30043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30043
BUILDING PROJECTIDEN'TIF'ICATION
BUILDINGADDRESS: SANITARYNO. AI'PLICAII NSUB FFIA DATF
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OW�wvpi@@NAME: HONM: - CONIRACIOR'SNAME: LIC NO: -
-� Jy-G✓C ties -1517 NIC CON'1'ROLM
RCHITECT/UNGINEER: LIC NO: ADDRESS: ❑
CONTACT: _ PHONE: i BUILT ING PERMIT INFO
❑ Consultant Fees Pald'by Applicant(Initial) BLDG . ELECT PLUMB MUCH
El KV ❑
LICENSED CONTRACTOR'S DECLARATION QT'Y. ELIiCTRIC PERMIT FEE
I hereby affirm mat I um licensed under provisions of Chaplaf 9(commencing JOB DESCRIPTION
GaZ with Section 7000)of Division 3ofthe Business and Professions Cade,maid,pact.is RESIDENTIAL-:
O Orce PERMIT ISSUANCE
41"E.
Licenfalse
a Class Ueffect. -
V U License Class Lir,p ❑SFDWI- ❑KITCHEN REMODEL
4 Dam Cuntrmmr APPLIANCES-RESIDENTIAL / CADDRION ❑PLUMBING RE-PIPE
F{{....Zap ARCEI'IECT:S DECLA RATION ❑MUFTI-UNIT' ❑STRUCTURAL
r/Z Iundersmdm lansshall hausedos public manors PANELS MODIFICATION
rotaYP Pu DPTG 200AMPS ❑INTERIOR El CHIMNEY REPAIR
b42 OWNER-BUILDER D Inull Licensed Prnfessimml 20MO(NIAM15 IMPROVEMENT
ECLARATION
q tY W 6 1 hereby affirm that 1 am exempt from the Contractor's License Taw for the OVER I{IOO AMPS '0 BATH REMODEf/REPAIR 0 DEMOLITION
LLO y U following reason,(Scanlan 9031.5,Business and Professions Code:Any city or county SIGNS 11ECTRICAL C OTHER -
O tj which rai ids n permit to construct,alter,improve,demolish,m repair any sWewre
�Q primm its issuance,ido res naw he applicant for such pennitto file asignedsmarrout SPECIAL CIRCUIT/MISC.
ythat he is lleenwd pursunnno tun,do,ilonso❑he Comramor's Lirensc Law(Cbapter9
00 (commencing with Section 700(taf DiOlion 3 ofthe Business wd Professions Code))r TEMP.METER OR POLE INS2 COMMERCIAL
d o Y that he is exempt themfmm and the basis for are alleged exemption.Any violation of ❑NEW BIAG/ADDITION ❑DEMOLRION
..y Section 90315 by any appllaural nt lot. al suhja'ts the applicant or civil pcnalty)f POWER DEVICES CI'ENANT [I 1700D SERVICE
FZ> not more man rive hundred dollars F$500).� IMPROVEMENT a0 C rn
l,axownefthc,mpcny.mmyemployaewith n
wagostheirsole c)mpensatma, SWIMMING POOL ELECTRIC 1
will do the work,and the structure is not intended nr offered fors ile(Ser.9041,Busincsx COFFER
63 and Prnlbssions Cnde:The Contractor's License law does not apply to an owner of OUTLETS-SWI'PCHES-FIXTURES
property who hu....or improves thercsm,and who does such work himself or through -R
his own employees,provided that such Improvemams am not Imcnded ar oRned for NEW RESIDENTIAL EI.FCTR
sale.If.h)we,ca.4e building or improvement issald within one year ofcompletiogthe '- l SQ.IT.FLOOR AREA $/SQ,IT.
