30432 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE'RTINO I BUILDING•ELECTRICAL PERMITNO. ^ O q ^^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 4 3 L
BUILDINGPRWECT IDENTIFICATION -
SANITARY NO, APPLICATION SUBMITTAL DATE,
O NER' NA E: P ' — 1 TRA • NAME: LI n NIC �CONTROLk
RCHITE /ENGINEER: LIC NO: DR S: f (— ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT ` PLUMB MECH
❑ ❑ El AK
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby offiw that I em licensed under provisions of Chapmr 9(commencing JOB DESCRIPTION
aZ with Section701 of Division 3 of th,Businessand Professions C ndmylicenseis
00 or full force andr�'vNtyg(� 1 PERMIT ISSUANCE, RESIDENTIAL:
0FUZV Levine_, 1 Lic.M • ❑SFDWL El KITCHEN RE-PIPE
,r N6� Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
- 1Frr D In RCHTTECT'S DECLARATION �� PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO'./1� 1 understand my plans shall be used as public records, ' MODIFICATION
O Z::11pp : UPT02MAMPS
F 4 Eq' 9 Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
41� OWNER-BUILDER DECLARATION 201-10F)AMPS IMPROVEMENT
YYSS''11 G 1 hereby corm that I Anexempt from the Coac
mrmrs License Law for the OVER EgAAMPS El BATH REMODEL/REPAIR 0 DEMOLITION
O S - fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
P+ 0 y which requires a pemm m conswet,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit in Fie aligned statement SPECIAL CIRCUIT/MISC.
,i�FF,Fy��,,�`�!(y That ha is llcerued pursuant mtaepmvlsloos of the Conwator's Lioeose La (Chapter9
'z+000 (commencing with Section 7000)of Division 3 ofthe Businessand Pmrcrowns Cod.)or TEMP.METER OR POLE INSTI COMMERCIAL.
6 c that he is exempt Iaerefrom and the basis fur the alleged exemption.Any violation of
^ Section 7031.5 6 applicant for j pp penalty ❑NEW BLDG/ADDITION ❑DEMOLITION
y y any app permit subjects the applicant to a civil 11 of POWER DEVICES ENANT ❑FOOD SERVICE
Iqq,y a rm more than Eve hundred dollars($500)_. MPRO MENT
Oa ❑1,as ownerof the property,mnriyemployees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will dothework,andthe he Contractors
ont is notintended Lawdofor sale(Sea7044, wner of — 6-1
and Professions Code:The C its themm License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
popery who builds or improves thereon,and who does such work himself tar through'
his own employees,Provided that such improvements are not intended or offered forNEW RESIDENTIAL ELECTS
- SQ FT.
sale.If,harrower.the building or improvement is sold withinoneyearofcompletion."m SQ.FT.FLOOR AREA $/SQ.FT.
er-builder will have the burden of proving that he did not build or improve for Pur- -
Five of sale).
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Pmfeasious Coda:)The Conuaetor's Li- ^
cense Law does not apply to an owner of pmpesty,who builds or improves Y r
thereon,and QTPLUMBING PERMIT FEE A yy"
who conwas for such projects with a commemr(s)licensed pursuant to the Contractor's Y
License Law. PERMIT ISSUANCE O
I am exempt under Sec. ,tl&P C for this..,on - Ia
Owner Dem
ALTER-DRAIN&VENT-WATER(EA) N
ifiWORKER'S COMPENSATION DECLARATION '' BACK FLOW PROTECT DEVICE C�/Y L/r `UrS
I hereby ew under penally of pe jury one of the following declarations:
❑ (have and will maintain a Certificate of Comsem to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND, - TYPE CONSTRUCTION
sation,as provided for by Section 1I00 of the Labor Code,for the performance of the STORIES
work for which this perm it is issued. FIXTURES-PER TRAP /
1 have and will maintain Worker's Compensation Insurance,es required by Section
3 of Nc��L.bqq,Cod for the performance of the work for which Nis ed." GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Weak Pre cc canter and Policy tins _
Carrier Liu\\Policy No.: I'LL/�I) GAS-EA.SYSTEM-OVER 4(EA) ' '
CERTIFICATE O'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEdNDUSTRL WASTE INTERCEPTOR
(This section need not becorn,mucd ifthe pminit is home,hundred dollars($100) BUILDING DIVISION FEES
or loss.) GREASETRAP - s
I certify that in the performance of the work forwhich this penat is issued,l shall PLANCHECK FEE
notemplry any person in any mato,,masmlxcome subjecno the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. NMGRADINGFEE
z action Laws of California.Date
O O Applicant WATER HEATER WNENT/ELECTR
PP y NOTTCETO bjctto me Workers If,after Com,,aking sation rCisions of of Exemption youou muld
stWATER SYSTEMTRE•ATINGbecome subject m Ne Workers Compensation provisions of the Inbar Cnde,you must WATER SERVICE
tZCat themUCTIONLENDINGAGENCY ' NEW RESIDENTIAL PLMB. SQ,FT.V0 (hereby affirm that there ie acmnswhion lending agency for the performance of me work for which this permit Is issued(Sea 3097,Cm..C.)ULender's NameLender's Address - TOTAL:
W I certify that 1 have read this application and state Out the above informer(in is BUILDING FEE
ry h correct.I agree to comply with all city and county ordinames and state laws(elating to QTY. MECHANICAL PERMIT FEE
V z building crnxwction.and hereby authorize representatives of lois city to enter upon the SEISMIC PEE
above-mentioned properly for inspection purposes.
)agree indemnify p City pe g PERMIT ISSUANCE
(We) m save,indeinnif d keep harmless the Cit f Cupertino against ELECTRIC FEE
liabilities,judgmemsmosts and expenses which may in any way trome against said City PETER OR ADD TO MECH.
in consequence of the granting of this pewit PLUMBING FEE
AP ."UNTANDS AND'WILL COMPLY WITN ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)SOU MECHANICAL FEEAIR HANDLINGUNIT(OVER 10,000 CFM) CONSTRUCTION TAXSignaturner., Date EXHAUST HOOD(WDUC)ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATIONor future building mccupanLsmre orhandlehaurdmusmamrial HEATINGUNIT(TD 100,00013711)
as defined by the Capertion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532pd? - HEATING UNIT(OVER 100,000 BTU)
E]Yea 7N
t ' VENTILATION FAN($INGLE RESID) PAID
Will me applicant or future building - Data Receipt tl
pp g occupant use ea Air a or Mane which BOILER-COMP 3HP OR I00,00m BTI(
la mil hazardous air contaminants as defined by the Bay Area Air Quality Management ( )
DieWct7 { BOILER-COMP(OVER 100,000 BTB) - TOTAL:
[D yes ❑No ,
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
forma Health no Safety Code,Sections 25505,is toy and 25534.I toander-standify m that if the NEW RESIDENTIAL MECH. SQ.FT. t
of t e�ea dura not currently have o met p that o is ua c eofa Certificate
notify the occupant
of the requirerarnts which must be met prionoissuancebfa CeniOcate of Occupancy.
t
` Owner or authorized agent Data TOA ISSUED BY
f OFFICE