30851 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERNIT PLUMBING-MECHANICAL �,O8�11
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMI'1'AL DATE
es
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: IAC NO:
C (Nr `—���t NIC CONTROL#
1RCHITELT/ENGINEER: /-` LIC NO: ADDRESS: ❑ V��
'v L/ lVF
orrrACL .
PHONE: BUILDING PERMIT INFO
,-,^ �-y M', 1�� x ��n, ❑ Consultant Fees Paid by Applicant(Initial) BLDG- ELECT PLUMB MF.
��}�' LICENSED CONTRACTOR'S DECLARATION . QTY. ELECTRIC PERMIT FEE
tT m
I hereby ato al I am licensed order provisions of Chapter 9(commencing JOB SCRIPTION
E�Gc4Z with Section 7000pdInfslon 3 of the Bmfnesxand Prokssines Code,and mylfecnsc is "- RESIDENTIAL:
00 i PERMIT ISSUANCE
W r License
Class 1 effect. ❑SFDWL ❑KITCHEN REMODEL.
bspypp License Class " Curnm APPLIANCES-,RESIDENTIAL El ADDITION Ll PLUMBING RE-PIPE
y d W1 Da¢ TS DELL
;
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
ZING I uncensored my plansshell be usedrspublic records PANELS MODIFICATION
O Z'4's p UP TO 200 AMPS-
E.4 F'MLicensed Professlonel El INTERIOR El CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
1' ¢
Thereby affirm that 1 am exempt from the Contractor's License Law for the - OVER I"AMPS - ❑BATH REMODEUREPMR ❑DEMOLITION
O T1 U following reason.(Section 703L5,Business and Professions Code:Any city Or county SIGNS ELECTRICAL " ❑OTHER
whl h s Perm,, coast t atm improve,dernelodo or repairryshucture - '
Ig-;yy
prior in its issuance,slai requiresthe applicant for suchpicanott rile a signedstatement SPECIALCIRCUIT/MISC.
bathe isl a sed Polaroid to the provisions fthe Contractor's License La (Chapter9
WCWO
(commercial,with Section 7000)ofDivisi 3 oft Business andProfessions Code)or TEMP.METER OR POLE INST, COMMERCIAL:
1 Ise o oC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW,BLDG/ADDITION ❑DEMOLITION
IQ 0. Section]WLS by any applicant for a perm it subjects the applicant ton civil penalty or POWER DEVICES
W^'m : NANT ❑FOODSERVICE
aOnot more then lift h ndowd11-1 dollars y employees
Eli,as owner aloha property,or my empinyeexwimwages asTheirsoleemmpenswimn,• 'SWIMMING POOL ELECTRIC IMPROVEMENT
1st will Jo Be work,and the stimemre u not intended conflicted for sale(See,7194,Business ❑OTHER
ad C m and Professions Code:The Contructer's License Law does not apply m as owner of OUTITFS-SWITCHES-FIXTURES -
1666 property who builds or improves thereon,e`nd who does such work himself or through
his own employees,abv imcdfdtat such improvements are not Intended or.Rend far NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year ofcomplerion,the _ - SQ,FT.FLOOR AREA $/SQ,Fr.
comeer-lailderwill have the burden of proving that M1e did not build or improve for Par-
Pose of sale.). fl T
❑1,as owner of the pmperty,am exclusively contracting with licensed contractors to
consumer The project(Seo.7044,Business and Professions Code:)'I'he Contractors Li- t r
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLU BINOIPERMTt tII, FEE s
who contracts for such projects with n eoemetor(s)licensed pursuant to the Comrecours �f
License Law. PERMIT'ISSUANtl _` -7
L]1 am exempt underSea. ,B&P C for this reason
Owner Data
ALI'HR-GRAIN&VE -W RBA) ' - VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.D F.
Thereby al artionderpanaltynfrfCauene ofthe following WmkcasCm
]Ihuve ane will for
ire Corti fate of the LalrCode,for the Woormace at the DRAINS-PLOOR,kOOP,AREA,CO / STORIhSs�,'J U' TYPECONSTRUCIHON
anon,as which
thi Por mi Ss issu 3]00 of the Labor Cale,for the performance of the y
work have and
this maintain
tonissued n PIXq'USES-PER TRAP s � ��� NOV 1 have end will Came.