cr-builder will have the burden of proving that he did not build or improve for par- .,
pnsown
of soled,
C 1.as owner of the properly,um exclusively convecting with Menaced contractors in 5N NAL v
I construct the project(Sec.1044,Business and Professions Cndep The Convenors Li-
cerise Low does not apply ds an owner of property who builds or improves therm,and QTY. PLUMBING PERMIT FEE
who commcu for such pmjeets with a commends)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
num examptun tSix, ,B&P C for this reason
_ wner -�7 Date ALTER-BRAIN&VIiW-WATER(EA) VALUATION
ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE jcia
I hereby afrimt under'penalty of perjury one of the Hallowing declarations: �4i 'sa
I have and will maintain a Certificate of Consent to self-insum fur Workers Comped- DRAINS-FLOOR.BOOK AREA.COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this permit is issued. 17IXI JRES-PI7R TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section — 411011
3908 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Crimp oss imi Insurance conic,and Policy another on:
Caimier. Policy No.: GAS-EA.SYSTEM-OVER 4 Q3A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE? GREASFONDUSTR1.WASTE IN1 ERCEITOR
(This section need not be completed if the permit is forme hundred dollars(S 100) BUII.DING DIVISION FIEES
or less.) GREASETRAP PLANCHECK FEE
I certify(Ind ia the part'o'mance of the workfor which thispunad is issued,l shall SEWER-SANITARY-STORM EA.2IMIIT.
not employ any person in any manner s)as to berme adijoet o the Worker'Compete ENERGY FEE
O z sation laws of C.lifomia.Date WATER HEATER WNENT/ELECTR
z 0 Applicant GRADING EEE '
ti NOTICE TO APPLICANT.If,after making this Cenirinte of Exemption,you should WATER SYST HJs1TRIIATING a SOILS FEF.become subject m the Worker's Compensation provisions of the Labor Cole,you must
4kI Ponhwhlb comply with such prnvlsiumnr this permitnhull ha deemed revoked. WATER SERVICE
Q
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Pr. PAID
VO '•Thereby mfirn m:nrom isssued(Sea3nlcoling agency fnnheperLtmmnaamT Duce ReceiptN
0Fa Lew)rk for wM1leh mispemdt is issued(Sea 3N7.Civ.CJ
Lenders Name TOTAL:
Lender's Addmss TOTAL.
' � y 1 certify that I have read this application end stem that the have infunnation is to O� BUILDING IrEE -
N comet.l agree to comply with all city and county ordinances and state laws mlatingm QTY, MECHANICAL PERMIT FEE
(,) � building conxtructi)n,and hereby nnthari>creprrarntntivre of thischymenmrupon the SEISMIC FBE
above-mentioned property for inspection pan,..'
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT'ISSUANCE ELECTRIC FEE
Iinhllities,judgmenrs,costs and expanses which may in any way same against said City ALTER ORADD TO MECH.
in consequence,of me gaming of this penin, PLUMBING FEE
APPLICANT UNDF TANGS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT I TO 10,0(10 CFM)
SOURCE RF,OUI NS. MECHANICAL FEE
AIR HANDLING UNI'P(OVER 10.000 CFM) CONSTRUCTIONTAX
1' p nntranor Data EXHAUST HOOD(W/DUCT HOUSING MITIGATION FEE. HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hmarduus material HEATING UNIT(TO 100,000 BTID
as diined by[he Collards)Municipal Cede,Chapter 9.12,and the Health and Safety
Cade,Section 25532mo? HEATING UNIT(OVER 100,g)0 BTU)
❑Yee CNa PAID
VENTILATION PAN(SINGLE RESID) Data Re elpt Y
t Will the nit Imi m infurore building b the Bt use .Air ou nr devices which BOILER-COMP GHP OR 100,001)BTU)
min hwvdous air conlnminant as defined by the Bay Arco Air Quality Managcmem ,TOTAL, r
Districtl BOILER-COMP (OVER 100,0 BTU
E3 yes Corn �
Ihave read the,hazmdous materials requirement under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cause,Sections 25505,25533 and 25534,1 understood that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently ea tenant,that it is my respmsibilhy to notify the occupant
w (I
of the requirements ' must met prior to issuance of a Certificate of Occupancy.
/J
Ow (late TOTAL.: ISSUED
assIll—
OFFIC