30751 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY-
CITY OFCUPERTINO + BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION . APPLICATIONflPFRMIT PLUMBING-MECHANICAL 3 O 7 51
BUILDING PROJECT IDENTIFICATION
BUILDING'ADDRESS: - SANITARY NO APPLICATION SUBMITTAL DAT
O 'H'SNA 17 PHONE: CONTRACTLIC NO:
NIC CONTROL N
ARC 1 CUL'GINEER: LIC NO: ADDRESS: "NI ❑
CONTACT: - "PHONE: BUILDING PERMIT INFO
+ ❑.Consultant Fees Paid by Applicant(Initial) Bf OG ELECT PLUMB MECH
LICENSED CONTRACIOR:q DECLARATION QTY. ELECTRIC PERMIT FEE
I herthy affirm That I am licensed ands,provisions of Chapter 9(a narmarng JOB DESCRIPTION
OWZwith Section]OgBof Uivision3 ofthe Business and Pr.fcssions Code.andmyliomse Lx RESIDENTIAL:
Ii10 0
FPERMIT ISSUANCE ad in full force and effect. OSFDWL O KITCHEN REMODEL
aUV Licenx Clazs '' Lit. APPLIANCES-RESIDENTIAL OADDITION [I PLUMBING RE-PIPE
NQ6 Uale - Contractor
F.Drn ARCHITECTS DECLARATION PANELS f OMULTI-UNIT ❑STRUCTURAL
Z O H 3 1 u.demdm� my pions shall be a.J us public records „. MODIFICATION
02,—G UP TO 200 AMPS . MODIFICATION
O CHIMNEY.REPAIR '
W Liernsed Profcssionol +. 201.1000AMPS IMPROVP.MEN'I'
Q' OWNER-BUILDER DECLARATION
C �•' rOV1df HXXI AMPS 3TH REMODEIIREPAIR El DEMOLITION
Q '1 hereby affirm that l um exempt from the Contractor's License Law fm the
x606V following reason.Section 7031.5.Busineexand Professions Code:Any city or county SIGNS EI.ECOtICAL ❑OTHER/
1+13 LL which requires a permit to construct.slick,improve,dcmulish,or repair any manure W t
0g prior to its issubnce,elw requires the apPl..Sm for such permitm Rle axigned slammenl SPECIAL CIRCUIT/MISC. +
S y that he is licensed punuam to the mitummoufthe Comment,,License law Chapter
W 00y (commencing with Section 7000)of Division 3 ofthe Business and Professions Cole)or TEAM MLTF.R OR POLE INST COMMERCIAL:
ay.cOn that he is exempt doorman and the basis for the alleged exemption.Any violation of NEW RLDGIADDITION 'O DEMOLITION
pq N Scdion 91UL5 by any opplielint for n Permit sufloos the applicant to n civil lwnulty of 1'OWIIR DEVICES ❑TENAMI ❑FOOD SERVICE„
LrF_1 Z9' " ore than five hundred dollars($500), IMPROVEMENT'
= .,croflhe property,m.radar uyees with wages vs thci,whe aompcnwtinn, SWIMMING POOL ELECTRIC
SFOeas `ill du the work.end the stmaurc is nm inonded onsRereJ for ale(Sec]W4:Business ODTHER
al nd Podaasions Code The Contra<mr's License IJIW rims not apply m or owner of OUTLETS-SWITCHES-FI%TUBE
Pmpcny who builds or impmvex Hereon,and who does such work himself ur through -
his own employees;provided that such improvements am not intended at offered for NEW RESIDENTIAL ELECfR
"aid.IT howeveathe building or impmvemrnt is sold within one year ofcnmpletion;the SQ.IT.FLOORAREA $/SQ.IT.
owner-builder will have the burden of proving that he,did not build or Improve for pur- y.k pp
'pasecfs:de). P „ ' V^^
,
El
Las owner of the property,um exclusively counakling with licenced contractor,to AL.
construct the projen ISce.71144,Business and Profcssimcx C.JeU The Contractors Li- _
c se law Jms not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE DEC
whocratmdsfnsuch projects with aconwnmsu
00%)IiumNedpant mlhc Contractors 31 sJ/y��
Li<eme law. PERMIT ISSUANCE 19%
eseIs
lam mt under Sec lB&P C fur do,...a 7-Irf .
