30791 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 0
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
iG-1-7
OWNER'S NAME: PHONE: CONTRACTOR S NAME: LIC NO:
NIC CONTROL#
aRCHITEMAINGINEER: LIC NO, ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
e El El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 sent Iieen,ed under proli,iO111.1 Chapter 9((commencing JOB DESCRIPTION
Doo with Seon700(bof Division 3 of the Badness and Professions Cade.and my license is RESIDENTIAL
FWOO d
in full force and effect. PERMIT ISSUANCE
Z - License Class I.E. ❑SFDWL [I KITCHEN REMODEL
¢ U APPLIANCES-RESIDENTIAL. ❑AUDITION [I PLUMBING RFPIPE
G L Data Cambric',
FOuo ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
O to Z 1 understand my plans xhsll be used as public records MODIFICATION
UP T0200 AMPS C1 INTERIOR
-1 CHIMNEY REPAIR
�H..F.W Licensed Profeesi.n.l 201-10(X)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVERInputAMPS ❑BATH REMODEIJREPAIR [I DEMOLITION
L C 6 I hereby affirm that 1 am exempt from the Contractor's License law for the
ydOLU f.11ow'mgremnn.(Section 70315.Business unit Pfnfesions Code.Any city ar County SIGNS ELECTRICAI. El OTHER
3
U. which requires o peril to conslruct,alcor,improve,demolish,or repair any structure
ef-�OJ
prior o itsissuance,also require.uhe applicant for such Permit o Cite a signed.stammcm SPECIAL CIRCUITIMISC.
2 y that he is licenmd pursuant o the provisions of the Contractor's License Law(Chapter 9
Wyp0 (commencing with Section 701of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL.
a a ca that he is exempt therefrom and the haus for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
^N Section 7031.5 by any.ppli,arn fur a emat subjects the applicant-,rt,ml penalty.) POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more thin five hundred dollars(4500).
H Z Y• IMPROVEMENT
❑O ❑ 1,as owner of the popeny,or my employees with wages as their sole comKnsmion, SWIMMING Y00 RIC
will Jo the work,and lhestrcumeisout intended or of feted fnrstJe(Sw.9040,Business ❑OTHER
Y1 Mal Professions Coale:The Contractors License Law does nut apply to an owner of OUTLETS-SW HC TURES
6 3^ pmpeny who builds nr improves therton.and who Jots mcM1 work himself or through
his own employees,provided that such improvements are not intended cantered for NEW RESIDENTIAL.ELECT FT.
aide.If.however.flue building or improvement is sold within one year ofmmpletion.the SQ.FI'.FLOOR AREA VSQ.IT.
owncr-builder will have the burden of proving that he did not build or improve fur pur-
pose of sal.).
I]1,as owner of the pmpcny,am exclusively contracting with bect comorem s to
conamm the project(Sec 7044,Business and Professions Code:)The Immustnr's Liic
-
CIm,Law does..,apply to anomer of pntpeny whit build,,),rapnwes mereon.uad QTY. PLUMBING PERNIX FEE Po
who contracts for such pmjec,s with a commena(s)licensed pursuant m the Comment's P A B
Lucre Law, PERMIT ISSUANCE
(] 1 oro a top,s de Sec. .B&P farP.reason
ALTER (EA)
Owner -- Date • "RECp
W(A 'R'S COM SATION DIiC1.ARATIO BACK FLOW PROTECT.DEV ICE r�
1 h by affirm under penalty of perjury one of the Minivan declaa,ion r (✓f r
I have:mA will mainmina Cenilicac of Con...I m.mlf-insure for Wotker'17 .pea DRAINS-FLOOR,ROOF,AREA,COND. STORIES RYIf�iXCONSTRUCDON
