30439 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION40aERMIT PLUMBING.MECHANICAL �9
BUILDING PROJF,CT IDENTIFICATION
BUILDING ADORE SS: rCU �0 SANUAKYNO. APPLLIIC�ATIONSUBMITTALDATI
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�.R IMULIE G EER: LIC AU RFS ,.a ❑
CONTACT: PHONE: C BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Ini(ial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ;r
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby anion that I tun licensed under provision.:f Chapter 9(commencing JOE DESCRIPTION
CMZ with Scetion]DW)of Div nJofthe Busineseand Pr Yliccnse in R GiDF,t_ FN7, LAI:
u1UU in , est anJm VERMIT ISSUANCE
[-cam tell f—ogrc�,and�effecr //ll//�n ❑SMWL ❑KITCHEN REMODEL
�UV Liemmse F s Lie.a APVLIANCCS-RISIDE,N'I'JAL []ADDITION [:1 PLUMBING RE-PIPE
F.Z W Dem ConVaIna
tnda ❑MULTIUNIT []STRUCTURAL
I- a, ARCHITECTS UECLARATIOU PANELS MODIFICATION
ZOy4 l understand my plans shall be used as public records UP T08XIAMPS
OZ-0 -]INTERIOR [I CHIMNEY REPAIR
F�FW Licensed Professional 201-10DtIAMPS IMPROVEMENT
S f; OWNER-BUILDER DECLARATION OVER lots)AMPS ❑BATH REMODEI/REPAIR El DEMOLITION
SS W d 1 hereby affirin that I ,it exempt from the Commalors License Law for the
xyx❑EU following reasno(Section703L.5,Busing,and Profession.,Cute:Anycity or county SIGNS ELECTRICAL OTHER
a131L E" which reyuires a permit to mnmmn,otter,improve,Jemali,M1,or repair any awctum
^Oy prierto io,,,mnee,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC. I
Shy that he is licensed Per,vam us the provi,knoof the Cantowtoex Liannm Law lChapler9 f
Cy.dE (commencing with Section]g0)ofDivisionJ of Ne Business and Pmfe.asions Code)or TEMP.MITER OR POLE INST. COMMERCIAL:
E y ca a that he is exempt therefrom ani the basis for the alleged exemption.Any violation of ❑NEW HLDG/ADDITION ❑UEh10LIT10N
uXl I+. Section]031.S by any upplicum titre lwrmit suhjucts the applicum tn;t civil lwnahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE.
1—zV` not mdeflum Ess hundred dollms($5tNry. IMPROVEMENT
Q ❑ Las owner of the prol'en&or my employees with wager as their sole compcnwtion, SWIMMING POOL ELECTRIC
will do the work,and the omerme is not imendW nr nl&red for sale ISec.]DW.Raciness ❑OTHER
3 and Professions Cale:'Me Conaactols License Law does not apply to an owner of OUTLET'S-SWITCHES_I:[%TURIiS
pmpeny who builds or improver themon,and who does such work himself or through
his own employees,provided that inch improvements arc nut intended or offcen for NEW RESIDENTIAL ELECfR SQ
wle.if.however.the building or Improvement is sold within one year el completion.be SO IT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
F11,as owner of the property,am es(lu.sivcly continuing with licensed contractors to TOTAL: gag
conswa the pmj.t(Sec.7o bL Business and Professions Cade:)The Contractor's Li-
oarw Law does not apply to an owner of perpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whoa emmets for such projects with o amorctot(s)licensed pursuant m the Comtaetnts AA�a
License law. PERMIT ISSUANCE 'f/`r 80
❑l am aempt under Scc. ,B&P C for dib reason
Owner [).,a ALTER-DRAIN&VENT-WATER IEA) VALVA ON
WORKER'SCOM1'ENSATION DECLARATION HACK PLOW PROTECT.DEVICE -41/YtF(�Q�1U
1 hereby union under penalty of perjury one of the following Jttlzrarioa:
❑Ihave providlinuim,Seedinlficnenf he Lauo waft,home,