- ALIER-DRAIN&VENT-WATER(EA) - v ChtV1ll TION
ane WWItKEk:S COMPF.NSA1lON DECLARATION - BACK PLOW PRO'IiCT'.DEVICE OOv,
I hereby aDom under penalty of pe§ury ono of the lisllowing dmlurmluro:
❑�Ihave and will mainwindCmifcate of ConscnnmdGinsurc for Worker's Cumpcn. DRAINS-FLOOR,ROOF,ARLA.CONU. STORIES 'TYPE CONSTRUCTION
/ sari..,as provided far by Section 3700 of the Lata Code,for Ne pednmwnce of the
.,it for which this Nunn is issued. F'I%TURES'-PER TRAP
O 1 have and will nminmin Workers Compenwtion Insurance,as reyuirpl by Seca..
3700 ofthe lata Cxaln for the serfomlance ofthe work for which Nis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compemmion Insurance carrier and Policy number are: - -
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(IEA)
CER I'II ICA H OF COMPENSATION
EXEMPTION FROM WORKERS' (IREASE/INDUSTRLWASTE IN'I'ERCCVTOR
COMPGNSATI(IN INSURANCE BUILDING DIVISION FEES
(TTisxectiounwJnot ba cmmpined if the pennll is for one hmdreddolfins($100) GREASE'I RAP -
. or less.) PLANCIIECK ItiC
I certify that in the Performance ofthe work for which this permit is issuW.I shall SEWER-SANITARY-STURM EA.200 FT,
not employ any person in any m ner sn as to become subject m the Workers'Comps.- ENERGY PER
0 an..laws of California.Duke WATER HEATER WNEPT/ELECTR GRADING PEE
Applicant
(~ ^ NOTICE TO APPLICANT:If.attar making this Cenificme of Exemption,you.should WATER SYSTEM/IRE tTING
hecome subject to the Worker's Compem,non pow lions of he LataSOILS ITIE Code,you most '
rorbwilh comply with such provlsmrox or lhis poinit.xhull be deemed rewkcd, WA'I'1iR SERVICE
Q
D CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. o SQ.PT. PAID
U Z Uvm Hettiptp
V Q , Ilrcreby affirm that hert isaconstruction lending agency funhe perfmnnantt of
0+ f"' the work for which this pximil is issued(Sec.301 Civ.C.)
Lanais Nater TOTAL:
Le
�� nder's Address TOTAL: BUILDING FEE
I certify than have read this application and slam that the above moo aution is 1
F�. h QTY. MECHANICAL PERMIT, FEE
V bnlldingcttmstruction,undhcrchyaulh.rizc rcprexcnmlivcx of Nix citywools,m+mn the SEISMICPEE_
ahove-mentioned property for impeninn pmporcs. 'PERMIT ISSUANCE "
(We)agree o save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
fabilities.judgmema costs and expenses which may in any way seerve against wind City AI.TERORADDTOMECH.
in nxequence ofthe Granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO IT"CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.(1X)CFM) CONSTRUCTIONTA% '
Signature.f Applicant/Contraena Dore EXHAUST HOOD(W/DUCT)" / HOUSING MI'I IGATIONi PETE
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicum nr fumrc builJin6 sncupum sesreorhandlchamNommumn.1 HEATING UNIT TO IW.001)BI'U)
as defined by Ne Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cods.Section 25532(m.1 - HEATING UNIT(OVER 100.000 NOT
O Yea O No VENTILATION PAN(SINGLE RESID) ry ii
PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which
noir hazallom air conlumirmax as defined by the Bay Area Air Qmlity Marugcmem BOILER-COMP CHPOR 1100.000131U) f
District? "" I
bTcs ONo'k ❑OILFR-COMP(OVIER Its),(XX)13 J)
I
I have read the haLankax marnals rcquimmcmk under Chapter 6,95 of the Cod AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Core.Sections 25505,25533 and 25534.I undersmnd that if thc NEW RESIDENTIAL MECH. SQ.ET. ,
building does not currently have a rerom,that it is my responsibility m notify the mmpanr
ofthe requirements which must be met prior to resource of a Certificate of Rcup ary.
Owen or amhorircd agent UmeTOTAL: - ISSUED BY:
OFFICE
a