30551 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT'IDENTIFICATION
551
URGING ADDRESS: - SANITARY NO. APPLI
'�-1 CATION SUBMITTAL DATE
` � q-LG-q 6
HER'S NAME: 110NIi: ONTRACTOR'ti NAMC LIC NO:
V ATI-1 !- U CL NIC CONTROL
/ R HITE ?:NOINEFj LIC NO:
I �� DRESS:
C L �r15
CONTACT, PHONE: _ BUILDING PERMIT INFO
..Q Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUMB MEC
LICENSED COM'RACfOR'S DECLARATION2 QTY ELECTRIC PERMIT FEE '
1 twerhy affirm nor am licensed underro
pvixions of Cham
pur 9(eamenem, JOB DESCRIPTION J
1yOysOU ZO with Sectior,7000)of Dlvi.ion3ofthe Businessand Professions Gde.and mylicameis RESIDENTIAL:
Ffull force and effect. PERMIT ISSUANCE
UWE License Class Lic,M ElSIDE �TCNEN REMODEL
Date _ Commemr APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECT"S DECLARATION PANELS
❑
MULTI-UNIT ❑STRUCTURAL
Z O ^'—Iv Aer plans shell M used as public words MODIFICATION
OZ C UPTO 200AMPS
H.f' Licen tl Pro c nal ❑INTERIOR ❑CHIMNEY REPAIR
9Y OWNER.BUILDER DECLARATION 2014000AMPS IMPROVEMENT
C 6 1 y. orm that lam exempt from the Committers License Law far the OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
aO y U following reason.(Section 7031.5,Business and Professions Calc:Any city or county 'DOTHER
V. which as u t m consuuc6 alter,improve.demolish,or re SIGNS[LIiCfRICAI.
F Lx1O reyui-issuance,also
p pair ed structure
N priorloslensealsant trequires the applicant for such Contrator Licensle ae aw(Chtanem SPECIAL CIRCUIT/MISC. Lk
;!(<0 That m ncinnwdpumaam to the of Division 3 the Contractors License Law(Chapmr9
Iy a�00 (commencing with 5cetion]pllp)of Divisinn3of Ne Business and Professions Code)nr TEMP.METER OR POLE INST. COMMERCIAL:
1c that he is emry therefmm and the basis far the alleged exemption.Any sirloin.of Oy y� Section 7031.56 an ME)NEW BLDG/ADDRION ❑DEMOLITION
xe
H applicant far a permit subjects the applicant m a civil penally of POWER DEVICES
I„ oat more than
Eve hund dollars(SSW). ❑TENANT ❑FOOD SERVICE
C� ❑Lasowner of the'die,a'.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
tC` will do the work,and the structure is not intended mattered for vide(Sec.7044,Business ❑OTHER
6 a$ and Pmfessiens Code:The Contractor's License Law docs net apply to an ow'ncr of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided thin such improvements art not intended or offered for NEW RESIDENTIAL ELEM SQ FT.
sale.If.however,the building or improvement is said within one yearofcomplation,the Q, OORAREA Vsks.FT.
ewner-builder will have the burden ofproving that he did nal build or improve for par-
, peat of sale.), -
❑ 6 as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.704l,Business and Professions Godes Tho Contracmr's Li. �T�
c se Law does nm su
apply toownerofpropertywhobuildsorImprovesthereon,and QTY, PLUMBING PERMIT FEE SIE? 619 v
who contmets far such projects with a c mmicionn)licensed pmrmam m the Contmemr's
License Law. 1 PERMIT ISSUANCE
Iameaemgwdersee. ,Il&PCfarthisreason ` .•-
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam " VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE •
1 h«ehy eflirnt under penalty of perjury one of the following declarations: I I k-KiteJ
❑I have and will maintain a Certificate of Consent to self-houre for Worker's Compete DRAINS-FLOOR,RIDGE,AREA.COND. O /TYPE CONSTRUCf10N
smion,as provided for by Section.3710 of the Labor Code,for the perfomunre of Ne STIFS
work far which this permit is issued, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation insurance,as required by Section
37M ofthe later Code.for the performantt ofthe work for which this pertNt is aimed. GAS-EA.SYSTEM-I INC.4 OUTLETS 'OCC.GROUP APN
My Wy[}C[S�Jppg¢au n articr and Policy arr�koobbgp
CamierZ�.}�1�L_ Policy No.:LLt 4 n'�'is GAS-FA.SYSTEM-OVER 4(HA)
CERTIFICAT OP EXL'MITION PROM WORKERS'
COMPENSATION INSURANCE GREASHBNDUSTRL WASTE.INTERCEPTOR BUILDING DIVISION PEES
(This section nerd nm be completed if the permit is for..hundred dollars(S[Bit) GREASE TRAP
or IessJ PLANCHECK FEE
Icenily that in the performance of Ne Face for which this permh is issued,glstill SEWER-SANITARY-STORM FA.2W PC
y not employ any person is any nuvmer so as m become subject to the Worker'Cnmpcn- ENERGY FEE
eahm
Applicant
rIf Callfomla.Ddlt
O C Applicant - WATER HEATER WNENT/ELECfR . GRADING FEE
NOTICE TOAPPLICANT:If,rs a0«making This Certificate ofof l Labor ion,youshould
become mhj«t m the Workers Compensation provisions of Nc LaMsr Code,you mull WATER SYSTP,M/1'REATING SOILS HE
Wforthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
a �
U'z CONSTRUCTION itleLENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
L)Q Thereby affirm that there isacnnstmcrion lending agency for the performance of Oam ar t
"s f" the work for which this permit is issued(Sec.3097,Civ.CJ
WI.e.deea Name TOTAL:
Lenders Address - TOTAL: '
Iy I certify th l 1 have read this application and Slate that the have infmmmion is BUILDING `
In correct.I agree to comply with 01 city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT
Vz building construction.and hereby amrmice representatives ofNis city to enter Upon the FEE SEISMICFEE
,have-mentimied property far inspection impasses.
(We)agree rr save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilitieajudgmcros,casts and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.
in convection.of the totaling of'his pc,rml. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,gp CFM)
SOURCE REGUI 10 MECHANICALLE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA J
Si n emir Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FE
A9RfMU1S MATERIALS DISCLOSURE
Willi cant or future building occupant store or handle hmurdous material HEATING UNIT CTO IWA00 BTU)
ns defmnd by the Citation Municipal Cale,Chapter 9.12,and the Health and S:dcly
Code,Section 25532(1)7 HEATING UNIT(OVER 1 WN
❑Yea ❑No
VENTILATION FAN(SINGLate Receipt MWII the applaud or future building occupant use equipment or devices which BOILER-COMP(3HP OR 1.mil hazlNom air coruamin xa s a9 defined by the Bay Area Air Quality Management TOTAL:
Dronct+ BOILER-COMP(OVER Ift❑Yea ❑NoI have read the haratdous materials requirements under Chapter 6.95 of the Cali. AIRCONDII'IONMISSUANCE DATE
funds Health&Safely Code,Sections 255115,25511 said 85341 underta d that if the NEW RESIDENTIAL MECHbuilding does not currently have a tenant,that it is my responsibility to wtify Ne occupant
of Ne repurchase;which must be met prior m issuance of a Certificate of Occupancy.
Owner or authorized agent Dare D BY:
OFFICE