30042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO. O O(/I�T Z
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY No, APPLICA'T'ION SUBMITTAL DATE
e� I�Ck
OWNE 'S NAME: PHONE CO�N(D�t,ACTON'S N E: LIC NO:
e _�//Y1 ✓/`fNs NIC CON7ROLp
RCVrrECT/ENGINEER: LIC NO: F--CC.// App ES ( Lie. e.
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
{%P
377-7S2 - ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 bcneby affirm that 1 am licensed under proviumo of Chapter 9(commencing JOB DESCRIPTION
O0Z with Section 70(NBot Nsidon Softhc Business and Professions Code.and my license is RESIDENTIAL:
FWO in full f...cande0�'cct�� PERMIT ISSUANCE ❑SFDWL ❑KITCf{I:N NEMOULsh
�UU Licca / / 1.ic.N �Sfl�shN. APPLIANCES—RESIDENTIAL ❑ADDITION ❑PL MBINGRE-PIPE
F W flare Cnmmv J
m to ARCHITECTS DECLARATION ❑MULTI-UNIT ❑5 UCPURAL
F,O N PpNE1S
Z O Z 1 urderstanJ my plans shall Raved as public mcoNsIODIFICATION
OZ—O UPT020(IAMPS ❑INTERIOR CIHMNEY REPAIR
F4'n.,F'W Licensed Rofcssinnal 201.10110AMPS IMPROVEMENT
mJC2, OWNER-BUILDER DECLARATION OVER I(NNtAMPS DEATH REMODEURI?PAIR [I DEMOLITION
.0J 'a 1 hereby affirm mm 1 am exempt from the Contractor's License Law for the
k3 L U following reason.(Section 703 L5.Business and Professions Coda.Any city or county SIGNS ELECTRICAL ❑OTHER
W LL� which requires v permit to construct,after,improve,demolish,or repair any ninna re
F�•01 poor o as issuance.also requires the applicant for such Permit o file a signedsmtentcm SPECIALCIRCUFUMISC.
@,�} that he is licensed pursuanuo the provisions mf the Convenors License hw ICTuger H
m�00 (commencing with Section 7")of Division 3ofthe Business and Profession;Code)or TEMP.MINER OR POLE INST. !K COMMERCIAL:
Thar he is estran Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLfl 4• Section 9031.5 by nay applicant for a lxmrir subjects the applicant m a civil Mnally of POWER DEVICE ❑TE ❑FOODSERVICE.
y
not more Nan five hundred dollars(551X8.
.F.Z Y I OV�ZpEMEN'1'
xP.=O Q C]1.as owner ofthe property.or my employees with wages an their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and mexlNctam is not intended or offered for sale(See7044,Business THER
and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided dim such imPmvemems are not intended or offered for NEW RESIDENTIAL ELF,CFR SQ FT.
sale.If.however,the building or improvement is sold within one year of completion.the — SQ.FT. A' &SQ.T.
wnm-bdlder will fast,the burden oI proving that he did nut build a improve lpu
in rr
pose of'ale.).
