30533 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMB NO 30533
BUILDING PRO.INC'I'IDF.NTIFICA'TION -
BUILDINCADDRESS: SANI'I'ANYNO. APPLICA'I'IONSUBMI'ITALDATE
OWNER'SNAME: PNONE: C COWS CTO 'S NAME: LIC NO: N
CONTROL p
NIC CDHOL
ARCHITF.CTIIiNGINEER: I VLIC NO: ADDR SS: ❑
CONTACT: PHONE: - BUILDING PF,RMITINFO
v
�B' ❑ Consullanl Fees Paid by Applicant(Initial) B
5LLD0�DG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT Flili
1 bemby alRrm hoar I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QCZ with Secrinr7000)of Division 3 of the Business and Professions Code,and license is
WO, in y PERMIT ISSUANCE RESIDENTIAL:
1- fu11 fore and eIf _ r,/ ❑SFDWI. ❑KITCHEN RIiMGDPL
FQF..Uj License Clas+ Li0.M U(1^" APPLIANCES—RESIDENTIAL
sn66 Date cTsDECL A$IMLI ❑ADDRION ❑PLUMBING RE-PIPE
6,7m A CHITECTS DECLARATION PANELS ❑MULTFUNIT ❑STRUCTURAL
Z O > 1 understand my plans shall he used ns public records - MODIFICATION
O Z-Qq UPTO 21X1 AMPS
p iii 7 Licensed Professional ❑IMPROVERIOR CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-11X10 AMPS IMPROVEMENT
CCG I hereby affirm that 1 am exempt fee.the Cotr
nactor's License Law for the OVER 1(11)Ah1PS [3 BATH RLMODEIIREPAIR (]DEMOLITION
a
C <
41 LLU following reason.(Section 7031.5,Business and Profasiom Code:Any city or county SIGNS ELECIIII ❑OTHER
LLO which requires a permit to construct,alter,improve,demolish,or repair any swmme
prior to its ivsuunc,also acrylics floc upplicanr homely lxmaith,fleu.[ignNsmwoulan SPECIAL TIMISC.
�y that he is licensedpursoannntheprovisionsoftheContractor'sLicenseLuw(Chapter9
=00 (commencing with Section 7001 of Division 3 of the Business and Professi�nsCode)or, TEMP.MIffIi O POhE),NST, COMMERCIAL:
6 L y that he is exempt therefrom and the basis home alleged exemption.Any violai.n of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031,5 by any applicant for a pemduubjems the applicant oa civil penalty of POWER DIiVIC S
I+l^m ❑TENANT ❑FOODSERVICE
F. not mote than five hundred dollim(E500). IMPROVEMP
6 ❑ I,usownernfmopmpeny,mr nay employees with wages es their vole emtpensarion, SWIMMING POOL ELECTRIC IO A I-
O will do the work,and the structure L[not intended oroffcred for sale(Sec.7044,Business THER '-IO I. " t '^I•�d"
W m and Professions Code:The Convectors License Law does not apply to an owner of O TLETS—SWITCHES—FIXTURES P.a OaS�_.��np-{--'tnl a_ Ido
^ property who builds or improves therms,and who Joel sucM1 work M1imself or dvough
his awn employees.provided tbar such improvements am nor intended or ordered for W RESIDENTIAL ELECTR SQ I.T.
ale.If.however,the building or improvement is sold within one Ymtoferrmpiefonthe SQ.F:LFLQOPyxyy+ 51SQ.ET
ser-builder will have the burden of proving that he did not build or improve for pm. N 11 11J�
p se of aural. .
