30565 J
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL - PERMIT NO,
BUILDING DIVISION APPLICATIONQ'ERMITPLUMBING-MECHANICAL. 30565
TI
BUILDING PROJECT IDRNFICAI HIS
BUILDING ADDRESS: ii7p SANITARY NO. APPLICATION SUBMITTAL DATE
C � • a — 9-4t
OWNF$'�N E: 0 Pl`HONL: / CONTRACTOR'S ME: LIC NO:
Gif D / NIC CONTROhp
4RCH1'rECr/E GINGER: LIC NO: A EgS: - ❑ ��
CONTACT. PHONE: Ol �C res CQ •� BUILDING PERMIT INFO
�7 / ❑ Consultant Fee 9Paid b Applicant(Initial) BLDG ELECT PLUMB MECII
L ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby offrtn that l am licensed under previsions of Chapter 9(commencing JOB D SCRIPTION
X0qoZ verb Section7000),41b,dlen 3ofthe Bnsince,and Profession,Code,today Iieensetp RESIDENTIAL
0 in full force and eflec PERSO r ISSUANCE
aF.UU ).allose Classas
Liaa eT by ❑SFDWL ❑KITCHEN REMODELNQL Dale�/.�.—n—.—Cammnnr API'I.IANCGS—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
E.Dm 'r /� �(pARCUrrFUTS DECLARATION PANHIti ❑MULTI-UNIT [I STRUCTURAL
Z O r'Z 1 understand my plane slmll be used as public records MODIFICATION
O Z.--� UPT0200 nM1'.S ❑INTERIOR El CHIMNEY REPAIR
C=iN�„d1'p201-1000AMPS IMPROVEMENT
"4l Licensed Professional
W p )hereby affirm that 1 am exempt from the Comractnes License Law for the OVER 1000AMPS ❑BATH REMODEVREPAIR ZI DEMOLITION
$d06 U following reason.(Section 7031.5,Business and Professions Code:Any lily or county SIGNS ELECTRICAL ❑OTHER
BJ a W 1" which require.,a permit a IXmstract alley,improve,demolish,or repair any structure
E. prior to its issuance,also requires the applicant for such Permit it)file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the previsions of the Commerce.,License Law(Chapter 9 '
iwy.P1000 (commenuingwith Section 700fitof Division 3 oftbe Businessand Pafetoomi Code)or TEMR METER OR POLE INST. COMMERCIAL:
y o C
that he is exempt therefrom and he buxix for the ulleyed exeadioa Any violation of0 2CetstBLDG/ADDITION ❑D2MOhITION
uXl"t so
Section 7031.5 by any applicant fora permit omjectsthcnpplicama enalty a civil pof POWER DEVICES
[[[[[[......z} not more than five hundred dollars($500). 1 - Tli ANT ❑FOOD SERVICE
p6 0 Las owner or the property.or my eaployees with wages as Their scle compensation, SWIMMING POOLELECTRIC iMENT
t�C will do the work,and(lie structure is not intended uroffered ror sale(See.7194,Business T
and Professions Code:The Commences License Use does not apply to an owner of OUT LETS—S WITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such iniprovemmits are nor intended(ir offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.if however,the building or improvement is said within one yearofeompletint,rhe SQ. hOOR AREA $ISQ.IT.
moner-builder will have the burden of proving that he did not build or improve for pur-
pow,ofsale),
I,as owner of the pmpeny,me exclusively contracting with licensed...tasters to TOTAL:
construct the project(Sec.](44,Business and Professions Case:)The Commences Li-
ashore Law does not apply to an owner of pmpeny who build or lmpmves thereon.and QTY. PLUMBING PERMIT FEE
who counters for such projects with o commemoo licensed pursuant to Contractors
Larne Law. PERMIT ISSUANCE -
❑Iamexempt under See ,B&P C for this reason
OwnerUate VALUATION
ALTI7R—DRAIN&VENT—WATER(EA)' � '
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pctjury one mf the following drelamtionn:
Ihave and will nwimain uCenifcute ofConmm ns self-insure for Worker's Gsmpcn- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smi.n,as provided for by Section 37(10 of The Labor Code,for the perente nce of the
work for which Nis permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Workers Compensation Insurcer,as required by Section
1700 of the Labor Gelc,Ter the perfomnmca of the work for which thizpermitNia,tcd. GAS—EA.Sys'rt?M-1 INC.4 OUTLETS OCC GROUP APN
My Workers Coapenmlio n•ronce came,and Policy n s
Carrier: /�"Y1Palicy Nn.: GAS—GA.SYSTEM-OVIiR4(EA)
:I fl irmi7 OF[+XE! ION I ROM W R :ITS, GREASrJINDUSTRL WASTE.INTERCF,PTOR
COMPENSA9'ION INSURANCH
(This section need net be completed ifthe pennir is formal hundred dollars($100 BUILDING DIVISION PELTS
or less.) GREASETRAP PLANCHF.CK FEE
I certify that In the performance orme workfor which this permit is issued,l shall SEWER—SANITARY—S'i'ORM IA.200 FT.
