30840APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT' IDENTIFICATION
PERMITNO. 3 O H T O
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BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWNE 'S NAME NE: RACfOR'S A LICNU
C2_ ; 61
N/C
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•ARCHIT CTfENGINEER: LIC NO: AD
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CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
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BLDG ELECT PLUMB MECH
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LICENSED C ACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7")ofDivision 3 of Ne Business and Professions Coddc,and my license is -
w G%73l T PERMIT ISSUANCE
n full force and effect.
Licenu P Li<.# APPLIANCES - RESIDENTIAL ��
Dam Contra W2 ^ e ^
ARCHITECTS DECLARATION '
.I understand my plans shall te .,Was public record, PANELS
UP T0200 AMPS
JOB DESCRIPTION
RESIDENTIAL'
1)Fry77Al: ���[[['''
❑SFDWL CHENREMODEL
❑ADDITION PLUMBUJG RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL.
MODIFICATION
El INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT
Licensed Professional 201-1000AMPS
6
iqS O a. U
a F
OWNER -BUILDER DECLARATION OVER ]"AMPS❑
I hereby affimet at I um exempt from the Co.=,.,'s License Law for the
following reason. (Sermon 7031.5, Business and Profession, Code: Any city or county SIGNS ELECTRICAL
BATH REMODEUREPAIR ❑DEMOLMON
❑OTHER
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F O
which requires a permit to construct, alter, improve, demolish, or repair any structure
poor to its issuance, also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
ursuam to ftbe Contractors Law Cho tcr9
p provisinnsm ( p
modurno
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6
m
inigwiJ Professions Cwk)or TEMP. METER OR POLE INST.
p li erred the basis for the alleged exemption. Any violation of
that W is exempth Section ]000)of, basis for the
that he is exempt zany applicantsubjects the applicant to civil Penalty of POWER DEVICES
not hands, than five hundred dollars ($500).
not mom Nan five hundred dolls, (SSOo).
Las hwnerafthe property, or isnot moyees withwmgf...IcSc, 70mpenamion, SWIMMING POOL ELECTRIC
wdl dothewons andcd Business
COMMERCIAL:
Q NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FODU SERVICE
IMPROVEMENT
[j OTHER
e: Me Cummactu s LicensecnJed surot apply to an,
and Professions CdorinapoexdcmYs License Lawdoesoatapplytolfowner of OUTLETS - SWITCHES -FIXTURES
Law does
who builds or th thereon, and who does such work offered!fthrough
property
his own employeese Wilding that such mmprov,.Id are am intended completion, or offered for NEW RESIDENTIAL ELECfR SQ PI.
tided e deed or
sule.ILhowevegthe buil heburen of prmcnt idid he it nerve yearofatter.W<
owner -builder will have the burden of proving that he gid not build or improve for pita-
A SQ. FT. FLOOR AREA
&SQ. FT.
post of,ale.).
Vj III
REE V
I, as owner mf Ne popery em cxclusivdy contracting with ficenaeJ contractors m
con>wct the poseur IS.. 7044. Business road Prola,wo rs Cod, 11m C—so- or's Li-
nee law does not apply to an owner of property who builds or lmpnwes thereon,and QTY. PLUMBING PERMIT FEE
UO'E
HriNU
whommucts for such projects with a contractiabo licensed pursuant err the Contractor's
Licerl'n Law" t PERMIT ISSUANCE ejo
I am exemptunder See .B& P C fordinceason
ALTER - DRAIN & VENT -WATER (EA)
Owner Date _
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE
I hereby uffirm under penalty of perjury one of Ne following declarations:
❑ I have and will maintain r Ceniftcate of Consenuo self -insure for Worker's Compen- DRAINS- FLOOR, ROOK AREA, COND.
sation, as provided for by Section 37M of the Labor Cade, for the performance of the
STORI
T ONSTRUC ION
work for which this permit is issued. FIXTURES - PER TRAP
1 have end will maintain Worker', Compensation Insurance. as restated by Section
3700ofthe labor Code, for the performance of NC work for which this permit is issued. GAS - CA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP
APN
My Wolyr's Cgmpccoation nsurance carrier and Policy number are:
Cariec(L°Q/Lf1 Pnlmcy No.: GAS - EA. SYSTEM -OVER
CF.RTIFl ATEOPEXEMPFION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Z,'�
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(This section need not W completed ifma permit is for one hundred dollars (S Him GREASETRAP
tar less.)
I certify that in me pafmmunce.fde work far which this permit is issued, Ishall SEWER -SANITARY -STORM EA. 200 FT.
nor employ soy n in any manner as tobesIF subject to Ne Worked Compeer-
station laws lif a. D �. 55 WAFER HEATER WIVENT/ELECTR
Applicant �'
PLANCHECK FEE
ENERGY FEE
GRADING FEE
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NOTICE T APPLICA . e ter m reg th enificme of Exemption, you should WATER SYSTEM/IREATING
become su sat to the Worker's Compensation pr rsions of the Lahore Code, you must
forthwith comply with such provisions or this pemiuhall be deemed rmmked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ. FT,
Ihcr<byaffirm Nm there isuconswction lending agency for the perfonrmntt or
wok for which this permit is issued (Sm. 3041, Ci¢ CJ
Lender's Name
SOILS FIiE ,
PAID
Data a apt#
TOTAL:
Lender', Address T
I cadify Wt 1 have sad this application and state arm the above information is
correct. I agree to comply withal] city and county ordinances and state laws mating to QTY, MECHANICAL PERMIT FEE
building construction. and hereby euthomerepresentatives atthis city menter upon the
BUILDING FFA
SEISMIC FE
ELECTRIC FE
above-mentioned Property for inspection purposes. PERMIT ISSUANCE
rm
(We) agree to save, indemnify and keep harmless the City of Cupertino against,
PLUMBING FEE
liabilities,judgments, costs and expenses which may in any way accrue against sail City ALTER OR ADD TO MECH.
in consequence of the gaming of this permit.
MECHANICA Tfi
APPLIC UNDEft;TJkp!DS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 116(X10 CFhu
SO%R REGII RI ((
CONSTRUCTION TA
-�� / /j/ /jr/ AIR HANDLING UNIT (OVER 10.00s) CFM)
✓ (// TDam
�morm o ApplianUCuint or EXHAUST HOOD OYMUCT)
/ O ' M�IALS DISCLOSURE
HOUSING MITIGATION 'EE
HAZAR
Will me applicant or in(= building occupant store or handle hazardous material HEATING UNIT GO l 04000 BTU)
as defined by me Cupertino Municipal Cale, Chapter 9.12, and are Health and Safety
Cade. Section 25532fa)? HEATING UNIT (OVER 100,000 BTU)
❑Yes No VENTILATION FAN (SINGLE RESID)
PAID
Data Receipt#
Will me applicant tentbuilding occupant tau equipment or devices which
emithazunlous air contaminantsminanants as defined by the Nay Area Air Quality Management BOILER - COMP (3HPOR 100,0# BTU)
TOTAL:
District?
❑Yes F1 No BOILER -COMP (OVER 100.00) BTU)
I have real me hvvJous materials requirements under Chapter 6.95 of me Call. AIR CONDITIONER
ISSUANCE DATE
forma Hrulth & Safety Code, Sections 25505, 25533 and 25534.1 understood gat J are NEW RESIDENTIAL MECH. SQ. FT,
building docs notcummdy have a tenant, that it is my respmreibility to notify the occupant
of the rtquirnmms which must W ter poor 10 Issuance mf a Certificate of Occupancy.
ISSUED BY. �•
Ownerormffionmdagent Date _ TOTAL:
OFFICE