30950 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY Q p^�
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. O V V O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
^ BUILDING PROJECT IDENTIFICATION
BUILOINGADp 77 ` ^ SANITARY NO: APPLICATION SUBMITTAL DATE
0�-y.sya f.-1 i✓ G�ie1P�,lf YliS/ ONGrO )MF, �-rL�rNL7l ZTROL# 7
N/C CONTROL p
�'dRCHITECT/ENGIN SER: LIC NO: ADORE vow ewe,
- ❑
C TACT PHONE: BUILDING PERMIT INFO
QJ7pIN,g 1,i_� ��R� /��:T ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUAy� MEC
tMrP
LICENSEDD CONTRACTORS DECLARATION` (� QTY. ELECTRIC PERMIT FEE ,YJ/ rCfJ,
1 hereby nation that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
I%I��aZ wish S11IiOm'1IN10)of Div" n 3ofihe Business and f cions Code ddo�ppy llcenso is
FWO�. in full force coffer A� O �S PERMIT ISSUANCE
r� SFDWL El KITCHEN REMODEL
6WU Date Lic.tl ((// .•.•// APPLIANCES-RESIDENTIAL
FnG� Dale Conlmcmr []ADDITION El PLUMBING RE-PIPE
[F...=4py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
zpv�E 1 understand my plansshall he used as publicncered, MODIFICATION
0Z0 UP 10200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
r+HI"W Licensed Professional 201.10WAMPS IMPROVEMENT
..1 Oat I ma eUILDERum the RATION OVER 100JAMPS ❑BATH REMODEUREPAIR Q DEMOLITION
00000 W d i hereby affirm on I um exempt from the Contractors e:Any
Law for the
—O I` which followinquiresMason. erimiot 9onstru Business and Toamasina,;de lens Co de:Any easy orowrandare []OTHER
SIGNS F.LF,CTRICAL I r
'3�F which requires a permit m construct,alter,improve,demolish,or repair any swmurc
pdarto its issuance,alsomp,ru s the applicant forsuch Permit e file a signed statement SPECIAL CIRCUIT/MISC.
Za ,'at Not ha is licensed pursuenuo the provisions of she Conwetor's License Law(Chaptu9 --A CS
W dO (commencing with Section 70)(Bnf Division 3 main Businessand Professions Coca)or TEMP.METER OR POLE INET. COMMERCIAL
a ky a z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
at tNc Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ze ❑TENANT ❑FOOD SERVICE
u]ZZnet more than Eve hundred dollars(85(10). IMPROVEMENT
O ❑1,as owner of the pgeny,or umplryees with wages as their compensation. SWIM NG F'001,ELECTRIC
ro
will do thewmk,end the shuatum m not intended mnffered for ode(Sec.7044,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-. CHES-FIXTURES
R' r property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nes Intended or offered for NEW RE )' Al-El SQ ET.
sale.If,however,the building or lmpmermnt is sold within one yearofcompletion,the SQ.FT.FLOOR AREA $/SQ,PT.
owner-builder will have the burden of proving that he did not build or improve for put.
poste(sale).
❑1,as owner of the progeny,oro exclusively compacting with licensed erandommra at TOTAL:
construct the project(Sec.7044,Business and Professions CWc:)The Contractors Li-
cense Law docs not apply to an owner of properly who builds or improves thereon,and QTY, PLUM PER IT FEE
who contracts for such projects with a continuants)licensed pursuing to the Contractor's
License Low. PERMIT ISSUANCE sJ Q
IamexempruaderSm. ,B&PCforthi,omran
Owner Data ALTER-DRAIN&VENT-WATER BEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
ffirm /"1.'bo ''��,//l
1 hereby aunder penalty of pe jury one of the following declarations: 01.
❑ I have and will maintain a Certificate of Consent to self-in.snre for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONE. STORIES TYPE CONSTRUCTION
settop,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3100 ofthe M1nr Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work vrtierand Policy pttg"66 Q GAS-EA.SYSTEM-OVER Carrico Policy FROM
OR LrS'
F.RTIF CATS OF EXEMPTION FROM W ORKERS'
C PFNSATION INSURANCE. GREASFJINDUSTRL WASTE INTERCEPTOR BUWDINC )I VISI FEES
flTlsa nneed be wmpletWif the permit is(Drone hundred dollars($IIXq
or less.) GREASE TRAP
PLANCHECK PET.
Icenifyt a performance ofthe work for which thin permit is issued,(shall SEWER-SANITARY-STORM F.A.200 FT.
nog employ any p n any manner so c to become subject to the Workers'Cnmpen- ENERGY FEE
Oz sodium Laws of Ca p WATER HEATER W/VENT/ELECTR
7 Q Applicant GRADING FEE
Gl NOTICE TO APPLI :If,after making this Cenilicade of Exemption,you should WATER SYSTENYTREATING
a ; become whjeot to the rker'e Compensaion provisions of the labor Code,you must SOILS FEL
121 forthwith comply with such provisions or this permit shall be chanted revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT. PAID -
IherebyafPrmthatthereisaconstructioniendingagencyfortheperfermance,of Dat Receipt
Lir H the work for which this penn0 is issued(Sea 3097,Civ C)
0 Leader's Name TOTAL:
WLenders Address TOTAL:
a I certify that I have read this application and ,are that the above information is BUILDING FEE DO
r.t d1 correct.l agree to comply with all city and county ordinances and shoe laws relating to QTY. MECHANICAL PERMIT FEE
L.1 Z building construction,and herebyamhoom representatives nfdris ally to emerupon the SEISMIC HE
Z above-mentioned progeny for inspection purposes. PERMIT ISSUANCE Ch
(We)agree to save,indemnify and keep harmless the City of Cupertino against / ELECTRIC ME
iabilines,judgments,costs and expenses which may in any way acerueagainst said City ALTER OR ADD 3Y)MECH. Amy♦
in consequence offle granting of this permit PLUMBING FEE J V
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TQ 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. C S'Q
AIR HANDLING UNIT(OVER I ROOF CFM) CONSTRUCTIONTAX
Signature of ApplicantlConractor Data EXHAUST HOOD(W)DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU)
as retired by the Creech..Municipal Code,Chapter 9.12,hod the Health and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 1 GOOD BTU) -
❑Yms ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or Devices which Date Receipt#
rt hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHPOR 100,000 BTU)
District?❑Yes No
BOILER-COME(OVER 100,000 BTU) TOTAL:
❑
I have ted the hazardous matealsm niremams adder Chapter 6.95 of the Cttl- AIR CONDITIONER
ISSUANCE DATE
fomfff
is Health&Safety Cate,Sections 25505,25533 and 25534.1 loaders, Nm Bit, NEW RESIDENTIAL MECH. SQ.ET. / �1 ey-
building does not currently have a mart,that it is my responsibility to notify the occupant 4 1 /
of the requirements which must he met prier to issuance of a Certificate of Occupancy. {y�
Ownercramherimal agent Dote TOTAL: ISSUED BY: "
OFFICE '