the building or improvement is sold within one year of completionthe SQ FT FLOOR AREA $/SQ.FT.
maner-bodder will have me burden of poising that he did not build or improve for pur-
pose of soled.
I,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.70441.Business and Professions Code.)The Contractors Li-
cense Law due not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT PEE
who contracts for such projects with a contraclons)licensed pursuant to the Contractus
License Law. PERMIT ISSUANCE
E] 1 am exempt under Sec ,B&P C far this reason
OdX_ n.-V ALTER-DRAIN&VENf-&!�FA4 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the following declarations.
01 I have and will maintain a Cenificete of Convent to self-more for Worker's Comach DRAINS-I LOOR.ROOF,AREA,CONE.
satiun,as provided for by Section 3700 of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this perms e,issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
3900 of the Labor Code.for the performance of are work for which this Permit is Issued GAS-EA.SYSTEM-I INC'.4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are'.
Curtner Policy No.: GAS-EA.SYSTEM OVER 4 tEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR F
EW
(This section need nm Fe completed if the permit is for one hundreddollars(5100) GREASETRAP -
orlesc) PLANCHECK FEE
lcenify that inme performanceofthe work for which this permit is issued,[,bull SEWER-SANITARY-STORMEA.200FT
not employ any person in any manner so as to become subject to me Workers'Compen- ENERGY FEE
zZ Santa Laws of California DoneWATER HEATER WNENT/ELECTR
Q'Applicant GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMP REATING
a � become subject to me Worker's Compm^samon provisions of the Labor Cade,you must SOILS FEE
{✓;1 forthwith comply with such provismncor, this permit shall be deemed revoked. WATER SERVICE
aQi
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
U C) 1 hereby alum that there in a cnnswcmm lending agency for the perl'onnanceof
Date Rec<iplM
Le work for which this permit is issued(Sec_3097,Cis_C]
0 U Leaders Name TOTAL:
(11 Lender s Address TOTAL:
I unify met I have read this eppliwtion and stem tont the strove information is BUILDING FEE
�. ra70r) comet_I agree to comply with all city and county ordinances and sure laws relating to QTY MECHANICAL PERMIT FEE
V glbuilding construction,and hereby ambiance reprxwntativewf this city to enter upon the SEISMIC FEE
above-mentioned progeny for inupecuon purposes. PERMIT ISSUANCE
( )agree to save Indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
We
liabilities,judgments,costs andexpenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT 10,(00 CFM)
SOU G Ll IONS
MECHANICAL FEE
�9wl�l2 � AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ZARDOUS MATERIALS DISCLOSURE
P tgna ppli n Racmr {/ Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
ant
Will the Cupertino
no Muni iplbuilding de.occupant r 9,12,andthandle Heardous material HEATING UNIT(TO 100.000 BTIJ)
as defined io the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(u)p HEATING UNIT(OVER 100.000 BTU)
E]YO ]No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt%
Will the air conmorants a building occupby
yAuse ea Air Qualitment or y
deviceswhich
BOILER-COMP UHP OR 1(0,000 BTU)
mu haemdou..ter ummminants as defined by the Bay Area Air Ijuelity Management TOTAL:
'istric[2 BOILER-COMP(OVER Hat"BTU)
El Yes ]No
I have read no hemnious materials requirements under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE
fomin Doubt&Safety Code.Sections 25505,25533 and 25534.I undersand that if me NEW RESIDENTIAL MECH. SQ.ET,
building does not currendy have a tenant,that it is my responsibility m notify the occupant
m tris which most Be met prior to issuance of a Cenifi R of cupancy.
OwnerTr-adlessymern TOTAL: ISSUED BY
OFFICE