30730 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
CITY OF CUPERTINO .. Bun.mrvc-ELECI'RICAL� PERM.NO O 0
(BUILDING DIVISION "APFLICATIONIPERMIT PLUMBING-MECHANICAL. ',
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 'SANITARY NO.- APPLICATION SUBMITTAL DATE
7542 LOCKFORD "COURT
OWNER'SNAME: PHONE: ONTRACTORS NAME: LIC NO'.
SBEREZOVSKY , . Isaac 408 255-435 Wthl- 4/n/4c�froN G n 31- N'C q. CONTROL,
tCHITECTENGINEER: LIC NO: DOE S: �16� ❑ y 1 o 7
PARKET , Benjamin 06138 .J. uK 732. s1r�nQ cu•, (J ( l/
CONTACT. PHONE: . . BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PL MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
QR.4IaZ
11 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{ith Section 0000)of Division 3 ofine Business and Professions Code,and my license is RESIDENTIAL:
FOO infullfons and effect. PERMIT ISSUANCE - .,
�U� Licenseple Link -
L1 STOAT. El KITCHEN REMODEL
Counselor APPLIANCES—RESIDENTIAL DITION C1 PLUMBING RE-PIPE
1„ > ARCHITECT'SDECLARATION PANELS 16 MULTI-UNIT ❑STRUCTURAL
Z 1 undersmnJ my plans shall he used ns public recoNs ,. MODIFICATION
0Z�❑pUPT0 2M AMPS
' - . INTERIOR ' P �FFIWNEY REPAIR
Licensed Professional - 201-1000 AMPS. - IMPROVEMENT. 66// '
Qom+ OWNER-BUILDER DECLARATION OVER 1000 AMPS - El BATH REM A C1 DEMOLITION
yayx IY 1 hereby affirm that 1 am exempt from the Contractors Co License Law for the
WOGU following reason.(Section 7031.5,Business and Professions Code:Any city or county , SIGNS ELECTRICAL ❑OTHER ap
til�WO which requires a permit to construct,almm improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIMISC. 1 1 Lt
y that he is licensed pursuant tome provisions of the Connector's License Law(Chapter 9
OHO (commencing with Section]0001 of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.' COMMERCIAL: /N�
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 'El NEW,BLDCIADDITION ❑DEMOLITION
iC Y. Section]01.IS by any applicant for a permit subjects the applicant to n civil penalty of POWER DEVICES
[]TENANT ❑FOOD SERVICE
a„ .more th Rve It dredroll...($500). IMPROVEMENT
SF 6 (] I,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC -
O will doe work,and theumure is net itnemdedoroffered fursale(Sea.7044,Business ❑OTHER
msu
S and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES '
property who builds ter improves thereon,sad who does such work himself m through
his own employees,provided that.such improvements arc not intended or offered for N SIDENTIAL ELECTR SQ ET. "
sale.If,huaceeq the building or imprevement is sold within one year of completion,,the SQ.FT.FLOOR AREA $/SQ.ET.
owner-buildn'will have the burden of proving that he did not build or improve for put. _ -
pose m consumersale ,y L�o
ro
❑1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(See 7044.Business and Profesninns CndeJ The G,nh.cnsr's Li- -
nse Law does not apply to an owner of properly whe builds or improves memsen,and QTY. PLU 1 ERMIT FEE -
who contracts for such projocts with a contrachood licensed pursuant to the Contractor's _
License Law. I 'PE SSUANC6
I am exempt under Seo. ,B&P C for this reason
AL ER IN&VENT—WATER(EA)" e�
> Owner r
Data VALUATION ® '
w WORKER'S COMPENSATION DECLARATION BACKFLOW ECT.DEVICE
`beby affirm under Penalty of perjury one of the following declarations: Mf
Iadwill maintaina CeniMawofConsenttoolf-insure for Workers Compen- DRAB 00 R AREA OND. TO TYPE CONSTRUCTION
..spa,as provided for by Section 3]W of the Labor Code,for the performance of the -
workforwhichmisperutI,roued. FIXTURES— R AP -
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Cade,for the performance of the work for which this permit is issued GAS—EA.SYS TE IN .40TOLETS OCC.GROUP APN
My Work C m xatioa Insurance c r and Policy p�mbar Arp
cartiees7� nFH1✓� carrier PrulicY Na:iffl—'/4 GAS—EA.SYSTEM-OVF. ( -
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE GftEASE(INDUSTRLWASTE CEPTOR
(11n,section voedon be completed lfthopermh is formic hummed dollars(SIM) - B OMSION FH
or less.) GREASETRAP PLANCHEC 'EES
1 certify that in the pertormance of the work for which this permit is issuW,I shall4
SEW ER—SANITARY—STORM FA.200 PT. O
not employ any person in any manner so as to become subject m the Workers'Compcn- ENERGY
..tion Laws of California.Data WATER HEATER WNENLELECBR
O Q Applicant GRADING FEE
G NOTICE TO APPLICANT:16 after making mix CeniGcute'of Exemption,you should WATER SYSTEM/1'REATING
abecome subject m the Worker,Compensation provisions of the Labor Crude,you must SOILS FEE,
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
P Q ..
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB., SQ.FT. PAID '
U0 l far which
that them leawn(See.3nlending agency for the performance of Date R ipt
ti the work for which this patten Is issued(Sec.309],Civ,CJ 3 0,O
F Lender's Name
TAL:
V Lender's Address - T
W I certify that I have read had,application end state that the above information is BUILDING FEE
Vfaq 'crect 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
`.[ orbuilding construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE b
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Ikddlities,judgments,cosuand expenses which may in any way accom.lo Inst said City ALTER OR ADD TO MECH.
in nsequ urce of me granting of this permit PLUMBING FEE,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT p1R HANDLING UNIT TO 10,000 CFM)
SO CE REG TION ( q p - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of AppliernVContractor Date EXHAUST HOOD(AIMUCT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO IM.000 BTU)
as defined by the Cupertino Municipal Crude,Chapter 9.12,and the Health and Safety
Cede,Section 25532(x)^ HEATING UNIT(OVER 10,000 BTU)
❑Yes.. ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant ter future building occupant use equip.....e&vice.which Dale ` Receipt
us air comdminentsa defined by the day Area Air Quality Management BOILER-COMP(JHP OR IW,OIXI BTU) TOTAL:
�.eln.0
❑Yes ❑Nn BOILER—COME(OVER IClo"BTU)
_
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- x AIR CONDITIONER. ISSUANCE DATE '
fdnia Health&Safety Code,Sections 25505,25533 and 25534.I undersand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building does not currently have a tenant,that itis my responsibility to notify to oocupaat
of the requirements which must ba met prior o issuance of a Certificate of Occupancy. '
Owner or authorized again Date ISSUED BY:
OFFICE _.