30087 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30087
O 0 8
- BUILDING PROJECT IDENTIFICATION
BUILDING ADD SS �' - c SANITARY NO. APPLICAT NSU MITTAL DATE
S
O NE 'S NAME: PH +_ I ,C RAC TQ ' A Ly O
✓Z LL NIC C NT OL
RCHITECT NEER:' LIC NO: q BS: �/ 1r� - ❑
CO TACT. PHONE rJ�� - - BUILDING PERMIT INFO
I
y�� vE] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
L
❑
LICENSED CONTRACTOR'S DECons of CO QTY ELECTRIC PERMIT ! FEE
El
1 ion 0 affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Wr with Section title Divieiog3uf the Business nd Professi Code,and mylicense is RESIDENTIAL '
a in full fora title I. PERMIT ISSUANCE
rOQUG U V Lice Lic.YI. D SFDWL ❑KITCHEN REMODEL
Dare Conrranor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
[P..pm HITECT'S DECLA ION o ❑MULTLUNIT ❑STRUCTURAL
z O 5 zj I understand my plans shall be used as public records PANELS MODIFICATION
OZ-- MODIFICATION
UP TO 200 AMPS ❑INTERIOR' ❑CHIMNEY REPAIR
C y'F Lmeneed Professional IMPROVEMENT'
LL 201-1000 AMPS
OWNER-BUILDER DECLARATION OVER 1000 AMPS
.I hereby affirm thin 1 am exempt from the Connactnr's License Law for the [-]BATH REMODEVRHPAIR DEMOLITION
3 F following reason.(Section 7031.5,Business and Professions Code:Any city or coumy SIGNS ELECTRICAL T ER
which requires a permit m conswn,alma improve,demolish,or repair any structure�� hat
the fists cense pursuant
the th Provisions
isio softhe Contractors
License aw(Chapter 9 ramem SPECIAL CIRCULUMISC. -
d� thaboucmnwithSeamm7hoofvisislow3oheCommentsndProeLaonsCode)or
(commmciog with Seotion]IXq)of Divlgion 3 of the Business and Rvasslon Qde)or
❑O TEMP.METER OR POLE INST. COMMERCIAL
d e
that io is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 1031.5 � ❑NEW BLDG/ADDITION [I DEMOLITION
e handled applicant subjects the applicant Soacivil penahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y not morewne five thpubpedollvrsyempl. IMPROVEMENT
Q Q Lo the work.
.and pm perty,mmyemntended muwithttered wages for sale
role 044,8 sines SWIMMING POOL ELECTRIC - \
andwill dorhewons Code
structuress fors License Law ones of apply to a4,Rosiness - OTHER P
and Professions Cadet The Gmrracnfs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES '
Property who builds or improves thereon,and who does such work himself of through
his own employees,provided that such improvements we not imended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.however,the building at improvement is sold within oneyearofeompletiomrhe SQ.FT.FL OiC EA VSQ.ET.
owner-builder will have the burden of proving that he did not build or improve for put- `.
poseofsale.). UE 1a Uf, _1 to HQ
❑h as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Conhsome"Li.
cense Law does not apply m an owner at'prnpeny who builda or improves thereon,and QTY, PLUMBING PERMIT FEE -
whoeontractsforsuehpoliceswithaeomeactorb)licensed pursuant o the Commends
License Law.
[am exempt under Sec, ,B&P C for this reason PERMIT ISSUANCE
Owner Uma ALTER-DRAIN&VENT-WATER(EA), A - VJA�L,UATI0
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEA
/I/' \.
1 hereby affirm under penalty of perjury one of the following declarations: _
❑ I have and will maintain a Certificate of Cunsentto self-insure for Worker's Compen- EGREASUINDUSTRU
,ROOF,ASTORIES TYPE CONSTRUCTION
smion,re provided for by Section 3]00 of the Labor Cada,for the performance of the
work for which this permit is issued, - TRAP
❑'1 have and will maintain Wmkers Comp excith n Insurance,as required by Section
]700 of rhe bur Cale fmthe pertannance fine work for which this permit is issued. M-1 ING4 'OCC.GROUP AIN
My lff er's F sl en b Ins and Policy u
Carrier: Policy No.: r M-OVER4 -
CERT" ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE RL WASTE
(Thio section need am be completed ifthc permit is Intone hundred dollso(Sl00) BUILDING DIVISION FEES
or less.) - GREASETRAP PLANCHECKFEE
(certify thatinShe anymanpeffermanrce o as the
fine subject
bjech tto the Wpermit isiss'Comen- SEWER-SANITARY-STORM EA.200 FT.
not employ of person in any manner so as m become subject m the Workers'Compen- ENERGY FEE
O .`� smion Laws of California.Dote O
Applicant WATER HEATER WNENT/ELECTRNOTIC -
v GRADING FEE
Vl become TO APPLICANT:Wi If,after making this Certificate of Labor Co,you should
a � become object will.Worker's Com provisions WATERSYSTEMITREATING ,
J proration o sof the Labor Code,you must SOILS FEE
faMwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE _
L7.1 CONSTRUCTION LENDING AGENCY o 1 -
DZ NEW RESIDHNTIALPLMB. SQ.FT " PAID
VO l herfor by affirm which
there isand(Secontraction 0lending agency for the performance of Dam Receipt is ,
W F the work for which Nis permit is issued(Sm.J09],Civ.C)
O Lender's Name TOTAL:
W Lender'a Address TOTAL:
Pr' 1 certify I have read thisapplication and sorra that the shove information is BUILDING FEE
l.r y correct.I agree to
comply with all cityyand county ordinancesof and score laws relating QTY. MECHANICAL PERMIT FEE
.V buildiog ennawctlon,and hereby vuthorize representativessof xer to,.is city ro ento he
SEISMIC FEE
vbove-memioned progeny for inspection purposes. PERMIT ISSUANCE
(Wet)vgree m save,indemnify and keep harmless the City of Cupertino.,.last ELECTRIC FEE
liabilities,judgments,wsta and expenses which may in any way accrue against said City ALTFRORADDTOMECH.
inconsequence of the granting of this Permit. PLUMBING FEE_
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,hW CFM)
SOURCE REGULATIONS., _ MECHANICAL PEE `
., AIR HANDLING UNIT(OVER U0,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contacnr - Das EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or for=building occupant store or handle hazardous material - HEATING UNIT(TO 100,010 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t
Come,Smtion 25532(x)? HEATING UNIT(OVER 100,000BTU) .
ED yes No -
VHNTILATIONPAN(SINGLE RHSID) PAID
Will She applicant m Poore building occupant use equipment or devices which -
Dare RweiprM
st hazardous air contaminants as defined by by the
e Bay Area Air Quality Management BOILER-COMP CHIP OR 100,000 BTU)
Di
District? TOTAL:
❑Yes ❑Nn '. BOILER-COMP(OVER IIX1,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DA
forma Health&Safety Code,S tions 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building dcesn trendy hes anent,hat' is my tempo ability n notify lit occup t
of the requ' which S be n ce niE ace O cy -
or authoriz gem ate TOTAL:
ISSUED BY:
OFFICE