30752 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 3 0 7 52
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 .�J
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICAUON SUBMITTAL DATE
loo.9G �G+ skl.� /.blvd. C µ� 1%1
W R:S NAME: i'HONFr' CO AC'OR'S NAMIi: LIC�NO:
a -�) NIC CONTROL#
�ARCHITT.T/ENGINEVIL LIC NO: ADDRESS: lH ❑ (��
CONTAM: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 u3fhelicensed under and
P oua on%Code, 9 my license
JOB DESCRIPTION
OOZ with 5«tinn]OW)or DivisionJof the Business and ProfessionsCMe,and my license is RESIDENTIAL:
Oct in lull force and eff«v. PERMIT ISSUANCE
m" CSPDWL [I KITCHEN REMODEL
FQUV Dianna Clots DulynnlrContractor
u APPLIANCES-RESIDENTIAL []ADDITIONCPLUMBING RE-PIPE
N66 CL
ARCHITECT'S DECLARATION MULTI-UNIT []STRUCTURAL
Z O m F.D. 1 understand my plans shall be used as public records PANELS ❑ []STRUC[]STRUCTURALMODIFICATION
OZ4p UP TO 210 AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 2061000AMPS IMPROVEMENT
�d ; OWNER-BUILDER DECLARATION OVER (ROAMPS C BATH REMODELMiPAIRADEMOLITION
C w G I hereby affirm that 1 an exempt from the Contractor's License law far the
5d5�0wU following reann.(Section 7031.5.Business and Prdesions Coptic:Any city or county SIGNS ELECTRICAL COTHER
w 3W so which squirm a Parmh w amamet,alter,improve,dcmol ish,or repair any amemra
IL'1='OQ, prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCO ITIMISC.
9gg,�y than he is licensed pursuanpo the provisions of the Corrector's License Law(Chapter 9
�CO0 (commencing with Section FNp)of Us inion 3 of the Business and Professions CMe)or TEMP.MISTER OR PULE INST.
C,la,o fL that,he is exempt Ihercfmm and the basis for tM1e ellcgcd Gumption.Any violmion of C NEW B UG �I'IDN []DEMOLITION
X 4,
Section 703 IS by any applicant for a pemtit subject,thenppliaanno a civil pepur,of POWER DEVICES OT17NANT N ❑FOOD SERVICE
-=6not more IM1an five hundred dollars(5500). tVNI E ENT
I]I,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC (? �^
FFG will do the work.and the apnureis not intended or olTereJ lbr seta(Sec.]ILI4.Businesx CO
13 and Professions Code:The Contractors License law does not apply m en owner of 77
OUTLETS-SWITCHES-FIXTURES �.r_k�,
property who builds or improves theaok,and who does ouch work himself or through ' kar. Y
his own employees,provided tbar such improvement art nut intended or offered far NEW RLSIDEN'I IAL ELECT R SQ FT. uC1
axle.If.however.the building or improvement is sold within one year ofcompletion,the SQ.FT.pfryO� aV' $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun P p
sof sole.). `Y
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: .•
consumer the project(Sec.70,4,Business and Professions Code:)The Contractors Li- Ja'V
censo law does not apply as an owner of property who bpolds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for.such projects with a commemt(s)licensed pursuant to the Contractors
License law. PERMIT ISSUANC �2h 6�r
C I am exempt under Sec. .If&P C for Ihp recon L(/3„
ALTER-DRAIN WATER IEA) VALUATV
�)wn« `- Date
1 CI RS MPENSATION DECLlsRA'T1O HACK FLOW PROTECT.D
Ir itwileby f6pproomrvir a pewlryte of
of onert ofthe ch-insure fo Workerurv: 7 �V
Con,as itwillby eCertificat�of the Lair Costs,for
for Wader'sce of th- DRAINS-PLOOR,ROOH ;A.0 D. STORIES TYPE C(aN5TRI1CfiON
