30196 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-It LECTRICAL PERMIT NO. ^ O9 A I6a�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J{
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o •
rj (o QL
OWN 'S NAME: FHO E: •DNTRACfOR' N E: LIC NO:
'TVL.IMk�I JG^ NIC CONTROLp
ARCHITECT/ENGINEER: LICNO:' AD RES ❑
CONTACT PHONE: I IS� BUILDING PERMIT INFO
❑,Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION
wOQTY. ELECTRIC PERMIT FCC
1 hereby affirm that 1 ten licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section of Division 3 of the Business and Professions Code,and my license is -- RESIDENTIAL
I, - in full force node PERMI'TISSUANCE
.e F �,�i' j ❑SFDWL C1 KITCHEN REMODEL.
WUZr LicenseC Lic.p
16W Date Contra -a.. �wt APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
et,F,70 ARCHITECTS DECLARATION PANELS ❑MULTIANIT El STRUCTURAL
Z O y I understand my plans shall M used us pnbllc rccoNs MODIFICATION
0Zw-1 UPT02MAMPS El INTERIOR ❑CHIMNEY REPAIR
0 iii. � Lleenod!l'ndcssimal 201-IOOOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER I(NIOAMPS
s%W 6 I hereby affirm that 1 um exempt from the Contractor's License Law for the ❑BATH REMODNUREPAIR ❑DEMOLITION
3 a u following rcuson.(Section]031.3,11usiness unJ Irnfevsions Cotle:Any city or county SIGNS ELECTRICAL ❑OTHER,
4 which requires a permit to construct,alter.inquave,demolish,or repair any some um
17 prior to its issuance,also requires to applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
9pn} that he isliceired prommat t the provisions nfrhe Contractofs License law(Chapmr9
IyC OO fcommencingwith Sectiun 7100)ufDiri.sim 3.NIE.Businessand Professions CtNe)nr TEMP.METER OR POLH INST. COMMERCIAL
a y o n that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
trX] 4y
Section]031.5 bymy applicamfar.Permit omjecurhe applicam tort civil N..I,yof POWER DEVICES
FZi nett^°',than five hundred dallos[$900). ❑TENANT ❑FOOD SERVICE
C Q ❑ Lm owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC MPROVEMENT
G will do the work,and the strvcture is oat intended metered for sale(Sec.]0S4,Business OTHER
L62 and Pofessions Cade:The Contractor's Licome law does not apply m an Owner at OUTLETS-SWITCHFS-FIXTURES
property who builds or improves thereon,and who docs such work himself or though
his own moployces,provided that such hoprovemmus are not Intended or offered for NEW RESIDENTIAL ELECT It SQ IT.
ode.ll;however,thebudditilmimprovereni icsold within oneyeacofeompletion,the SQ.FT.FLOOR AREA $ISQ.FT .
owner-builder will have the burden of proving that he did not build or improve for pun
pose of sole.).
I,as owner,of the property,oro exclusively contacting with licensed contractors m TOTAL:
construct the project(See 704Q Business and Professions Cude:)The Count Ti-
cenve Laos does not apply to an owner of pariamy who builds or Improves theircon,and QTY. PLUMBING PERMIT FEF.
who contracts for such pmjats with a contmemns)licensed pursuant o the Combustors
License law. PERMIT ISSUANCE
❑Iamemmptunder Sec. ,B&PCforthisreason
ALTER-DRAIN&VEN'P-WATER(EA)
Owner Date VALUATION
WORKER'S mall,
ofN i DECLARATION HACK FLOW PROTECT.DEVICE ^ C)*
1herebyaffirm under Penally of perjury ICencofrhofollowing W.laer',Co
Ie,as anddide r for
ection icatc of'Ce cox;,'el the Worker's Conmem DRAINS-110011,ROOF ARCA,COND. STORIES 'i'YPFCONSTRUC7RON
ourk f as provi(be for mi Section 3]011 of the luhrir QNc,far the performnnue of the
work fns which this permit is issued. 11X'1'UItES-PER 3'RAP
1 hove and will maintain Wmkefs annpe.nati w Insurance,ce,h required by Semina a
J )of the LUM+rC,Je,for the perBrwancc of the work for which Nis permit is issued. GAS-EA.SYSTEM-11NCA OUTLETS OCC.GROUP APN
My Wi'2�e. m iorition lmumnce a icr and Policy um�,e afe
Carrierl�"}rM Policy No.: ua1I'"a+ GAS'-EA.SYSTEM-OVER CERTIFICA OPE%EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
or less)
(This section need not Be completed ifthe permit is foroae hundred dollars($100) GREASE TRAP BUILDING DIVISION FEES
PLANCHECK
Loy any that irahe performance oftsin cc fir so which this permits issued,mopelt SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any mangy s<its m 1 ecprB,subject m the Workecc'Cmnpen- ENERGY FEE
zi xation Laws el ice.D -Q Gii�p
7O � Appl isnot ��'�� WATER HEATER WNEN'1'7HIECTR GRADING FEE
q y NOTICE TOLl ANT IL ager making this Con,ficmm of Exemption,you should WATER SYSTP.M/fRF:ATING r
r�
been rne suhj t m the Wmkers Curn,mmion provldnns of the Labor Code,you must SOILS FEE
W by forthwith comply with such provisioror this permit shall he deemed revoked. WATER SERVICE.
as
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U hereby affirm that there is a construction lending agency for the perfomonce of Date Receipt It
the work for which this permit is issued(See 3097,Cie C.)
Q U Undoes Name TOTAL:
V [,.does Address TOTAL:
CI certify that 1 have read this applinnion and state that the alcove Information is BUILDING FEE
h correct.l agree to comply withal)city and county ordinances and sure laws relating to QTY. MECHANICAL PERMIT FEE
U � huildingconswcrion.andhemby aohnnze mpmwetatives ofthis city mentor uponthe SEISMIC FEE - 0
uMwe-nommood property for inspection purimm, ,
(We)agree to save,indemnify and keep hrundess the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
hiduliriasjuJgmeat,,costs and expenses whichnmy inany way.ornoag,rinq said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUM BING FEE
APPI.ICANT UNI .RST IS SAND 4ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO IHJ MI CFM)
SOURCERG TIONS MECIIANICALFEE
D AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
get ppladnVC owner Dme EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DLSCLOSUI HOUSING MITIGATION FEE
ill the applicant or future building occupant store or hrrWle hazanlous material BEATING UNIT(TO 100,000 BTU)
os d teed by the Cupertino Munieipal Cale,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(x)? IIPATINO UNIT(OVER 100.000 BTU)
❑Yes 7 N PAID
VENTILATION FAN(SINGLE RHSID) to I eceipt M
Will the applic to Or res a building byom,amthe B use equipment of devices which
r' hvuud,us air cmm�minams os de0nal by the Bay Acta At, Mrinagemm�t BOILER (3HP OR 100,1X111 BTU) -
cru - 9'OTAL: �
District? BOILER COMP(OVER 100.X01 BTU)
• ❑Yes Fl No R .
L have read the hasrdous nationals requirement under Chapter 6,95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomla Beales&Safety Code,ea tirm,thati,25573and25534.I to
theifthe NEW RESIDENTIAL MECH. SQ.FT. ^ w
goods
building does hat currently Core,Setions, 5ati,2553is my responsibility rte notify am mention
if the •/ (/
of rhe requirements which must W met prior to issuance of a Certificate of Occupancy.
Owner or aothereed agent Dam TOTAL: EDBY:
OFFICE