30440APPUCANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
'CITY
OF CUPERTINO- BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING- MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO
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3O4'Y'O
BUILDING ADDRESS:
Cu r-6n0 C.rv%,. 9so64
SANITARY NO.
APLICATIO
PN SUBMI'TI'AI. DAT[
ER'S NAM PHO L:
321,211
C RA R'S NAME:
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CONTACT. PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
i heresy atfimn mallmn hewed rinser provision, .t Chapmry (wmmwdns
thilection IIXID)ofDrvi 'nn 3o far Bus...an it ufasitu C,xle.andmylicenw is
wt 9� �}
n full furs and eff L (
Llcws as Lic. X
Dam � Contmcu,
ARCO[ 'TECI'S DECLARATION
1 understand my plans shall be used as public records
Qry ELECTRIC PERMIT FEC
- JOB DESCRIPTION
0SFDW RESIDENTIAL
❑ SFDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RIiPIPE
❑MULTI-UNIT' ❑STRUCTURAL.
MODIFICATION
❑ INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODFLi REPAIR ❑ DEMOLITION
❑ OTHER
.�
PERMIT ISSUANCE;
APPLIANCES— RESIIIF:NTIAL
PANELS
UPTO 200 AMPS
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I um exempt from me Contractor's License Law rnr the
following recto. (Section 7n3 1.5, Busince, and Profession, C,xle: Any city or county
which reclaims a permit m coarct. site,, Improve, dru n ,tc or repair any sbuctar
prior.its i..... re,alsorequires meappli,se, for such pe. am file. signed imminent
that he is licenmedmromentotheprovisions odds, Commences License ls.(Chap¢r9
(commencing with Section 7000) of Division J of the Business and Protections Cade) or
mat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit suhjedx the applicant to a civil penalty of
not more man five hundred dollars fSSW).
1, ria owner of the ro en,orm employ., with we their vine compensation.
❑ tP P y Yedfas pc
Business
illdothework, andme he Comrcum's mndusnrawdoes rot apply
and ery, who b Code: The Contractors License Law does not apply da an owner of
property, who builds or aided is thereon, and wm. does such work himself or through
his own employees, provided orsuch improvements an on intended or offered for
harimprovementilist he id noneild or i' provetiogthe
sale.if,howev will have
ownerhoilder will have the huMen of proving thm he did not hail] or improve for par,
pose.(m1eJ.
❑1,asowner ofrhepro. 70,1, Bexclusively correcting with) licensednoCcnnactors t.
, Li-
construct La the project (Sea o an Business and ay who Professions d sN,:) The C. flare
ttns<Isw docs not apply mon owner of pmpcny who builds nr'nnprovea thereon, and
who,muruna l'nr such mojacte Itis aconvadorlv)li[wsed purnv!un mllm, C.tvroelnrs
License lsw.
1amexemptunder Sec. ,B&PCmar doinessnn
201-1000AMPS
OV17R 1000AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT'/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT El FOOD SERVICE
'IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIXTUR[S
NEW RESIDENTIAL IiLLCTR FT.
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SQ. FI'. I0101(,A�l�
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CITY OF Wl"tHrINU
S/SQ PU
QTy, PLUMBING PERMFT PE
PERMIT ISSUANCE
ATTER — DRAINA, VENT—WATER HAI
Owner Dom
WORKER'S COMPENSATION DECLARATION
I herchy affirm under lsenalty of periary one of the following themselves
(have and will maintains Cenificam of Cnnscnnoself-inwureliu Worker's Ciatpen-
. tion. as provided for by Section 37M of the Labor Code, for the performance of the
work for which this permit is ivued.
�%! 1 have and will maintain Workers Compemmion Insurance, as rtquired by Section
4 of the Labor Code, for performance of the work for which this pemnit is issued.
My Wn 'r G n Nvariant hmstva carrier and Poli er c
Cartier: _Policy N�
OkK12RS'
CERTIFICATE( COMPENSATION
COMP mplete ON INSURANCE
INSURANCE
(This section nwd not be completed if the permit is futon, hundrtddollars (511X))
or less)
Icenil'y that in the performance of the work for which mLctis iswed,IxhuO
not employ any person In any manner so as m um
income subject e Workers' Comeo- p
smarm Laws of California. Dam
Applicant
VALUATION. ,
BACK FLOW PROTECT, DEVICE
DRAINS— FLOOR, ROOF, AREA, CONDI.
STORIES
'
TYPECONSTRUCTION
FIXTURES — PER TRAP.
GAS —EA.SYSTEM-I INC. 4 OUTLETS
OCC. GROUP
'
APN
GAS— F.A.SYSTEM-OVER 4(EA)
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IDES
GREASE TRAP
DLANCHECK PC[',permi
SEWER— SANITARY —STORM EA. .
- 200 FT
P.Nf?ROY FEE
WATER HLATER W/VIiNT/ELF.CTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Excnption, you should
become subject to the Worker's Compensation provisions of the Isdn Cade, you must
forthwith comply with such provisions or oris permit shall be deemed revoked
CONST RUCTION LENDING AGENCY
I hereby affirm that mem is. construction lending agency forme performance of
the work far which this permit is issued (Sec. 3097, Civ. C.)
lender's Name
WATER SYSTEMRREATING
SOILS FEE
WATER SERVICE
PAID
Dade Receipt
NEW RESIDENTIAL PLMB. SQ. FL
TOTAL:
Lender's Address
1 certify that 1 have rend this application and state that fashion Information is
correct. l agrace m comply with all city and county ominancesual,creeteasrelmieem
building construction, and hereby warn, represenmivcs .finis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitieajudgmcnts, casts snit expenses which may in any way account against said CitygL'fF.R
in consequence of the grsming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
TOTAL:
BUILDING FEE.
QTY. MECHANICAL PERMIT' FEE
SEISMIC FEF.
'ELECTRIC FEE
PERMIT ISSUANCE
OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT ('TO 10,000 CFM)
MECHANICAL THE
AIR HANDLING UNIT (OVER In" CIM)
CONSTRUCTION TAX
Signature of ApplicaMComractor Dam
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous martial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532mu?
❑Yes ❑No
Will the s licam or farm, building
pp g by tiro Bu AreaAir untdManawhich
I mamNnun air condvminnna as defined by the Nay Arca Air Quality Management
vitt]
❑Yes ON.
1 have mad the tremendous materials rc.25533 sunder Che Cali-
furls Heuhh & Safery Cade, Sections 25505, 255]3 and 25534. I understand that film
huilding Arws nm cuohmly,hnvc n mnanm, dhat'n iv my responsiM1ill/v m natirdthewcupum
nftherc m4f'i •mm�ct whirdnmsehuanet ori6ubissuance nfwrCe ficmP or
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION ME
THEATING UNITO`O 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt X
VENTILATION FANS INGLE RES ID)
notLER— COMP Olt 1W,WO BTU] )
TOTAL:
BOILER —COMP (OVER 1 W,000, BTU)
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL. MECH. - SQ. FT.
OFFICE