30058 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.-ELECTRICAL PI7RM IT NO, OO
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
s - � --fig--�
OWUU 1-1NAME ` ION COTRACTOR'S NAME: LIC NO:
;( 1 ael' _ O N ,` NIC COMIROLF
ARCHITLCIVENGINEER: LIC NO: ADDRESS: _ ❑
ACT: PHONE: , BUILDING PERMIT INFO
y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
77? ❑: C?' ❑ ❑
LIC17NSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that E.m lieenscd under previsions of Cholac,9(rnmmeneing JOB DESCRIPTION
wQZ with Section IIX()ofDivision 3 of the Buxinessand Professions Coda,mal my license is • / RFSIDENTIAL
F O in full force and eRea. �j p/ PERMIT ISSUANCE _ 7
VZ`�" License las QC IQ IisN C�7R F - - - ❑SFDWL ❑KITCHEN REMODEL
HQG Dae -�LConstncmr �•C✓SV '^g S� APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RIiPIPIi
ARCHOECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
'Don
PANIi1.5
Z O�? c 1 understand my plans shall be used v public recons MODIFICATION
OZ O UPT02MAMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-D)M AMPS
IMPROVEMENT
OWNER-BUILDER DECLARATION OM
OVER IAMPS
1 hereby uffimr That 1 tan exempt from the Cmorumm's License Law fir the .�BATH REMODEUREPAIR DEMOLITION
O d V following reason,(Section 7031.5,Business and Professions Code:Any city or countyC OTHER
which requires v permit to construct,altar,improve,demolish,or repair any structure SIGNS ELECTRICAL.
okawilI issuance,also requiresmevppLcmn forsmch pennitm lileaslgnedd.mment SPECIAL CIRCUI'VMISC. _
the he is]it...edpurwanumthc provisions ofthe Contmaors License Uw(Ch.pte,9
.1000 (commeodmg with Sell lna7M(d of Division Sof the Business and Pmfessinns Code)or TEM P MET ER OR POLE.INST. COMMERCIAL:
d A.X m C that he is exempt therefrom ad the basis home vlleged exemption.Any violation of y 0 NEW BLDG/ADDITION [I DEMOLITION
W,-,m Seesl.n]011.5 by onyappllcant fora permit subjects theapplicutto.civil Pewlry of POWER DEVICES FSD ❑TENANT FOOD SERVICE
not more than rive hundred dollars($500). IMPROVEMENT h as owner ofthe propery,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC -
$y'p. will do the work,und tbestmnure is not intended.,offered forode(Ser.]ID4,Business ❑OTHER
W 3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such irrpmvemenrs are our intended or offered far NEW RESIDENTIAL LLFCTR SQ FC
sale.l6 however,the building or improvement is sold within one year.fcompletion,the SQ.PT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did aur huild or improve fur put
pose of cele.).
❑1,as owner of the property,am exclusively contracting with licensed contructomm TOTAL: b 1
onsmun he project(Sure.](44,Business and Professions Code:)TIbe Cuntmemr's Li- I
use law does not apply to on owner of Iasi who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects with a conmmnm(s)licensed pumumntto the Contractors
License law' PERMIT ISSUANCE:
I am exempt under Sec. B&P C for this reason
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Un()
WOItnder PCOMI'ENSAfION DECLAllowinN BACK FLOW PRO'I'ECT.DEVICE
I herebya1Erm rain a Certify of pejuryone ofthefollowing orkerndns:
❑Ihave andwillforbyneion37Certificate ofComseat toLabor
Code,surefor Workersce mf the DRAINS-PLOOR,ROOF,AREA,COND.
s ton,es p nJW for by Section 3]fp of the tabor Cade,Int the ped'nrmanre of the STORIES TYPE CONSTRUCTION
work( ich this permit is issued. FIXTURES-PER TRAP
mud will maintain Workers Comperolo o Insurance,as requlovl by Sesaiun
31Woflhe laborCede,fimmo dbumance ofthework forwhich dexpermitis amed. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP API
My W. is CntyCemutirEw and Policy r-lM,�
Car,ier[(rl�I�ii�— Policy Nn,:A�m f 2-��1\ pL:J GAS-F.A.sysTRM-OVER 4 ILA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTR,WASTE IN RCEI R
(This sectimmuceiaot be complcrW due Permit is far one hundred dollars(SIM) BUILDING DIVISION FP.IS
or less.) GREASETRAP P�CHECK FEE
Loy any the,mile, ,foanyR lde,of the beconr whieum Permit iters ed,[,hallSEWER-SANITARY-S'rORM IM.200 PP.
not employ any person is any mvvner sr ax m becunm subject to the Workers Co.,.-Caper- FN GY IEEE
,Z .pion anws nl California Gum '
O WA'1'LR I IEATER WIVENT/ELIiCI'R
Applicata GRADING FEE
ti
NOTICE,TOAPPLICANT:If,Compensation
thisCertificateof Labor Codyou should WATER SYSTEM/TREATING -
a
become subject y the Worker's Compensation ermit shut of the cable Code,you most SOILS Flili
W forthwith comply with such pmvisinns or this permit shall be deemed revoked. WATER SERVICE
Q
CONSr UCIIONLENDING AGENCY NEN'RESIDENTIAL PLMB. SQ,1.7. PAID
V p Ifar by whicffirmh
that isoissued
construction0 lending agency for the performance of Dam Receipt If
F the work for which this pemsit is issue](Sec.J09],Civ.CJ
O U Lenders Name TOTAL:
1� lender's Aadilyt TOTAL:
I certify that I have rcaJ this application and state that the above information is BUILDING FF.Ii
iFw (4 correct.l agree to comply with all city and county ordinances and state laws relming10 QTY. MECHANICAL PERMIT FEE
U Z building constructor,and hereby authodu representatives ofthis city loenterupon Be SEISMIC FEE
.hove-mentioned property for inspection purproes.
PERMIT ISSUANCE msuvc,indemnify and kccp hrmlexs rho CilynI'Cupcninnayainl
I ELECTRIC FEE
liabilme,toora ania.of the m and of his perout. may many way aecrue aguinsuaid City p1:GER OR ADDTO MECH.
in oLICA ace of the granting Df AN permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'0 MOM CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 1(1,0(1)CFM) CONSTRUCTION TAX
Signature of Applicunt/Contrucmr Date EXHAUST HOOD(WMUCq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplema.rfar.building occupant aorc or handle hazmd.us material HRATING UNIT(TO IOLCM BTU) '
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Surety
Code,Section 255320)] HEATING UNIT(OVER 100,000 BTU)
❑Yea C3 No VENT[LAI[ON FAN(SINGLE REBID) PA IU #p
kcccipt
Will the applicant or future nt
re building occupay A equipment or devices which BOILER-COMP OHP OR 100,000 BTU
Gum M
emit huznrdnus air cnnmmin.ms as JcOncJ by the Hay Arco Air Quality Mamrgenrem ) TOTAL. Z
Named?
❑Yes No BOILER-COMP(OVER 100,(pO BTU)
Ili the hazard. atenals requirements under Chapter 6.95 of the Cali- . AIR CONDITIONER - -
9 P ISSUANCE DATE
he i alth& .Eery C ,Sec ns 25505,es no, Imp 25534,1 understand that if rhe NEW RESIDENTIAL MEf.H. SQ. �^ �/
M1u' Ing doe Curren yhav to m,dodoes is my resporoibiliry to notify the.ccupant ( OY d
therid,ta, a is hi Iso d cof a Cedol aof(xcu n
w aorouths i Uvta TOTAL:
OFFICE