30781 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 7 1
CITY OF CUPERTINO BUILOINl;-ELF,CTRICAL
PIiRMIT NO. O 1 H 1
BUILDING DIVISION APPLICATION/PERMIT PLUMG. I5ING-MECHANICAI. 30781
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BUILDINPROJECT IDENTIFICATION 3
BUILDING ADDR17SS' SANITARY NO. APPLICATION SUBMITTAL DATE
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RN NAME: PHO CONIRACT)RS NA �: �LIC�NO
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�IARCHiI'CCI'/F: GINEER: LIC NO AryR //600 0.� ��� ❑
CONTACI: PHONE: VVL1��7[ BUILDING PERMIT INFO
ar_ - ❑ Consultant Fees Pail by Applicant(Initial) HLIH'i ELLCT PLUMB MECfI
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I,ICENSEDCONFRAC OR'S DECI.ARATION QTY ELECTRIC PERMIT FEF.
I hereby from mat 1 it,licensed ender pr.,ki sof chapter v Bmmmcmchtg JOB D CRIPTION
z with Section 7")of Division 3 of the Husiness and Profs sinus Cade.and my license is R - IDENTIA
PERMIT ISSUANCE
F-B Lifallcmfortcnod cc �� ❑SFDWI. Fl KITCHEN REMODEL.
Z<-U License Class Lic.N Q [, A LIANCES-RESIDENTIAL C1 ADDITION [I PLUMBING BETTE
Q S Deter Eoamaclar -1�/L/—
—rolECTS DECIARA'I'ION ❑MULTI-UNIT []STRUCTURAL
Z O V,z I unden,e ad my plies shall be used as public me-rd, PANEL MODIFICATION
pz 4Q UP TO ZIX) YS ❑INTERIOR 0CHIMNEY REPAIR
rQ int.IY Licensed Professional 201-IWIIAMp IMPROVEMENT
ag�-1 OWNER-BUILDER DECLARATION OVIiR IINq AMPS ❑BATH RE EDREPAIR ❑DEMOLITION
L W< I hereby infirm the 1 am caentp(from the Cmnmaor'r Clause I,aw for the O
�( g a V following reason.(Section 7831.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL
0+136-f' which meant,a permit to cnrowet, he,improve,demolish e,repair any aweame
F P:O� omloh,issaance,ahem, m,the applicant lmsuch permit filen signed statement SPECIALCIRCUIT/MISC.
fly that he islicensed Pursuant to the provisions ofthe Contractors License law(Chapters)
COMMEWrap O� (commencingwith Section](I00)ofDivision)ofthe buainessaml Professions Cede)m TEMP.METER OR POLE INST. R
G L c W Thal he is exempt Iherefront and the basis for IM1e alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Way Section)OJL5 by eby applicant foe. .it subjects the applicant m a civil pcnniry of POWER DEVICES ❑TENANT FOODSERVICE
t mom than five hundred dollars(5500). IMPROVEMF W
C ❑ Laso%neroflhe properly ormy employees with wages as their sole competitor , SWIMMING POOL ELECTRIC
will do the work,end the snmenti a ix not intended car offered for sale(Sec.]tw,Business [-]OTHER
W and Professions Calc The Comomme,License Law does not apply 10 an owner of OUTLETS-SWITCHES-FIXTURES
L 3 property whe huildx or improves demon,and who docs such work himself or through
hie own employee,,p,.video that such improvements are nor intended or offemd for NEW RESIDENTIAL CLELTR SQ FT
mle.IL hoes¢ver,the buiidingorimprovcmem is sold withinoneycm ofcomple(ion.the SQ.FT '.DOR AREA 5/SQ.IT.