Worker's Comped- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
ration,as prte i for by Section J]IX)of the Inlwr Cale,fur the performance of the
forwhich Nis pa ,
maintain
issued. P1%TVRPS-PER TRAP
w T have and will maintain Worker's Compensation Insurance, required by Section
J]10 of the lsMnCade, onhe Perl'nrmm�ecorofthe work lin whichh this permit is issued GAS-PA.SYS TEM.I INC.4OUTLETS OCC.GROUT' AI'N
My Worker's m t c' 'rand Policy ,�/1�1' GAS-B.SYSTEM-OVER 4(EA) '
Cartier: na t n Policy No .r.bA
CIiItTIFICA'1'Ii OF E%.MPION FRO WORKERS OREASIJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(]Tis seedionneed ten be examNete)if Ne patent is for ante hand"de,ters(S IW) GREASETRAP
ur less.) PhANCHECK FEE
I certify Nm in the Performance of the work for which this permit is issued l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any perwn in any manner m is m become subject o the Worked Crimper. ENERGY FEE
Z cation Laws of California.Data WATER HEATER W/VENT/ELECUR
zQ Applicant GRAVING FEE
y NOTICE.TO APPLICANT.If,after making his Cenifiese of Exemption,you should WATER SYSTEMl1REAI ING SOILS FEE
't•^ became subject to the Worker's Compensation provisions of the Labor Codc,you most
1x31.'may fo d wilt comply with such provisi.....orchis permit shall be deemed revoked. WATER SERVICE,
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Data Roacipea
1 hereby affirm Nm there is a eonstmnion landing agency for the performance of
UNe work for which this Permit is issued(Sec.3097.Co,C.)
R• f•' Loral Name TOTAL:
TOTAL:
{U Lendds Address
C 1 certify that 1 have mrd this application and same that the nlxwe informanon is BUILDING IEE
FN cmrece.l agree to comply with all city and county ordinances convene laws relining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
UZ building sonsvmnbmand barebrionamita mpresenutivaofthis dry to carer upon the
In ove.nentioned prnpeny,for inspection parpaaa. PERMIT ISSUANCE
(Wc)agree to.save,indemnify and keep handless the City of Cupertino against IiIjiC1 RIC FEE
hadidoes,judgments.costs and expenses which may in anyway accrue against said City ALTERORADDTOMECH. PLUMBING FEE
in omequence of the granting of this Peoair
APPLICANT UNDERS'T'ANDS ANI)WI LL COM PLY WITH A LI,N(IN-POIN'P AI R HANDLING UNIT(TO 10,100 CFM) MECHAN[CAL FE 17
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.0)(1 CFM) CONSTRUCIONTAK
t Signature of Applicant/Contractor Data EKHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi 11 the applicant on fumrc buildingaenpant store or bundle hazardous material HEATING UNIT TO 100,000 BTU)
as defined by Be Cupertino Momer A Cade,Chapter 9.12.and the Health and Safety
Cade.Section 8532(a)] HEATING UNIT(OVER 110.000 Ill U)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices whichBOILER-COMPfJHP OR ItX1,g0 B'N)
emit hazardous air contaminants as defined by the Buy Area Air Quality Management TOTAL:
Disvicfi❑Yes ❑No BOILER-COMP(OVER 100,N)O BTU)
I have revel the hvuWon,malarial,requiremems coder Chapter 695 of the Col. AIR CONDITIONER ISSUANCE DATE
Inmia 1lealth&Safety Cadc,Sections 85115,2553]and 255 4.1 maders umi chat if the NEW RESIDENTIAL MECH. SQ.IT.
building) nmcunenlyhavearenant.thafitismyne,puni mtyton ify the occupant
o th el t% c et _ aqt' )§if t ancy.
I //Oa J
�ovma,m.0 ry aged [).to 'V'I'AL: ISSUED BY:
OFFICE