30317 APPLIQANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PRo]ECI'IDEN]'IFICATION
BUIIAINGADDR S: �I'[�gry / SANITARY NO. APPLICATION SUBMITTAL DATE
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CONTACT. PHONE: IBUILDING PERMIT INFO
❑ Consultant Fell Paid by Applicant(Initial) B4DG_ ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE Ir�JY, �je
1 hereby affirm that 1 am licensed under provisions of Claimer 9(commencing JOB DESCRIPTION
oaz with Section 700())dDivision 3 ofthe Businessand Professions Code,and my license is
OO 'n fall force and¢Ree'. PERMIT ISSUANCE
W i— i, - L O KITCHEN REMODEL.
�U'U��5 Lcense Class Contractor
APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
HE Date Contractor
HITECp$DECLARATION ❑M LTLUNIT ❑STRUCTURAL
F-Z y¢ PANELS
Z O w�q 1 understand y plans shall be usW ax public records MODIFICATION
Oz-, UPT02MAMP5 Ell IEl INTERIOR ❑CHIMNEY REPAIR
Hln�- Licensed Professional 201- IMPROVEMENT
OWNER-BUILDCR DECLARATION V II MPS ATH REMODEUREPAIR O DEMOLITION
I hereby affirm Nat I am exempt from the Contra cmr's License Law for it
O M U following reason.(Section 7031.5.Business and Professions C=4:Ah to y iL
Owhich requires a permit m c.nswch el¢r,immrovc,JemoliphrafFyylr a su re
prior to its issuance,also requires the applicant for such permit iTiEr.sig he nt CI C UIT C.
} that he is license)pursuam'o the provisions of Ne Contractor Law( - r9
O� (commencing wiN Section]00o)of Divisinn3 of the Business C' TEMP. TF, RPOL INST.
'PAf`t�' t m
d n y that he is exempt therefrom and the basis for Itie allege)cxctrfp ovin n r N :D(t/e�DDR'10 DEMOLITION
to
Section 7031.3 by any applicant loco permit subjensthe appEic mactvil pe rya POWER DEVICES �TF,(SrpNT f•J`O s� FOODSERVICE.
F.y�y
not more than five hundred dollars(5500). �Y IMPROVEMENT
�y 6 sownerof the property,or my employees with wages as the �mpemation, SWIMMING POOL ELECTRIC
i C a^it JO Ne work,unJ the stmnurt is iwtimeMed.r.Bertd(or rale u.]f/44,Business OTHER
C4 a d Professions Code:The Commctors License Law does not apply to an owner of OUTLETS-SW ITCHES-FIXTURES
property who builds or improves thereon,and who dues such work himself or through
his own employees,Provided Nm such improvement"are not intended or.Bcred for NEW RESEDENTIAL ELECTR SQ FT.
cele.IL however,the building or improvement is sold within one year of completion,the SO FT.FLOOR ARCA S/SQ.PT.
owner-builder will have the burden of proving Nat he did not build or improve for pur-
poseofsale.). ° 1 q�`A CO3
❑1,as owner.f the property,em exclusively convecting with licensed conwcmm m Q�k111
ennswm the project(Sec.]Ik4,owner
of and Professions ds or
The Convecmrs Li- �
nu owdoes nmapply t.as ownerofractorproperty who buildsor improves Concluand Q'IY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant the Comrecmra , Lon
iccnsc Law. PERMIT ISSUANCE
❑ 1 an exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER EA VAIAATION
wrer Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIC alo
thereby of mai under Penalty teperjuryoneof thefollowingor dorl,ce Co
r ve provide forbynection 37M of the LadlmCode,for
for Workersce mm em DRAINS-FLOOR.ROOF,ARCA,CUNU. STORIES TypECOySTRUCTION
I
u provided for by Section 3]00 of the labor Cade,for Ne performance Of to �G-/{—'�
work for which this permit is issued. FIXTURES-PER TRAP 1/
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00of Ne Labur Code,for Ne peifowanceofthe work for which Nispermit isissucd. GAS-FA.SYSTEM. INC.4 OUTLETS OCC.GROUP PN
My WoRers Compcnsatinn Insurance carrier end Policy number are: , 3 ��
Cartier: Policy No.: GAS-PA.SYSTEM-OVER 4(IIA)
XEff/`
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR D S]ON FEES
L OLis.seclion need not he completed iflhepermit is forone hundred dollars($100) GREASE TRAY
or less.) PLANCH b
(certify that in Ne performance. ¢work forwhich this permit is isauM.l shall SEWER-SANITARY-STORM PA.200 ET.
r notemployanyperamin unymanner swM1ecome subject N the Workera Compen- ENERGY 'E `
Z visionlaca.f C.1ifo. Date WATER HEATER WNEPT/ELECIR
O Applicant GRADING FEE
y NOTICE TO APPLICANT:If.alter making this Cedirtcate of Exemption,you should WATER SYSTEM/IREATING
abecome subject to the Workers Compensation provisions of the labor Code,you must SOILS FEE.
{kl forthwith comply with such provisions.,this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LF.NDENGAGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
Ihereby effrm',eohere ass wins ,30[ending agency for the performance of
Date ReceiptM
V the work for hill,Nis permit is tuned(Sec.309],Co.CJ
u'' I--� lenders Name TOTAL:
O V Landers Address L
a1 artily that I have read this implication and slate that the move information is BUILDINO FEE aia—a
N cori l agree to comply with all city and county oninerices and state laws minting to QTY, MECHANICAL PERMIT FEE
U z building conewetiogand,erebyamhodee rcpresmm'ises fdais city m anterupon'he SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree[native,indemnify and keep hmoti ss the City of Cupertino against ELECTRIC FEE
l liabilities,judgments,costs and expenses which may in arty way same against said City ALTER OR ADD TO MECH.
in wnscyvence of the granting of this permit. PLUMBING PEE
is
APPLICANT UNDERSTANDy7rjp WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IR"CFM)
SOURCE REGUL NS. MECHANICAL FEE
AIR HANDLING UNIT LOVER IO,q)O CFM) CONSTRUCTIONTAX
SignmurcofApplicaraWman for Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupant store or handle haurdous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)] 1 HEA1ING UNIT(OVER 100,000 BTU)
❑Yes _ o VENTILATION PAN(SINGLE.RE.SID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt p
molmsairconmminants definedby Ne Boy Areu Air Quality Management B0ILER-C0MP(3HP0RI00I1IDBTU) pr
in]
❑Yes No BOILER-COMP(OVER IIq,(NhIBTU)
Lhave most the Emotions materials rcquimments under Chapter 695 of the Cali. AIR CONDITIONER ISSDAN EDATE
forma Health&Safety Code,Secillass.2k505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have n at n is ability to notify the occupant
pf me unuirem hmus , f,�Bf^e Cerifica's,
` £ l—u---� z-P=cmavv
lot nQ
net s euNodttd agent Dam VT \ ISSUEDBY:
OFFICE -