30301 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL . PERMITNO.,
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. 30301
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO: APPLICATION SUIIMI'IIAL DATE
SaJ-7 Izz, � ZSR
D NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
-082 �xf+a�manr� 9529-
NIC CONTROL#
ARCHITECT/F. LIC NO: ql/:4� ���l o R s ❑
CONTACT: PHONE: BUILDING PERMIT INFO
s ❑ Consultant Fees Pald by Applicant(Initial) BLDG' ELECT PLUMB MI:CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
1 hereby affirm that I nm Ii,aa,esl ower mciimoa,of Chapter 9 f care irm, JOB DESCRIPTION
LV
WOO with Seeftim7100prf Division 3ofthe Ba,mIllinl Pmfewians Codgand my Interseis RFBIO_FNTI_AI•
1- O� in Poll force and PERMITISSUANCE RESIDENTIAL
W oo License 'c.p "36 ❑SFDWI. ❑KITCHEN REMODEL
.F a[' Dole ontraaor APPLIANCPS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N 7 on ARCHITECTS DECLARATIONPANELS ElMULTI-UNIT ❑STRUCTURAL
ZO Z v3 1 understand my plans shall be used as public scans,$ MODIFICATION '
:1 UPT0200AMPS
1,4—W Licensed Professional
[I INTERIOR CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IOIX)AMPS IMPROVEMENT
W=4 1 hereby affirm Nm I am exempt from the Contractors License Law for the OVER lll(I(IAMPS ❑BATH REMELF EPA1R 11DEMOLITION
E O6 F following reason.(Section 7031.5,Business and I'mkanons Code:Any city or county SIGNS ELECTRICAL ❑OTHER Tyoln�103�
V] O which requires a permit to conswct,alter,improve,demolish,or repair any stmw
cre
prior it) Issn:utac,also requires N.apPlieuin far such perming Blcnsigned saament SPECIAL CIRCUIT/MISC.
vW�y that he is licensed pursuantto the provi.inn.ofthe Contractor's License Law(Chapter9
IyCOO (commencing%mb Section 7ME of Division 3 afthe Business and Prefiessions Code)or TEMP.MET ER OR POLEINST, COMMERCIAL: T�
d o n that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4•
Section 7031.5 by tiny applicant for a pcmtit subjects the applicant)a civil Penalty of POWER DEVICES
>on not more than five hundred ddlars($50% TENANT ❑FOOD SERVICE
a07 L as owner of the property,onny employees with wages as their sole compensation, SWIMM ING POOL ELECTS IC IMPROVEMENT
will da the work,and the$trocar.knot intend,,gr of fared for sale(See 9194,Business ❑OTHER
and Professions Code:The Contractors License Law Nies not apply to sea owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEcTR SQ FI'.
sale.If,however the baildingor impmvemet,iseold withinoneyeo.fcoardidian,the SQ.F..MOOR AREA $/SQ.FI'.
ger-builder will have the burden of proving that he did not build fir improve for par- A
poseof,ae.). P A
Fl 1,as owner of the property,am exclusively convecting with licensed contractors o TOTAL:
construct Ilse project(Sea.7044,Business and Profn,ian,Caft,Ilte Conwcmrs Li- �p�1
cense law docs not apply to an owner of property who builds or improves thereon,and Ql'Y. PLUMBING PERMIT FEE AR ,2s
who contracts forsuch#rajah with a conrtworfs)licensed pursuant mthe Convacmr's ctt�y L M/w/
License Law. PERMIT ISSUANCE
/'
❑ 1 am exempt ower Sec. ,B&P C for this reason sy/- Liu
Owner
ALTER-DRAIN&VENT-WATER(EA) LIDN
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Ihereby affirm under Penally of Penury one of the following declarations:
❑I have and will maintain a Certificate of Consent In self-insure for Workers Compcn- DRAINS-FLOOR.RIDGE AREA.COND. STORIES ,TYPE CONSTRUCTIONsation,as provided for by Section 3]110 of the Timor Code,for the performance of the
I k for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section '
3 UO of the Labor Code,for the performance ofihe work for which Ni+permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worky.'s CoI ff tom umnce J Policy nu Ibar, OCC.GROUP AIN
Carrier. C�OCIe F32Q Policy Na.:�kl/n //02L�0 GAS-EA.SYSTEM-OVER 4I EA)
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE- GREASEANDUSTRL WASTE INTERCEPTOR
(Thissection needtint wv....in adarn ifthepit is forone huwrcddollars SIDE) BUILDING DIVISION FEES
or less) GREASE TkAF 'PLANCHECK FEE
I verify that in the performance ofthe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM CA,301 FT.