mener-builder will have the burden of proving that he did not build or improve for put
p]'e nl sale.),
has owner of IM1e pmpvnY•am exclusively contracting with licensed<mnmdars to TOTAL: /
corewct the project(Sec.]Ufa.Business and Pmfessioas Code:)The Contractor's Li. )
e se Low does not apply m an owner of property who builds or improves Intent,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjects witho eon(mc(m(n)licensed pesuanl loth,Cnmmcter's '�
License Lew. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA VALUATION
Owner Date,
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1hereby il mai under penalty of perjuryone t)the insomfollowing orkerCa
Ibeve and will maintain tion 37W of theUbou ode. o fur Workers Camped. DRAINS-FLOOR.ROOK AREA.COND. STURIIS Al e Ill CONS'IRUC'I'ION
ismf r provided for by Section 3'!00 of the Labor Code.Room performance of the YVT~ `
or for which this permit in issued Fl%TURES-PER TRAP
w have end will maintain Workers Compensation Insurance,as required by Section
00ofthelabor ode,forthe rfo.nceof Neworkfor�bthisp m1iittissiiasuuul. GAS-EA.SYSTEM-IINC.a OUTLETS OCC, Cagp ALIN
CWr: Qdtnc a�i1+n1 unnc carricrlolcy Noy—w•a GAS-EA.SYSTF.M-OVER alis) d91�A 1IHH
CERTIFICATED EXEMPTION FROM WORKERS' GR[ASFIINDUSTItL WASTL INTERCEPTOR
COMPENSATION INSURANCE _ sRUl�pllj¢,PIRLgIONttl1S
(rhe,ac(ion need oat hecmniceed iflhepemnii is fmone hundred dollats(S ILK) GREASEI'RAP
or leas.) PLANCTIIiCK THE
I certify that in the perfmmanceoflhe work for which this permit is issued.l shall SEWER-SANITARY-STORM E.200 FT.
not employ any person in any manner—,m become subjecrao the Workers'Compen- ERGY FEE
Z ,cation laws of California.Date WAIER HEATER W/VENT/ELEMR
ZApplicant GRADING FEE
ria NOTICE?TO APPLICANT:IF,aher making this Certificate of Exemption,you should WATER SYSTEM/BEATING SOILS FEE
abecome mbjeel Iso the W..ke,I Cmmpcnsmien Provixinns of the Labe,Code,Yom must
W forthwith comply withstich provisions or this Pernitxhall Le deemed revoked. WATER SERVICE
CONSTRUC'T'ION LENDING AGENCY NEW RESIDENTIAL.LMB. SQ.FT. PAID Dale Reccipl R
U O
1 hemby affirm the there is v conuwetion lending agency lar Ne parfurmanee of
LL E` the work for which this permit is issued(Sec.TOO.Civ.C.) TOTAL:
O U Lender's Name
Lender's Address TOTAL,:
�•' C 1 certify that 1 have read this.1im miaa and ham tha the above information is BUILDING FEE
iEi h comet.1 agree to comply with all city and county ordinances and state laws miming to QTY MECHANICAL PERMIT FEE SEISMIC FEE
building construction,and hereby authorize representatives of ihlscity to enter open the
abovemmenlioned property far inspection pugmses. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save indemnify and keep harmless the City of Cupertino against
habilhien,jodgmmals,c sts and expenses whkhmay i n any way accroe ag mins said City hTER OR ADDTOMECH. PLUMBING FE
in con quenceoflhe mating of(his penmil
APPI CANT UND STANDS AND W OMPLY WITH ALL NON-POINT pl ANDLING UNIT(TO IO."CFM) MECHANICAL FEE
SOL' CE RECIIL )NS.
AIR HA LING UNIT I' OVER 10.000 CFM) CONSTRUCTION TAX
rata of Ap tears nntm EXHAUST 'OD(W/DUCT) HOUSING MITIGATION FEE
IIA%ARDOUS MATERIALS DISCLOSURE
Will the epplimmum future buildingsceopantxtor,m handle haaardaus material ]ABA'T'ING ON[ )100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(O 100,fXp HTU)
Code.Section 25532(¢)'1
E]Yes F1 No VENTILATION FAN ISIN LE RESID) PAIL
Dme Receipt x
WIII IM1e applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR H X111 BTU)
t haazrdom air canmminarta as defined by the Buy Area Air Quality Management
matt' BOILER-COMP(OVER 100.1X0 U)
E]Vex 0N
I have read the hamrdeas martdals acquirements under Chsprtr 6,95 of the Cali- Al R CONDI I'IONER ISSUANCE DATE �5
fomiv Health&Safety Code,Sermons 25505.25573 and 8 bihl,mnnalitytth the if the NEW RESIDENTIAL MECH. IT.
forma He ma molafety ahavea(emn65505It ismy rand M5ility(odersta(heet if am
of the re,uimnents which must he react prior in issuance of a Certificate of Occupancy.
Owner or amhori'ud agent Dem TOTAL: ISSUED BY:
OFFICE