30169 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY.
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'-MECHANICAL O VA ,9
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATI
D I.I. ler --410-7
OWNI"R'SN ME: PHONE: CONTRACTOR"NAM& LIC NO:
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS.. ❑
GG.� c- M7 Ulf'
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEqD
o
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
POO with Section]0 )of Division3mf the Busine and Profess�i./..Cade,indmylicedseis PERMIT ISSUANCE RESIDENTIAL:"
F� i t full forceand effem.C'� �X l��_ ❑SFDWL - ❑KITCHEN REMODEL
V 'j Licetue Close U #
F�(8 Date i�--_T�-Q� Contractor APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBING RE-PIPE
Fpery ARCHITECTS DECLARATION PANELS ❑MULTEUNIT ❑STRUCTURAL
Z O�2 Z 1 undersand my Atmos shall be used as public records MODIFICATION
OZ-, UPT0 200AMPS
❑ - ❑IMER [I CHIMNEY REPAIR
r,�� Licensed professional 301-10(10 AMPS IMPROVEMENT
�j
OWNER-BUILDER DECLARATION OVER 10010 AMPS
ly Q I hereby affirm that 1 em exempt from the Comintern.License Law for the ❑BATH REMODE $PAIR 0 DEMOLITION
gip$,O4 V following reason.ISmtimn 7031.5,Business and Professions Code:Any city or county SIGN513LECTRICAL []OTHER
✓a LL O which requires o permit to construct,alter,improve,demolish or repair any structure
JJJ prior to its issuance,also requires the applicant fr suchpemiitt file signed statement SPECIAL CIRCIJIT/h115C.
that he is licensed pursuant the provisions or theC- tacmisl nseLaw(Chapter 9
• OG (cnnnenengwth Samrr700Xfi.f]1vismr3.ft1oa Bominc,stundI fe'.ima Code)nr TEMR MEEK OR MLEINS"T. COMMERCIAI< -
4 0 2 that he is exempt mcconarn ad be basis,for the alleged excmpu n Any violation of - E)NEW BLDG/ADDITION [I DEMOLITION
ag5ro4• Section 7011.5 by any applicant f^rnpennit subjma dam,licain toacivil'penalty of POWER DEVICES
t++ m (]TENANT [I FOOD S1iRVICE
{. n more than five hundred dollars($500).
C=6 1,as owner ofthe norm employees with woes as their sole compensation, SWIMMING Man.ELECTRIC IMPROVEMENT '
cF ❑ pope y yc p y g .ensu
_❑ will dathe wons and the he Core is rotintended items,Lawedfurul apply to
an Business []OTHER
a 3 and Professions Cadet The over nom's License Luo dues not work
hi s if owner of OUTLETS-SWITCFIIS-ITXTUR
his own who builds or improves thereon;end who does such work himself or through it
his own employees,provided that such mentis old w art ranon intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
u1e.ILhowevm.the buildingmimpmvement is he within one yes completion,the puts SQ.F I'.FLUOR AREA S/SQ.Fi.
owne.f.1dm will have the burden of proving that he did not build or improve for Aran- W
posed suwne
4 10
❑ I,a owner of ct property,,B exclusively Punctilious,with licensed unnwnnrs i. TOT ��
use L.the project(Sas an Business and Professions Code:)The Contme.n,..- g�
gli
cense Law Jmsnm apply to en owner of property who builds or improves thereon,and QTY PLUMBING PERMIT E sG
who Pmntmcts for such projects with a Ponuactous)licensed pursuant the Conm¢mrs ls•ot, � �
License Law. PERMIT ISSUANCE V
❑ Imo Pxemlilnmder Sec.' ,Il&P C for tbisrea'.. VT+�•. zY
Owner Dmc ALTER-, GRAIN&VENT-WATER(EA) LUATION
WORKr;R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy affimt under penalty of perjury ane of the following declarations:
❑I froward will mainuina CenificateofConunttoulf-insum fur Workers Compete- DRAINS-FLOOR.ROOF,AREA,COND. STORIES - TYPE CONSTRUCTION
word.m provided for by Section 37M of the Labor Code,for the performance of the -
work for which this permit is issued. F[XTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
37W of the labor Cada for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS
My Workers Compensation Insurance canter end Policy hlk7::
OCC.GROUP APN
Carrier, L,% Ad.IT,n\ Policy Nu.: Ills-G'(tyf(J�" GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OFEXEMPIJON FROM WORKERS' 017
COMPENSATION INSURANCE GREAMIINDUSTRL WASTE INTERCEPTOR
(This section need not he completed if Ne Permit is formic hundred dollars($100) BUILDING DIVISION TEL'S
or less,l GREASE TRAP'
PLANCHECK FEE
I codify that in the a.,manance c;p I work for which ibis permit is issunk 1 shell
nm employ any person in any manner sn us in brernnu suhjecun the Worken'Compem SP.WLN-SAN]TARY-STORM[A.20(1 PI'. LNERGYFEE
Oz amus.Laws rceffinrnia,Doe i2.�Z$ -O'-7 WATER HRA7"IiR W/VENT/ELI?CI'R -
7 0 Applicant h'0/�—� GRADING PEE
G w"
NOTICE FO APPLICAid:1L after making this Certificate of Exemption,you should WATER SYSTEM/I'RF-ATING
F't become subject to the Wmwer Compensman provisions of thu Labor Code,yon must SOILS FEE
Wwr forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PEKE. SQ.FT, PAID
V 0 1temby affirm that Nem is a construction lending agency for the performance of Date Receipt It
r. the work for which this permit is issued(Sec.3097,Civ,C.)
0 F's Lenders Name TOTAL:
WLenders Address TOTAL:
G I certify that I have reed this application rand state that the move information is BUILDING FEE
M correct.I agree to comply with all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE
G building construction,and hereby malborizc repranatisci or this city to enerupon the SEISMIC FEE
above-mentioned property for inspection purposes.. PERMIT ISSUANCE
(We)agree it,save.indemnify and keep harmless the City of Carman against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way raceme against said City ALTER OR ADDTO MECH, PLUMBING FEE
in .sequence of the granting of this,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL'NON-POINT AIR HANDLING UNU('ID 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR I[ANGLING UNIT(OVER 10,000k CFM) CONSTRUCTION TAX',
Signature mf ApplicanisComractor Date M14AUST HOOD OV/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materia[ HEATING UNIT TO 1001,0110 BTU)
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532ho? HEATING UNIT(OVER 100,000 BTU)
OYes []No - VENTILATION PAN(SINGLE RESID) PAID
Date RccciptM
Will the applicant ora future building occupant use ea Air u m devices amen
emit hazardous air conaminoms as defined by the Bay Area Air Quality Management BOILER-COMP(7HPOR IOII,000BN)
District] TOTAL:
Yes ❑No BOILER r COME(OVER 1110,0110 BTU)
❑
I have read the hmmims..lenals immirammnts under Chapter 6.95 of the Cali- AIR CONDITIONER -
ISSUANCP.DATE
fnmiu Health&Safety Code,Seniors 355115,25513 and 25574.I undersand that if the NEW RESIDENT IAL MGCH. SQ.NT,
building"-1 not1ure Ply have tenant,that itis my responsibility tonally the accu.unt
of the requirements which must be met pnoc w issuance of a Cemicale of Occupancy.
Owner or nuthonzedagent Date TOTAL: ISSUED BY:
OFFICE.