not emson ploy any perin any manner m as m became subject m the Workcn%Compca- ENERGY ITE
Zsation Laws of California.Dam
'O WATER HEATER WNENTB?LECIR
Applicant - GRADING FEE
h NOTICE I'O APPLICANT If,afar making this Cenifcfte of Exemption,you should WATER SYSTEMCTREATING
ahecome subject to the Workers Compensation provisions of the Labor Cnde,you marl SOILS FEE
liJ fonhwithcnmply with such provisions or Nis permit shut]be deemedue,oked. WATER SERVICE
U0 CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLM 13. SQ.FT PAID
U l for by which dntbmtherc issued(ruet30G,lending
s.agency for performance of Data Rtteiptp
w �
'he work sienna eM1 Wspern,t is issued(Sea J09],Civ.C.)
Q U lander',Num. '10'1'AL:
Isnder's nA,ress I OTAL:
0. 1 certify Ilett 1 invented this application and sate that the above Information is BUILDING ITI3
TA .area.]agree bt comply with all city and county Ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U Z building construction,tied hereby authadze representatives ofthis city to enter upon Ne SEISMIC ITE
above mentioned property for inspection purposes.
(Wa)agree to save,indemnify and keep harmless the Coyof Cnpertinn against PERMIT ISSUANCE ELECTRIC IEE
liabil'aia judgments,casts and expenses which may in tiny wayacem,against said City ALTER OR A DDTO MECH. LUMBING ITB
1
in csequence of the graining til'thi.s permit
P
ei
on
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I Was)CPM) MECHANICAL.FEE
SOU 'REGULATIONS.
i(•�ZS - AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCr10NTAX
Signeare ofApplican/Contractor C/ Date EXHAUST HOOD(W/DUCI'1 HOUSING MI'I'ICATION FEE,
MATERIALS DIS O 13
Will the applicant or future building occupant saran,handle hazardous material HEATING UNIT(TO 100.0010]111H `
as defined by the Cupertino Municipal Code,Chapter 9:12,find the Health and Safety
Code,Section 25532(ayl HEATING UNIT(OVER 1110.000 BTU)
❑Ye, 0N PAID
VENTILATION FAN(SINGLE Rf?SID) Uma Receipt#
Will Nc air contaior fmenturehuifmcdiding by
ty Ae.Air nat in,QOalil,Mieas nakentoh BOILER-COMP(3HP OR 100,000 BTU)
mit hazardous air containments ox define)by the Bay Area Air Quality Mnntigemem TOTAL:
toric'?
❑Yes ONO BOILER-COME(OVER Ma Nd IBTU)
' ,
I have read the haz:Wous materialsrtuiremca under Crater 0.95of the Cali- AIR CONDITIONER #
9 P ISSUANCE DATE
fomia Health&Safny Code,
eaSections
.ilnu25505,M533 ika, cad2553Q1und,rr,ll Natifthe NEW RESIUI3NTIALMECH. SQ.19'.
building,ogs not s which haven tenon,that h is my mspoo Cavity rc motif y Ibu occupant
nf Ne reslui¢nams which most Internal prionolssuenee fife Cenitieae o[Occupancy
Owner or authorized agent Dam TGTAL: ISSUED BY:
OFFICE