30621 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
>' BUILDING-ELECTRICAL . PERMIT NO.
CITY DI CCI VISION I PLUMBING-MECHANICAL 30621
BUILDING DIVISION APPLICATION/IaERMIT
BUILDING PROJECT IDENTIFICATION
LDINGADDRHSS: /I SANITARY NO. APPLICATION SUBMITTAL DAT1
II r o
PHOVj I CO OR'S NA E: .1 O:
SIC CONTROL#
4RCHITECf/ENGINEE ICNO: pD E ❑
2j- it 3twil -f 7 y
CONTACT: PHONEILDING PERMIT INFO
❑ Consultant Fear;Paid by Applicant(Initial) B ELECT PLUMB MUCH
❑ ❑ ❑
Lan that
LICENSED CON n licca ACnder pORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am fflic ed under provisions of Chapter 9(commencing I, JOB DESCRIPTION
hOm0 with Section]it if Diviainn3 ofthe Business and Professions Csde,enAm b ante ixRESIDENTIAL:
FOO infill foCrc�e en�dcffW� �F Y c PERMIT ISSUANCE
sYOwj
WE ❑ADWL ❑KITCHEPLUMBINREMODEL
aU License Lic.p
tFisQW Omc Contractor / I6 APPLIANCES RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
p.7m ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCfURAI.
PANELS
X.O 7�. [understand my plans shall M used es Public reamisMAD
IFICATION
j OZ� UPTO 200 AMPS ❑INTERIOR IMNEY REPAIR
I4•�F"W Littnud Professional 201.10DOAMPS IMPROVEMENT
OWNERmJ "aj dot
exempt ifi DECLARATION OVER ItNX)AMPS ❑BATH REMODEUREPAIR ODEMOUTON
0.' I hereby affirm Nm 1 am exempt tram the Commaor'e License Lew for the
U ❑OTHER
a O a following rtaun.(Section]031.3.Business and 14.fessinna Cssle:Any city or county SIGNS ELECTRICAL
WO F. which mqulres o permit ,,comminmL alter,hnprove,demolish,or repair any structure
print.its iesusnce,elso requires the applicant for such pernivo EleasignW statement SPECIAL CIRCUIT/MISE.
} that he is licensed pursuant to the provisions ofthe Contmcmre License Law(Chapmr9
(c.mmencingwiih Secoon 7IXXB.f Division 3nftheBmincssmad Professions Code)., TEMP.MHTHR OR POLE INST. COMMERCIAL6qi5 0lY than he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
W^w Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Zp, not more than five hundred dollars($500).
no] red , IMPROVEMENT SWIMMING POOL ELECTRIC
$y'
will Jofinximk,Coale steC encoiri License
ow does cut it,pec.to ad,Business El OTHER
a and Professions Cale:The Cothere's License Lew does not appl,to if owner of OUTLETS-SWITCIILS-FIXTURES
.. property whompl builds or improves t thereon,and who dies,such work himself or through
hie own employeese pro, that such mentis sold
ora not intended or pffercd for NEW RESIDENTIAL IiLLCfR SQ FT. 47
sale.if.however,the building or improvement is sold within oneyear ofcompletion,the 5 ORARFA VSQ.Ii
poser-builder will have the burden of proving that he did not build or improve for our.
of toren' s TOTAL: /
I,as owner of the nee.704 ant exclusively mneso ng with licensed mntmcmrs i- (Y��
otwe a the does
(Sec.o an Business and property
who
i builds
Code:)The Gatherers nd Q V 2 8199E 1
%hu roawdcesnotapplr roan with
awner ofpactods\sbensed srsuantoves thethereon,and TY. PLUMBING PERMIT FEE
who comrvcu f.rsuch pmjeca with ueumrvdnr(Olicenud pursuant Comrvetoh
License Law. - u PERMITISSUANCE
I am exempt under Sec. -,B&P C for Nis reaun w4l La si a'�(I
Owner DateALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Comped. DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for Nm
e performance of the
work for which this pant it is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compenami.n trainmen,as required by Section -
3700idhe b C fort performsceofthcworkforehich this permit is issued. GAS-EA.SYSTEM.I INC.a OUTLETS
}� OCC.GROUP APN
My Waders yylo mne ler and Pdiuy� GAS-FA.SYSTEM.OVER J(EA)
Garner. J LJ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASNINDUSTRI,WASTE INTERCEPTOR
(This mctimawcd not be completed if he Permit is bounce hundreddollars(3100) BUILDING DIVISION FELTS
or less.) GREASETRAP PLANCHECK FEE
I ecatify Nat in she performance ofthe work for which this Permit is issued.(shall ink
SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the W.rkmf Cnmoen- ENERGY FEE
,Z sation Laws of Calimmia.Date
O O Applicant WATER HENITR W/VENT/ELECrR GRADING FEE
tiNOTICE TO APPLICAN'T:If,after making this Certificate of Exemption,you should WATGR SYSTEM/TREATING
become subject to the Workers Compensation Provisions of the Labor Cale.you must SOILS FEE
Lia forthwith comply with such pevisiomem this permit shall Is,deemedmvoked. WATER SE RVICE
Q
] Z CONSTRUCTION LENDING AGENCY NEW RFSIDF.NTIALPLMB. SQ.FL PAID
U O it me which thi thatthemi issue Se,,.30 lending agency fnnhe performance of RaeiptM
Li. r the andarx a which this permit is issued(Sec.3(197,Civ.CJ TOTAL:
F" Lemee.Name
V Lenders Address TOTAL:
0. 1 certify fl m I have read Nis applicmion and smte Nat the above informution is BUILDING FEB
UJ correct.l agree to comply with all city and county ordinances and amm Iowa minting to QTY. MECHANICAL PERMIT FEE
U bsove-orsonedpmand for
uuttionprposesenmtives.(thiscity ns enter uMsn on, SEISMIC Ffifi
above-(We)..,me
far inspection keepses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenin.against ELECTRIC FEE
liuhilities,ju cros,costs and expenses whichnsay in any wayicerm against quid City pLTL•N OR AUD'TO MLCH.
in conuque of Ne gaming of Nis is;
PLUMBING FEE
APPLICA,sA UNDERSTIVDI AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0)0 CFM)
SOURCE <EGULATIO MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
rare of Appli anUComrazerarc EXHAUSTUOOD(W/DUCT)
HA7ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION E
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I Mood BTU)
as deposal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Ser tom 25532(x)7 HEATING UNIT(OVER 10X1,000 BTU)
Dyes No
' VENTILATION FAN(SINGLE RPSID) PAID
Will Ne applicant or future building occupomt use a imminent or devices which Doe Recei M
•emihazmles air conmminan¢as defined by the Ray Area Air Quality Management BOILER-COMP(3HP OR 100,00IIBTU)
Dtstnc@ TOTAL:
❑Yes E)No BOILER-COMP(DVCR I(X),OIXI BTU) fnin
I have rood the hom minas materiak requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Foods Health&Safety Code.Sections 25505,25533 and 255N.1 understand that if the NEW RESIDENTIAL MECH. SQ.Pr.
huilding does not currently have.term.that it is my responsibility he may the occupant
of Ne retluimmenis which trust he met prior it)Nat anee of a CertlGeam of Occupancy.
Owner nr anNnrized agent Dare TOTAL: I ISSUED BY: e
OFFICE