,. not employ any person in any manner m u.tojyccm?cy�'IeclTy rhe orkers Compcn- WATER HEATER WNEN'R?LECfR F'VERGYFEE
Applicant
nt of Co' r ia.�a�b I Q�1 B _�� GRADING FEL?
O NOTicant����.. f.h�,FW.�Z.i�TT,,yirK(-1 cam nl P.xe�ir mptinn,ynu>Irnn Ed y NOTICE T'O t,.the Worker's
Compress WAJ'I?R SYST'1?MfIREAI')NG
f~ become subject m the Worker's Compensation previsions of the labor Coda,you must SOILS FEE '
tifahwithcomply withsuch provisions.,this .it short b,deetnedrevoked. WATER SERVICE
Q
CONS].is.combustion
LENDINOAGf arry NEW RESIDENTIAL PLMB. SQ.IT. PAID
I bercbymf nn that the.isamnsuucti097.Cis,agency for the perfomunce of Darn Receiptp
F•s the workLend,,,borne
which this permit i.,issued(Sec.3f1Y],Civ.C.)
^ Q Lender's Naar TOTAL'
{U✓:1 Lender's s TOTAL:
Sandy
0. 1 certify that 1 have rwd this epplicaion and qme that the aMvc information is BUILDING 17EE
GOcorrect.lager o comply with all city and county ordinances and sate laws relating to Q'I'Y. MECHANICAL PERMIT FEE
U 7- building construction,and hereby authorial representatives of This city to enter upon the SEISMIC FEE
uMme-menrional progeny for inspection purposes.
(War agree to save,indemnify and kap harmless the City of Cupertino against PERMIT ISSUANCE I.I:CMIC FEF,
liabilities,judgments,costs and expenses which may in any way uccruengaiest said City ALTER OR ADD TOMECII.
Inconsequence of the gaming of chis pennh. PLUMBING FEL?
APP ANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0(1)CFM)
SO C EGULATIONS, MECHANICAL FEE
AIR I IANDLING UNIT(OVER IQfXXI CPM)
� C CONSTRUCTION TAX
nates (App icanV on tune ate EXHAUST HOLD OVMUCO HOUSING MITIGATION FEE
il!aI IAZARDOUS MATE RIALS DISCLOSURE
Will Ne applicant or future building occupant some,handle hazuNdusnmtonid HEATING ON IT TO 100,000 DID)as defined by the Cupertino Municipal Code,Chapter 9.12,and the Berlin and Safety
Code,Sermon 25532(n)? HEATING UNIT(OVER 100,000 BTU)
❑Yes �^ VENTILATION I-AN(SINGLE RES)Of PAID
Dote Receipt p
Will the sit crams or futuremal.building occupant use equipment or devices which BOILER—COMP(3HP OR I(]O,bD RTU)
i alar hazaNws air conmminams as defeat by th.Bay Area Air Quality Mumtgemaot TOTAL:
niLbuilding
d ^ �''
Yes -Urvo BGR.ER—COMr(GVER IBo,am BTU)
ve read the hazardous malreals regoirenmms under Chapter fi 95 of the Cali- AIR CONDITIONER IS ANC E
th&Safety Code,Serious 255(5,25533 and 25534.).Mad .d Nat if Ne
NEW RESIDENTIAL MF.CH. - $Q.Fr. ..✓1(
cs not currently have t tenant 1 tirisnsyrespomibilitytonaifyNeoccup t
re hichmust met m monarenceefeCamiti...rofOccupancy:
u e t Dm TOTAL: ISSUEDBY:
OFFICE'