Worker's Compensation Insurance,h required by Section '` 71
My m ImD;CorCnsationthepnince career and Policy
l number This permit is issued GAS-EA.SYSTEM-I INC.40UTLETS r
My Workers Compensation lnsumnce carrier and Policy nmmbeCerc: O(5 ri\\ki\r�.AFN
Carrier: Policy Nm.; GAS-EA.SYSTEM-OVER 4(EA) VV 1.
CERTIFICATE OF EXEMPTION FROM WORKERSGREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE �tjlrlGI�ING OD'd{ION FELS
(This section need not be completed if Ne permit is for one hundred dollars(SIdB)
mrless.) GREASE TRAP
PLAN'('H��KTEE�GU
I certify that in the D,Hermance of the work for which Ods permit is issued,I shall
SEWER-SANITARY-STORM EA.200 Fp.
antendry any personinanyinamersme6mbect:mesubject m,he Workers'Compen- ENRROYFEE
�Z smfon Laws of California.Dam WATER HEATER WIVENTELECUR
z 12 Applicant - GRADING FEE
(..T NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
1-' ? hemmer aideat m the Worker's Compensation prnvi,i.ns of the Labor Code,you most SOILS FEE
4aS1 fmrthath comply with such provisions or this permit shall he deemed revoked. WATER SERVICE -
Uz CONSTRUCf10NLENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
Ihereby whichaffirm thatthem fssued( ec.i0lending agency for the performanceof Dam Rweip,W
U � The work(or which this permit is issued(Sec.309],Cie CJ I
c) Ll Lender's Name TOTAL:
{1a Landers Address TOTAL:
1 certify that 1 hove read this application and state that the above information is BUILDING PEE.
Z) correct.1 agree to comply with all city and county ordinance,rad state laws relating to QTY. MECHANICAL PERMIT FEE
U , building conswetlon,and M1ereby amhmrize reprcsemo,ives ol'this city to enterup�n the SEISMIC FEE
above-mentioned property far inspection purpwc. PERMIT ISSUANCE '
(We)agree to coELECTRIC PEBve,Indemnify and keep dandles,the City of Cupertino against -
Iiabillties,judgments,costs and expenses which may in any way accrue against said City ALTER 0RADDTO MECH.
in mnaeq speco of the granting of this PLUMBING PEE
APPLICANT UNDERSTAND D WIT L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEF. '
SOURCE REGllLAT10 S. O _
AIR HANDLING UNIT(OVER If1,00)CFM) CONSTRUCTION TAX
TguatnreOfA icen/Commcmr Oatc EXHAUST HOOD(W/DUCT) - -
HAZARDOUS MATERIAISDISCLOSURE
> HOUSING MITIGATION FEB.
Will the applicant r fitmre building occupant store orhandle haeaMous rational HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)'1 11EATING UNIT(OVER 100,00)BTU)'
[3 y" ❑No
VENTILATION PAN(SINGLE REBID) PALO
Date Receipt#
Will thedmu,air oiauntorfuturc building cuempby tiro IT use Am.Air roaral or
Manas which
gement BOILER-COME TRIP OR IW,IXq BTU) '
Or
ist District)
s fir cumaminants as dcfin�by tire Bay Arca Air Quality Management TOTAL:
ismicf! BOILER-COMP(OVER 100,000 BTU)
Fl ❑No
t
' Iheve real the hazallous materiels reyuirementx under Chapter 6.95 of Ore CWAIR CONDITIONERT- ISSUANCE DATE
t forme Hwlm&SrGay Code,Sections 25505.25533 and 25534.1 uodusmnd,hot If the NEW RESIDENTIAL NIECE. SQ.FT s
I building does no,currently have a tenant,that is my responsibility to notify the occupant
of the requirements which must he mea poor to issvnnce ora Certificate of Occupancy.
III Owner or authodead agent Dates, TOTAL: - ISSUED BY.
" OFFICE