30028 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL. PERMUN0 3 O O//�L H
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
/boob --�c�6o Mo r9 �I/^�C
OWNER'S i/
'S N�AME: PHONE.: CO I'RACfOR'S NAME: LIC NO
1WaTO S rzJ & `-.�OA 7 N/C CON'TROL#
RCHUMCT/ENGINEER: LIC NO; ADDRESS: ❑
7 MkJL)N&AnfL/+ uc
CONTACT: PHONE: BUILDING PERMIT INFO
3S7v-3J 36 [:1CongRllant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
V ❑ ❑ ❑ ❑
LICENSED CONTRACTODECLARATION QTY. ELECTRIC PERMIT FEE
I hereby a0irm root l um licensed underer provisions m'Chapter 9(comnteadng JOB DESCRIPTION
aZ with Secliva 7")of Division 3 of the Businessund l'rofeswonx CWe,andm license is 2 6 PERMIT ISSUANCE
00 y RESIDENTIAL:
p[... infullforee^de 1�9 /• ❑SFDWL [I KITCHEN REMODEL
U[Lf,..J� License lass J Lic.p �N APPLIANCES-RESIDENTIAL
Contrdcmr CADDITION ❑PLUMBING RE-PIPE
>0.0. ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O�p I understand my plans shall be used as public records
MODIFICATION
OZ o UP TO 20TAMPS [I INTERIOR OCHIMNEY REPAIR
Licenudlrofessional aQ 201-1001JAMPS IMPROVEMENT......]]]]41 OWNER-BUILDER ,C DECLARATION
P+� 6 I hereby affnm em that I exempt from.thdoe Cunvamnr'x License Law lin the OVER IMM AMPS ❑BATH RF.MODEURP.PAIR [I DEMOLITION
O FU. following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELRCTRICAL C OTHER
M0.0 r which requires a permit to construct,alley,improve,demolishWnur
,or repair any se
gpnorto its issuance.also requires the applicant such pemm m file a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant to the provisions of the Contmcmrs License Law(Chapter 9
Ge O0 bon mendngwith Seettn 17")of Division 3 of the nosiness and Professions Gxic)or TEMP.METER OR POLE INST. COMMERCIAL•
dfx�qo C that he is exempt Ihemfrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
W^m Section 7031.5 by any applicant for a perWtmbjecl¢theappli...t to a civil penalty of POWER DEVICES / ❑TENANT [I FOOD SERVICE
4,ZY Hat more thin five hundred dollar(SSW). IMP ROVEF ;
p6 MIasawneroflhepropeny,or my employees with wages as their sole compensation, SWIMMING POOL ELE IL
C� will do the work,and the¢wcturo is nntimended nr nlfcred for sole(Sea 7M4.Btoinws DOTHER r 19.tIV
and Professions Code:The Contractor's License Luw does not apply Ira an owner'uf OUTLIT!S-SWITCHES-FIXTUR
pmpcny who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvement are nut intrnded or aReral for NEW RESIDENTIAL HLEC R FT.
.Jr.If.however,the building or Improvement is said within one yew ofcompletion,the SQ.FT FLOORARFA f/SQ.FT.
owner-builder will huvethe burden ofpoving that redid not build ro mpmve Porpur- Ile l: ld
pose of ale.). 6
C 1,as owner of the property,am exclusively convecting with licensed convenors In TOTAL: n
convect the project(Sec.7044,Business and Professions Code:)The Contentions Li. JUN
'1 O '19QyA
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE JUN 1 1 Jv
who contracts for such projects with a contractor(s)licensed pursmat to the Contractors
Licenm U.
Cm l eexempt under Sec. ,B&P C for this mason PERMIT ISSUANCE CGIY Ur t;UmhI Ah
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE I� 000
l hereby affirm under penalty of perjury one of the following declaentiona: ( V
C lhave and will maintain a Certificate ofCammat to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCf10N
ration,as Provided for by Section 371X1 of the Labor Cede,for the pedar ,mance of the
work for which this permit is issued FIXTURES-PER TRAP
F-1 1 have and will maintain Worker's Compensation Insurance,in required by Section .�
37M of the Labor Cede,for the performance ofthe work for which this proud,is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Workpp�A��aaoro a' Irtsurrggppcecnrrierand Poiic•��W;��praPs,
Caricr.'g'T1JPFQLIA-'I-'a Policy NUl-' Jy GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEES
(Th is section need not be compicted if the Penni[is fusion,hundred dollan(t 1 Of GREASETRAP
or hour) PLANCHECK FEE
I certify and in the perfomunceafthewml,for whichthis permit is issued,l shall SEWER-SANITARY-STORM EA.2110 IT.not employ any person in any manner to as to become subjectto me Workers'Compcn-, ENERGY THE
O
section Laws of California.Data D Applicant WATER HEATER WNENT/ELECTR GRADING FEE
(n NOTICE TO APPLICANT,11 after making this Cerifrcam of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of the labor Code,you must SOILS ME
Wq try
forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDL'NTIAL PLMB. SQ.FT. PAID
U O L for by which
t i thermic i is aconstructioned(Se. 97,Cing agency fonhc performance of Data Receipt N
0 1- the work for which this permit is issued(Sec.]097,Civ.C.)
0 U Lenders Name TOTAL:
L7J Lender's Address TOTAL:
g� 1 certify that I have reed this upplicwion and xmm that the above infonnstinn is BUILDING LLE
fA correct,l agree to comply with all city and county ordinances and,two laws miming to QTY. MECHANICAL PERMIT FEE
V Zbuilding consvuclion,end hereby awhoder representativesafthis city m ene,,am the SEISMIC FEE
r above-mentioned property for inspection purposes.
(We)agree in save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way seems,againslmid City PETER OR ADD TO MECH.
a.consequence of Ne grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX
Signature of ApplicantCmnlracmr Data EXHAUST HWD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wil l the applatim or furore building oeopaat store or handle momentous material HEATING UNIT C170 I00,000 BTU)
as defined by the Capetian Municipal Cale.Chapter 9.12,and the Health and Safely
Cede,Section 25532Ia)7 HEATING UNIT(OVER IW,bW BTU)
Yes
VENTILATION FAN(SINGLE RESID) PAI
R
Will Us,air contaminants
building by the nt use Bay Area
devices which BOILER-COMP IMP OR 100,000 BTU)
mit hwurdnus air comamimmte as defined by the Bay Area Air Quality Management TAI.
Dlsmm7
[J Yet BOILER-COMP(OVER 100,000 BTU)
1 have read the hazardmu$}No nus materialsAIR CONDITIONER ISSUANCE DATE
ryuirernenu under Chapter 6.95 of the Cali-
foram Health&Safety Cede,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT.
building does not currently have a tenant.that it is my responsibility to notify Om occupant
f ¢mems rich moat/,yrael pdorm iasumceafa Certli I of Occupu y
o r / a lA^JO
Own nr authnm�f'ed ageni—'� Date TOTAL: ISSUED BY.
OFFICE