30435APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL I PERMIT NO.
BUILDING urvISION APPLICATION/PERMIT PLUMBING-M4ICIIANICAL 30435
BUILDING PROIFCT IDENTIFICATION
OW R'. NAME:
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CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT' IUM MECH
❑ ❑
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LIC CNSEDCONunOdWS rProviDECLARATION
I hereby affirm that 1 umfhelicensed under provisions ofChapterCode. 9 (commencing
with Section it0)of Dlcisi.niof the Business and Professions Gsle, and my license is
in fail /-,
ands ' ( V
Licca �n (�J Co # Sc
License
Dem O - r'1 Cunvaa.r
ARCHITECT'S DECLARATION
1 understand my plans shall he used as public records
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
CSFUWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT CSTRUCTURAL
CHIMNEYREMODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEUREPAIR ❑DEMOLITION
C OTHER
J1I
PERMIT ISSUANCE
AYPLIANCPS-RESIDENTIAL
PANELS
UP TO 2W AMPS
F F
LS j 9 J
W Q
aW5 a U
F W W� y
4
NSPECIAL
P
Licensed Professional
that I se -BUILDER DECLARATION
I hereby af0rm that I um exempt frim IM Contractor's License Law for the
following reason. (Section 9071.5. Business and Pmfesai... Cade: Any city or county
which itsissuance.
millions. hermit to constmel, alter, improve, tlemmsh, or repair any swment
prion t also mq rc. the applicant1 hpc rx ice signed statement
Ihah I dp rsun n ih p ns of the C t ror'sL 1 (Chapter
201-1000AMPS
OVER IINIfIAMPS
SIGNS ELECTRICAL.
CIRCUIT/MISC.
TEMP METER OR POLE INST
COMMERCIAL,
NF.W BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
p0
L o W
W ,^may
F?Qn.lmorc
(cam g with Secy J000)MDivisionJ fth . Bcss dPrfe, sCodiom
that he is exempt thembour and 'he m1i, far the alleged xempl A y Marion of
Section 7031.5 byanyapphcam fora pe. it sell the applicant tU a civil penalty of
than live hall dollars S500).
❑I, es owner of the propene. or my empinyccs with wages astheir sole nrmpemaion.
will do the work, and the structure is not intended or offered for side (Sec. Pln. Business
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWI 'I'CHIS- FIXTURES
3 w
and Pmfessiam Cede: The Conoactors License Law docs not apply to an owner (if
property who builds or improves Thereon, and who does such work himself or through
his own employees, provided that ,such improvements are not intended or offered for
NNW BESIDES I'IAL ELECTR SQ F1'.
sale. If. however, me building or improvement is sold within one year ofcompletion. the
s eohuilderwillhavetheburdenofpricingthathedidnotbuildniimprovefurpur-
pe,x.f,dr.y
S FT FLOOR AREA
A D
$/SQ. Cl
TOTAL
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project ISW.7044, Business and Professions Code:) The Contractors Li -
came Law does not apply to an owner of pmpcnth
y who builds or improves ereon,and
udiocarnmem forsuch projects with a contractors) licensed pursuant tothe ContmnoLs
�ryy��®A
'nr�R 24 REC'6
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE l
Lianas Law.
❑mToexempt under Sec. ,B&PCfonhis reason
���' Uf.kiUY[%jf
ALTER - DRAIN & VENT- WATER (EA)
)ryU
Owner Dam
VALUATION
WORKER'S
rpeadtTPE•NSm, or DECLARATION
1 hereby afOnn under penally of perjury one of the following sumfor Jedoer's Co
❑Ihave aro will main mi nn Cen. 3700ficam ofConeent
tion, as provided for by Section 30110 of the Labor Cade, for the performance of the
Labra ods. are for Worker's Connote- the
BACK FLOW PROTECT OF.VICIi
DRAINS - FhOUR, ROOF, AREA, C D.
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
ryk for which this permit is issued.
