30305 ' a
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^( g^�
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30305
S O V O V
BUILDING DIVISION APPLICATION/I'ERMIT PLUMBING'-MECHANICAL `{!
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'R'S NAM : I'H(INE:� �� CONTRAC9Y)R' NAS1 B: LIC NO a
,V\ AE: NIC CONTROL#
RCHITF.CT/ENGINEER: LIC NO: ADDRESS: is ❑
CONTACT
�\` A PHONE: YY_�J BUILDING PERMIT INFO
i\ G7l 03 ElConsultant Fag Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
y pro Bionsof Cha QTY ELECTRIC PERMIT FEE
I ion? affum Nos I am licensed under pler 9(commencing JOB DESCRIPTION
OOC witallforaa]Bfl(1)of DivisionJofthe Business and Prolessi scoot).and mylmen.is
O O PERMIT ISSUANCE RESIDENTIAL:
in full force and ..
Vz U License Lic.p ❑SFDWI. KIT HEN RP,MOUF.L
6L Dom _ Gontmcror APPLIANCES-RESIDENTIAL []ADDITION UMBING RPPIPE
Fly A -HITECFS DECLARATION PANELS ❑MULTFUNIT ❑STRUCTURAL.
Z O y 3 1 understand my plans shall be used as public records MODIFICATION
OZ0 UP TO gal AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Professional 20140100AMPS IMPROVEMENT
44�d •.I OWNER-BUILDER DECLARATION OVER I000 AMPS L1 BATH REMODEL/REPAIR DEMOLITION
ortC
Q I hereby.(See mat 1 am exempt from she Comn,Cad License Law for the
06I whichrguiresaerinitn]OJ1.40ualter,and Pe.demolish,
Co de:A.,oil,orcountySIGNS ELECTRICAL []OTHER
F O F which requires n permit m.nnweL ohne impmve,demolish, fi repair any ormewre
C prior 1. issuance,also reunites the applicum fur such perminn nleesigned nmmmem SPECIAL CIkCUITIMISC.
2 y5. that he is licensed pursuant the provisions of the Comrecto's License Law(Chapter 9
^yK p0 (commencing with Section]0adyof DivisionJofthe Busimusiml Pruffromcs Code)or TH R METER OR POLE INST COMMERCIAL:
yy� that he is exempt tberehom and the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
+ SgRs Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICHS
Ray ❑TENANT ❑FOODSERVICE
p, not more than liven oeany"arly om01. - IMPROVEMENT
Q (] Lex ownerofthe prosomeon myemplmd,ci with wages mtheir(win compensation, SWIMMING POOL ELECTRIC
wall da the work,and she he Cont is not s License Law do for sale(Sec.
to(Yw,Business 11 OTHER
6 m and Professions Csslor The Co.x dome s License Low does not apply s an owner of OUT LETS-SWI'I'CIIES-FIXTURES
pmpcny who build)or improves Ihcrcon,and who does such work himself nr through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR S
sale.ILhowever,the building or improvement issold warinoneyearrecomplathe SQ.FT.FLOOR AREA S/SQ.ff.
owner-builder will have the burden of proving that he did not build or improve torpor.
posa of sale.))
❑ I,as r of the property,ton exclusively contracting with licensed contractors m 10
consumer the project(Sec.7614,Business and Professions Cod.:)The Commcm.Lior
-
cense law does nm upply torn ownerof,l,,cy who builds or improvesdauriu,and QTY PLUMBING PERMIT
who contracts for meth projects with a mecocmes)licensed pursuant o the Contractor's ' -
Limn.ce Law. PERMIT ISSUANCE
❑lemeaempsunder Sec. ,B&PCfor this reason
n
_ ALTCR-DRAIN&VENT-WATER IEAI AUG
Owner Dme 11—AlU QIP
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby mErm under pmmV of pe,mYcnc of the fallowing declinations: (AI) (v/l vVf Lt,t htII
I havemd will rmiemime CeniticamofConsemto self-immre for Worker's Compem- DRAINS-FLOOR,ROOr,,AREA,COND. STORIES TYPO CONSTRUCTION
some,m Ir voided for by Section 3700 of the Lubec Code,Code,fnr Ne performance of the
work for which this pendt is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Campensmion Insurance,as required by Section
37Mofdhe Labor C.rle,for the performance ofthe work for which this permit issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
/p/ygy (ICC.GROUT' AI'N
My Cem`erof/!/'J{f
Policy No.Yn^mbca�e�C'1
/L_7 GAS-EA.SYSTEM-OVER 4IRA)
CERTIFICATE Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI?ASFIINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit Is for onehundWrdnllurs IS 100)
GR
or less. GREASETRAP PLANCHECK FEE
I emit"lis,in the performance of IN,work for which this permit is issued.)shelf SEWER-SANITARY-STORM F.A
not employ my person in any manner so as to became subject m the Workers'Craft . .
J20(1 fTENERGY FEF.
� Z moon La i,of Cu111'orine.Date WATER HEATHS WNENT/BLECTR
Q Applicant GRADING FEE
to NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WAFER SYSTEMOK13ATING
a '^ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Lkl G forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE -
Q
0.
CONSTRUCOONLENDINGAGENCY NEW RESIDENTIAL PLMp. SQ.FL PAID
U 0 Ihcreby affirm that men iseconstmnion lending agency for the Performance of Dam Receipt#
fL l-+ the work for which this Permit is issued(Sec.3097,Cie C.)
O U Lender's Name TOTAL:
Lender's Address TOTAL:
G 1 certify that I have mad this application and state that But above information is BUILDING FEE '
IA or.,.I agree......ly withal)city anal..of,ordinances and store laws totaling In QTY MECHANICAL PERMIT FEE
(,) buildingconswctionandherebymwh.risrcpresem.atives mNiscity mentcruponfle SEISMIC FEE
ahove-mentioned property for inspection purposes,
(We)agree to save,indemnify and keep homeless the City of Cupertino agrinn PERMIT ISSUANCE ELECTRIC ME
liabilities,judgments,costs and expenses which may in any way name against said City AUFERORADDTOMECH.
in consequence of the gmn.ing of this permit, PLUMBING FEE IN.no
APPLICANT UNDP. STANDS AND .CO LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCB RE IO �.,/ MECHANICALFEE
AIR HANDLING UNIT(OVHR 10,BCFM) CONSTRUCTION TAX
Signam pplicanVCommucu Date EXHAUST HOOD IWMUCG
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willtheapplicom or future building usmIxtrumme or handle hazardous material HHA'I']NO UNIT(FO 100,000 II'1'U)
as defined by the Cupertino Municipal Cotte.Chapter 9.12,and me Health and Safety
Code.Section 25572(e)? IIwING UNIT(OVER 100,0M BTU)
C]year 0 N
-, VIiM'ILATION PAN(SINGLE.NESID) PAID
Date Receipt#
Will the applicant m Pomo building by the Bl use .Air Qu rn device.which BOILER-COMP DHP OR 100,000 BTU)
emit hnaardous air mmaminems as defined by the Bay Arco Air Quality Management TOTAL:
District?
0y. 0 N ROILER-COMP(OVER I00,0001ITU)
I have read the hzmdous.,cost,requirements under Chimer 6.95 of the Celi- AIR CONDITIONER ISSUANCE DATE
f.rnia Health @ Safety Code,Sections 25505,25573 and 2.5574.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have m tenant.that it is my responsibility to notify the occupant
of the regmiretmuts which must be mm.prior In issuance of a Codllicate of Occupancy,
Owner or uuNmiud agent Date 'POTAL: ISSUED BY:
OFFICE