smirk, r provided for mi Ss issu 77W of the IaMr Cale,far the performance of the
work for which ibis permit Is issued, FIXTURES-PER TRAP
371have andwill odr,fon Worker's ante ofthewrk for hihrequire by S«tiun
37M of the lahn Calc,for Porhnmanca of the work far which this permit is issued, GAS-EA.SYSTEMUI INC.SOUTLETS OCC GROUP APN
My Worker's Compensation Insurance cornier and Policy number are
Cartier: Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERT[ITICA'rl?OF 17XEMPrION FROM WORKERS'
COMPENSATION INSURANCE GREASIJ]NDUSTRL WASTE INTERCEPTOR BUILDI VISION FEF_S
(Moo,ctlon need not be eomplard ifthc prom,is(near.handmaid dollars(SIM) ORT:AS['I'RAP or less.) PLANCHECKfI?li 11Cr
(certify that in the performance of)M1e work for which this permit is issued.ishall SEWER-SANITARY-STORM EA.200 FL
not employ any pe aon in any pamper so os to become srhjecl topic WorkersCompcn. ENERGY FEE
0 Z cation Laws of California.Date WATER HEATER WNENT/ELECfR GRADING F
Z Applicant
NOTICE TO APPLICANT.If,other making Ihis CcniOcute of Exemption,you should WATER SYS'rEMTRtEATING
a; become rimer,m the Worker's Compenmtion Pnwisions of the Labor CMe,you pmt 50145 FEE
fon osith comply with such provisions or this permit shall be deemed revoke, WATER SERVICE
LQ
DZ CONSTRUCTION LENDING AGENCY NI7W RESIDENTIAL PLMN. SQ.PT. PAID
V C I herebyalfrm thru vie is uomswcuom lending agency far the perfmrexam.f Dae Rccciptp
F the work for which this pumit is issued(Sec.307,Gv.C.)
lL ULender's Name TOTAL'
Leader's Address TOTAL:
a I cooly that 1 have acid this appliamtion aid ,are Lha the above Information is BUILDING FEE a/
cor«v l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICALPERMIT FEE
C.) Z building conslpcoon,and hembyamhmim representatives of this city m enter upon the SEISMIC PEE
above-mentioned property lit inspection purpose. I'IiRM1T ISSUANCE
(We)agree m.save,indemnify and area founders the City of Cupertino against ELECTRIC FEE
Iiuhilitics.mdgincna,costs and cxptover which may in only Wuyaccrun against said City ALTER OR ADI(TO MECH.
PLUMBING Ft
in nsgarrom nine gmming of this pcmpit. i
APPLICAN IDERS'TANDS NO WILL COMPLY WIT ALL NON-POINT AIR HANDLING ON]r(TO 10,000 CFM) MECHANICAL FEE
S> `CEA]IONS 2
/ �J AIR HANDLING UNIT(OVER 140W CPM) CONSTRUCTIONTAX
S nor eo ppl VCommc Du EXHAUST HOOD VODUC'F) HOUSING MITIGATION FEE
HAZARD S MATERIALS DISCLOSURE
Will the appllcanl or future building accupare store or handle haetNous material I IEATING ON IT 001 offer BTU)
as defined by the Cupertino Municipal GNe,Chapter VI 2.and the Health and Safety
Code,Section 255321uf! HEATING UNIT(OVER 100,000 BTU)
❑Yes CNo PAID
VENTILATION FAN(SINGLE RESID) Dale Receipt#
Will the applicant or future building Occupant use equipment or devices which
BOILER-COMP(3HP OR I W,qO BTU)
.mit haeardnus air ummminants as defined by the Ray Arca Air Quality Management TOTAL:
DislricC! BOILER-COMP(OVER 100.000 BTU) Nx
C Y<a "'No
refinements AIR CONDITIONEN
I have cad the hmardous materials b urMcr CIIvMor h95 of the Cali- ISSUANCE DATE
fomla Health&Safety Cee,Sanies 25505.25533 and 25534.1 understand that if the NEW RISIDEM'IAL MECH. SQ.IT.
buildingdocs not currently have a tenial,that it iuny responsibility m notify the accupanl
of the requirements which tuner Mand pdnr to i.....met.Certificate of Occupancy.
Owner or authovcd agent Dae TOTAL ISSUED BY:
OFFICE