30461 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION)TERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: VV12v--•• SANITARY NO. APPLICATION SUBMITTAL DATE
O NE 'S AME: � PHONE: COKTRAC[OR'SNgN LIC NO; �JLZ�
G a Be/ r M,.. — Z NIC CONTROL Of
ARCHITECT/ENGINEER: LIC NO'. /DDRF.SS: f Idw ❑
CONTACT: PHONE: Consultant
�e�btd �` �$-?��� BUILDING PERMIT INFO
onsultant Fees Paid by Applicant(Initial) BLDG RLECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ox El 1:1 ID
1 hereby arum mal I am licensed under prosisions or Chapter 9(commencing JOB DESCRIPTION
WOZ mSortion9000)of TiMoon 7ofthe Bnsincas,md ProfeWons Code,and my license is RESIDENTIAL:
I+I W P in PERMIT ISSUANCE
F ty_ in lull fume and cff t ❑SFDWL ❑KITCHEN REMODEL
-ec U Licen.cE ,. I.ie.. 37 —,Z 2 .
6 U _ � APPLIANCES-RESIDENTIAL. [-1 ADDITION ❑PLUMBING RE-PIPE
vFi64 Uam T'SDEo 1
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURALF'yZ l understand my plans shall be used as public record% PANELI ��M�ODIFICATION
OZoC UP TO 200 AMPS C1 INTERIOR L{L-HIMNEY REPAIR
F4FW Licensed Professional ZIII-10grAMRS IMPROVEMENT I
��C=4 OWNER-BUILDER DECLARATION OVERIODOAMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
a 1 hereby Affnin he,1: xe
nn exempt ford tire n
e Co loact,as License Law fohe
xx'�6U following....(Section]OJ1.5.Business and Prufassinns Code Any city or county SIGNS ELECTRICAL []OTHER
W 3 LL y which metric,a permit to minuacL altar,hapinvc.da nnliah,nr repair any sunclure
F•LL�S prior to its issuance,also requires are applicant for such prrmino file a signed summand SPECIAL CIRCUIT''IMISC.
that he isliceroed rommattothe proviNionsnf[lie Contractor's License Law(Clet, Y
�y'p0 (commencing withSaction7000)of Division I mum Business and Profession,Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d cC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
WAN Session 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
t more than five hundred dollars($500).
FZ1• OTHERIMPROVEMENT
=Q O Las heowner
wak.flhe thalami..is employees with wages reale their compensation. SWIMMING IK)OhIiLECTRiC
will Jumewons Codec[he CotisnmsLicens Lawddfurar apply 71044.Businessto
❑OTHER
1 w
and arofe who
Codon ire,Contractors Chemo Lasmo law tiros not apply m if owner of OUTLET;S-SWITCHES_FIXTURES
property who builds or improves,...hn,and who does such work deed(it or though
his own however
the
provided ohm such mentis old w are not im rof m offered for NEW RESIDIiNT1Al.ELECTR SQ FT.
sale.If.M1owever.the building or improvement is sold within one yemof completion.the SQ.FT.FLOOR AREA S/SQ.FY
crbuilder will have the burden of proving that he did not build(ir improve for put.
pose ofsale.). TOTAL: AU
1,as owner of the property,am exclusively connecting with licensed contractorsto
constructec
me project(Sm. Business and Professions Gdep Ane t- oaannr'a I- (] 7�
nee Law dues not apply so an owmimproves net Of who builds or pre
roves theon.and QTY. PLUMBING PERMIT FEE / 996
who contracts for such projects with a contractor(%)licensed pursuantm the Comment,s - /r
License law. PERMIT ISSUANCE. •
❑ Iesmexempt under Sec, ,B&P Clet this reason �,111'..
ALTER-DRAIN&VENT-WATER(FA VALUATION-
Owner Ilam
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby uRnn under penalty of periury tine of the following declarations:
O l have and will maintain a Ccnificare ofConem to mit-insure for Wmkefs Compcn- DRAINS-FLOOR,ROOK AREA.COND. STORIES TYPE CONSTRUCT ION
xasion,to pmvidcd for by Sectio 37110 of the Labor Code,nor she performance or the
.,it for which this permit is issuW. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Second
37Wofthe labor Code,for the performance ofthe work for which this Permit is isucd. GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APSE
My Wnrka% a�nsa VtI cr and Policy nu
CarriccJ Policy No,/7 ra�IQ��9l GAS-E7A.SYSTEM-OVER407A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAg[%1NIIDSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is Intone hundred dollars(S100) GREASETRAP
or PLANCHECK FEL?
leis)
I moifytha mile performance mile work forwhich this perm is issued,I"all SEWER-SANITARY-STORM EA.200 FT.
not mnploy any person In any o u na,at,C,res bmorm, uhim,or the Worker,'Compcn. ENERGY FRE
Q Z salum Laws of Culdrandr.Data WATER HEATER WNENTIELF,CTR GRADING FEE
(2 APPlicam
NOTICE TOAPPLICANT.-IL after making this Cerificataof Exemption,you should WATER SYS'TEMG"REATINO
a;
Ise cnne mbjcm n.the Worker's Cnmperocamn provisions of the Labor Carlo,you must SOILS FEE
forthwith comply with such provsions or this permit%hull he deemed revoked. WATER SERVICE
Q
a' CONS'1'NUCfION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FI'. PAID
U C Ihereby affirm that thele is a construction lending agency for performance of Date Rrreiplk
{I. 9:!- me work for which this permit is issued(Sec,3097.Civ.C.)
Lendefs Name TOTAL:
C) UWLender's Address TOTAL:
a. I certify that I have read this application and state that fire above information , BUILDING FEE
FVAI reread.lattice to comply wrli all city met county ordinances ind,ratc laws relating um QTY. MECHANICAL PERMIT FEE
U building construction.and hereby autherim representatives of this city to enter upon the SEISMIC FEL7.
abovomcmioned propmy,lin inspection pur,ows. PERMIT ISSUANCE
(WO)agree to save,indemnify and keep harmless The City of Cuperrnu against ELECTRIC IIiE
Iiabi plies,judgments,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
in mmeq sere of the granting rd cis pcmmit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO IXRMCFM)
MECHANICAL FF.E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.010 CPM) CONSTRUCTION TAX
Signature of ApplicanUComracmr Data EXHAUST HOOD(W/DUC'D HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazudous material HEATING UNIT(TO 101.007 BTU)
as definul by the Cupertino Municipal Code.Chapter 9.12,and the Hashh and Safety
Code.Section 25532m)Y HEA'T'ING UNIT(OVER 100.0071t'1'U)
yes El Na
VENTILATION FAN(SINGLE RESIII) PAID Doc Rettiptp
Will the applicant or future building occupant use equipment or devices which
'emit hamrdous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(IHPOft IW,(X0I BTII) I(HAI.
D,nma9 BOILER-COMP(OVER 100,000 BTU)
E3 Yes 7 N
AIR CONDITIONER
I have read to haroaouamerialn mmc
quireros under Chapter 6.95ot thCali-e i-
dmISSUANCE DATE
fared Health&Safely Corte.Sections 25505.W33 and 255Y1.1 uMerstand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does nor cunently have u Ienanl,that it is my respnmsihilay to notify Lha occupant
of the Iryuimmrnts which must he met prior m issuance of a Cetificme of Occupatoy. I I &:::,
Owner oroodudzul agent Date TOTAL' ISSUED BY:
OFFICE