1,as owner ol'the property,um exclusively contracting with licensed contractors to - TOTAL
comuct the project(Sec.9044,nosiness and Professions Cods.9,te Comraeo8s 1,6 APR 18 KCI
use Law does not apply a an owner ofpropcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who eontmets for such pmicers with a commeer(q licensed pursuant m the Comments
License Law. PERMIT ISSUANCE
E]Iamexempt underSite. ,B&ItCf.rthis.,an Cf(Y Ur t,urEHf N
Owner Dae
ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑),have and will maineinaCmificute nfConsennoself-insure for Worker's Com,.- DRAINS—FLUOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. TEXTURES—PER TRA
F�t have and will maintain Walker's Q�mpensatinn Insurers,as required by Section
5701)afthe LuMu Code,fur the performance ofthe work for which this permit is issued. GAS—PA.SYSTE 11 OUTLETS OCCGROUP AI'N
many My Work j�Co tion lnmrynce cart rend Pull
Cartier `n'Z t.L ,Policy No.; GAS—EA.SYS - VER4Bi) -
CERTIFl AUO'COMPENSATION'FIIUN FROM INSURANCEORKER$' G'OP.NIS d GREASE/INDUS STE INTERCEPTOR
(This section need nor he cem,lemd iOhe permit is for, humlred dollvrs(%11101 BUILDING DIVISION FEES
or less) GRE45C'I'RAP PLANCHPCK FEE
Foy anytheinthe inmy manner
to become
whicht[.,he Wonviix- raper-is issued.I,hydI SEWER—SANITARY STORM EA.200 FT.
not employ any person is any manner ss as m become subjceuo the N'nrkcrs'Compen- ENERGY IEE
D2salon Laws of California.Date WATER HEATF: NENTRiLECfR
Applicant GRADING FEE
. rA NOTICE TO APPLICANTlIf,tdw,cakingthis Ccnifiateof Exemptiond no should WATER SYS :MRREATING
a ; become suhjeeno the Worker's Compensation provisions of the Labor Code,you nest SOILS 17213
forthwith comply with such provisions in this permit shall be deemedrevoked WATER SERVICE
0
CONSTRUCTION NEW RTSIDENTIALPLMB. SQ.FT PAID
UO
E hereby affirm that them ivaconstruction lending agency for perfatmanc<nf Dare Heceiptp
W. H the work for which his p arty,is issued(Sec.3097,Civ.C.)
O U Lender's Name TOTAL
Lender's Address TO'TA, ^
G1 codify that 1 have rend mis.,plication and stem aha the have information is BUILDING FEE 7 /
h correct.I agree ecomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z buildingcomucrion,and hertbyauthndmrepresentatives ofthistayvsenteruponthe SEISMIC FEE G
throve-mentioned property,for impmtion purynscs. a
PERMIT ISSUANCE.
(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
Iiabiliries,judgnnn¢,csts.ndexpenvev which may in any way accucagain[t said City ALTER ORADDTOMECIL PLUMBING pill
consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLINGUN GIG 10,000CF MECHANICAL FEE
SOURCE REGULATIONS.
AER HANDLING UN ER 10 CFM) CONSTRUCTIONTAX
Signature of Applianl/Commear Dae EXHAUST1001 W/D C'f) HOUSING MITIGATION FEB
HAZARDOUS MATENIAIS DISCLOSURE
[Willthe applicantorfnlre building occu,ant dome.,handle baaedous matenal HEATING 1 RHI,IX)n BTU)
Is defined by the Captains,Municipal Code.Chapter 9.12,and the Health and Sofcry
Code,Seen..25532(e)5 HEATING UNI OVER 100,0(X),BO)
❑Yes VENTILA'T10N F (SING, RESID) PAID
Date Receipt,
Will the uppllan[or luuuc huilJing occupant use equipment or Devices which BOILER—COMP DH RIFX)'(0)BTU)
,.• emit hazardous air coneminomv as defined by the Bay Area Air Quality Management TOTAL
Dostlf� Q
nctp
❑Yes XNn BOILER—COMP( ER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITI ER ISSUANCE DATE
funis Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the .NEW RESI UENTIAL MECH. SQ IT.
building does not currently have a tenant.that it is my responsibility to nmify the occupant
of the rm,uiremetswbich must he met 1,,lm issuance of a Cmricams,f Occu ey.
LA;
Ownerortuthonled Sem Date TOTAL ISSUED BY:
OFFICE