$ I have and will maintain Worker's Compensation Insurance, as required by Section
J of to Labor Cwla, 4a to perfmmanec ofthe work for which Nis permit is issued.
at p s ion Insurance carrier Policy fdmRr akq
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC GROUP
APN
GAS -EA. SYSTHM-OVER 4(EA)
1r�yN�O0
Cartier. Policy No.: �1�01 C L f L
Cancer Poli
CF.RTIPICA EOF EXEMPTION FROM WORKERS'
GRCASrANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
GREASIi TRAP
BUILDING DIVISION FEES
(This section need nnl:acc.mpletal ifthe pemtk is forow hundred dollars ($I W)
or Icsc.)
PLANCHECK FEE
Z
z O
I eenifythat in be rfgnare eofthe work for which this
pe thwWaA issued,hSEWER
Pat employ any parson in any manner so as m became subjmt m IhgWorkcrs' Co.,.-Comn-
salon taws Of Celifomin Dam
- SANITARY - STORM CA. 200 FT.
ENERGY FEE
WA'l1iR HEAT'IiR WNENT/ELECTR
GRADING FEE
.N.
W
NOTICE this Genital of of Exemption, you should
NOTICE TO APPLICANT: If, Compensation provisions of the labor Cake, you most
become mhje<t m the Worker's Coons or this
fonhwit<omply with such provisions or this pcnnit shall he darned revoked.
WATER SYST'FM/I'REA'1'ING
SOILS FEE
WATER SERVICE
PAID
Date Receipt#
4 A
az
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FN
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CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a construction lending agency for the performance.(
the work frwhich this permit is issued (See 3097, Ci¢ CJ I
NEW RESIDENTIAL PLMB. SQ FT.
Lender's Name
LenderAddrexs
1 twenty that I have mad this application and state thin to adrve inf.rmmam is
correct. l agree it) comply with all city and county ordinances and state laws relating to
building comarmitfil herebyauthon,ce"Presenmtives oftis city m emerapnn the
nbave-mentioned propene far emnifyian purposes.PERMIT
agree to save, indemnify and keep h:vmlcs @c City of Cupertino agninsi liabilities,judgments, costa and experses which may in any way accrue against aid City
consequence of the granting of this scroll. APPL AMT UNUERS NDS AND W .L COMPLY WITH ALLNnON-qPOINT
F,IfI TI )N.& Vll•_ {�
Signature of AppbcuH aft actor Date—EXHAUST
HA .#RDOU$ MATERIALS UISCWSURE
Will toapplicant orfuture building occupant t Door handle hazardousmaterial
as definedto Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Satin 255326a09
Yes 7 N
TOTAL:
TOTAL:
QTY MECHANICAL PERMIT FEE
ISSUANCE(We)
ESEISMIC
ALTER OR ADD TO MECH.in
EE
AIR HANDLING UNIT (TO Igt100 CFM)SOUR'
AIR HANDLING UNIT (OVER IOJIBO CFM)
HOOD (W/DUCT)
CONSTRUCTION TAX
HOUSING MITIGATION FEE
HEATING UNIT (TO IW.111X)BTO)
fIEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER -COMP OHP OR 1 W.0tlif BTU)
Will the applicant or future building occupant use capital Or devices which
omit hmations air comamii ams.1 defined by the Bay Arca Air Quality Management
Dubuc(!
❑Yes ❑N.
PAID '
Date Receipt Of
TOTAL.
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER
I Love readthe hazardous materials requirements under Chapter 6.95 of me Cali-
fomia Health le Safety CWc, Sections 25505, 25533 and 25534. I understand that if
ISSUANCE DATE
the
building does not currently have a tenant. that it is my responsibility to notify the execution
oft. requimmema which most harrier m issuance of a Cenificme of Occupancy.
NEW RESIDENTIAL MECH. SQ. FT.
ISSUED BY
Owner or authnrvcJ agent Date
TOTAL:
OFFICE