other.us provided for by Sent,,3701 of the Labor Gale,],,,,he peflonnim c of the V
work for which this permit is issual. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,ax required by Section
3700of Ne Labs Cdcfo
.for the performance ofthe work for which this permi,is issued, GAS-FA.SYSTEM-I INC.J OUTLETS OCC.GROUT' AI'N
My Workers Compensation Imumn<e carrier and Policy number arc:
Carrier: Policy No.: CAS-FiA.SYSTEM OVER J(FAJ
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASUINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('ntisxcnion had nut hec.ngqeted iftn,pemtil is futon,hundred dollars($](X)) GREASF TRAP
or less.) PLANCIIECK PEE
1«nify that in thepcdorarec.fthe work forwhich this petit is ismcJ,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subjeeun the Wmkerr;Camper. ENERGY FEE
O Z scion law"d California.Dae WATER HEATER WNEN/ELECIR GRADING FEE
O Applicant
`
NOTICE 10 APPLICANT:11:after making this Ccnhicae nt Ex,maclm,you sboated WATER SYS"I EM?RFA'I'INC, SOILS ME
abecome subject tothe Workers Compensation provisions of the labor Code,you must
[31forthwith comply with such prov tome,or this peril shall be deemed revoked. WATER SERVICE
in
a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
V 0 Thereby affind that them is u conswclion lending agency for the performance of .at
aeiptX
the work for which this pemtil isosoed(Sec.3097.Co,CJ
u" Lenders Nome TOTAL:
Lender'.,AJdrtxs TOTAL:
y 1 eenify,ha 1 have mad this application and slam Martin,above inhmnation is BUILDING FEE
FUIn correct.l agree to comply with all city and county ordinances and state laws ncluting to QTY. MECHANICAL PERMIT FEE SEISMIC FEE) Z building ammmetion,and hereby nuthprise nprescmmivcs of the city to emerupon the
above-mentioned property for inspection pinpoint PERMIT ISSUANCE AT
(We)agree to save,m4comify and keep hwrmlcvs the City of Capacitor against ELECTRIC FEE
dabil'nies,juJgmcnts.coa,and uxpeace wh'ahmay tunny vay.ecore agcou'l snit City ALTER OR ADDTO MECH.
unstyuena oI It granling ofit,x i,. PLUMBING FIiE
APPLICANT ERSTAND. nN WILL COMPLY WIT ALL/ON-POINT AIRRANDLINOUNIT(TO 10,0WCEN) MECHANICAL FEE
Sig R'sI(I' SONS. / 1
// AIR HANDLING UNIT(OVIdR 10.000 CFM) CONSTRUCTION TAX
Signet e:�. Appllcan ontructor Da EXHAUST HOOD(WIDUCf) HOUSING MI TIGAI'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will mespplicam or I.M.building ocenpansmreor handle h.epr, a ma¢rial HEATING UNIT(TO 100.0110 BTU)
as shamed by the Cupertino Municipal GWe,Chapter 9.12,and Me Health and Sntety
Cuda.Section 25532ha)7 HEATING UNIT(OVER Ift(XMl BTU)
El Yes El No PAID
VENTILATION FAN SINGLE RESID) One Rcccipl#
Will the applicam nr future building occupant use Wuip ram or devices which
it havardous air contaminants as dcfnd by the Hay Are.Air Quality Management BOILER-COMP(JHP OR 11XI,f100 BTU)
emTOTAL:
Dobictp BOIU'R-COMP(OVER 100,000 BTU
❑Yes ❑Nn
I have read the hareadous materials lluirements under Chapter 6.95 at the Cab. AIR CONDIT'IONIiR
aISSUANCE DAIS
fomia HwIN&SafctyCde.Satinns 25505,255]3 and 255U,1 ulWefxmml that if the NF.W RFSIDENIAL MECH. SQ.FT
building ds not currently leve atcnrnbut it is my ressprnsihda,,,notify thcoccuPnt
of the res rimments which past be met Prior to issuance of a Certificate of Occupancy.
Owner or authorir.ed agent Due TOTAL: ISSUED BY:
OFFICE