0 1,as owner of the property,am exduxively contracting with licensed common.at TOTAL. OCT
1 $ X996
continue,the project(Seo.7r' .Hairs.and Professions ColeThe mmn
Cole) Cmols— i
cense Law does not apply to an owner of property who builds or improves thercnn.and QTY, PLUMBING PERMIT FEE
who contractsforsuch projects with acontmnor(s)licensed pursuant to the Connector's
License Law. PERMIT ISSUANCE CRY UI- k/IJI-LI1111YU
n I am exempt audit,See ,13&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner ])cut �/ U
WORKER'S ti ofiN,ju,,.DECLARATION BACK PLOW PROTECT DEVICE
I bertby effrtm under penalty of perjury one of The following declarations:
❑I base and will maintain a Certificate of Consent o self-inim for Workers Compere DRAINS—FLOOR.ROOK AREA,COND, STORIES TYPE CONSTRUCTION
sation,au provided for by Section 3701 of the Tabor Code,for the pednmomet,of the
Vr ,which this permit is issued. FIXTURES—PER TRAP
Q'7 have and will mountain Worker's Compensation Insurance,as required by Section
3700afthe Lahar Gale.for the paro...foccul he work fin which Ilii,permit nI...ad, GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
M1
Warker'S Cnmpenmtion Inmmnte canner and Policy n�Qt
Cartier: ff.� iJ Policy No.: J n 'A GAS—EA.SYSTEM-OVER 4(EA)
CEItTIFIC COMPENSATION
ATION I N FROM WORKENS' GREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FLES
(This section need nm be completed a(he permit is furan,hundred dollars 1$10) GREASETRAP
ar less.)(This
FISH s0
leamythmia Neperforman.rod'Ncwork forwbich Nix permit is isstcd,ishdl SHWEIt—SANITARY—S'IORM HA,200 IT,
not employ any perm In any another sit as to become%object to No Workers'Conroe[. ENERGY PEE
Z scion Law,of California.Date WATER HEATER WNENT(ELECTR GRADING FEE
Z O Applicant
.N.. NOTICE TO APPLICANT:IL attar making this Certificate of Exemption,you should WATER SYSTEAUTREATING
E" become subject to the Workers Compensation previsions of the Labor Code,you must
' SOILS FEE
forthwith comply withsuch provisions or this .it shall be diseases!revoked WATER SERVICE
IIJ Q PAID
CONS'1'RUC'IION LENDINGAGENCY NEW RESIDIiNT1AL VhMB. SQ.I'I'.
z Ihereb Ilirm ilial there is a<nn.ewctien lcndin I'ar rhe rfarmance of Date RecciptN
Ds O ya .agency Pe
W 1" the wpermit is for which This peris issued(Sec.1097.Civ.C.)
t<ndcrs Name TOTAL:
U
Y W Lender's Address TOTAL:
[.. 1 certify that 1 lives read Nis application and mam,hm the above information is BUILDING FEE
Val comer.I agree us comply with all city and county ordinancesend stole law.a relining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V & halldingeouswction,and hereby anthnize representatives of nhi.sciny m emcrulam the
abovomentioned prnpery fav impaouon purposes. PERMIT ISSUANCE
(We)agree ut save,indemnify and keep Names,the City of Cupertino....nst ELECTRIC FEE
Iiabildiesjudgmerm,costs aaJ expenses which may in any way notice against said C'nY AUTERORADDTOMECH.
in consequence of the granting of this per ,. PLUMBING HEm
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO H10p CFM)
MECHANICAL ITE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0X)CFM) CONSTRUCTION'FAX
Signature of ApplicanUConlractor Doc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA]ARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant share or hamic hazardous material HEATING UNIT(TO 100.010 BTU)
as defined by use Cupertino Municipal Code,Chapter 9.12.residue Health and Safety
Code,Smnicn 25532(07 HEATING UNIT(OVER 10falf)BTU)
Yes
VENTILATION PAN(SINGLE RESID) PAM Uvic Receipt is
Wit the applicant car future building occupant use equipment or devices which
;Trl!haouchur,air contamimai ddinad thyme Bay Acta Air Quality Morm,cmm, BOILER—COMP OHP OR 100,000 BTU)
IL14:1 _ TOTAL
Disvict^
❑Yea ggio BOILFiR—GQMP(QVER 100,000 BTU)
I have real the harallous materials requlmmems order Chapter 695 of the Coli- AIR CONDITIONER ISSUANCE DATE
Lane Health&Safety Code,Sections 25505,25533 and 25534.1 understand than if he NEW RESIDENTIAL MECH. SQ.IT.
haiWing docs not currently have o mount.Ilial it is my ms,unslbllity no notify the occupant
at IS t nv ich s ct r ratvwamac of n Coni l'vete of ce pvn .
Owner or auNa g<m Date T0'fAL: ISSUED BY:
OFFICE