30588 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /D r/1
' EUIEDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. J 5 VX
BUILDING PROJECT IDENTIFICATION
UILIIING ADDRESS: - SANITAkYNO. APPLICATION SUBMITTAL DATE
iti S Ill' s2, Lave Cu e�G�.a CA 9soa4 Lo ( � .
O NF:R'S NA � �• N PHPC
(lN1' C NTI!, 'SNW AO LC `6 NIC CONTROLM
RCUITECSIENCINEEk: LIC NO: .ADDRESS: ❑ ,
CONTACT: PHONE: - BUII,DING PERMIT INFO
/J h O ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION' QTY ELECTRIC PERMIT FEE
C Z w, I Uneby amrmm 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
N
th Section 7000)of Division 3 ofthe Business sad Professions Cnde,and my licmtxe is A RSIDRNTIAL
�o in full force and effect. PERMIT ISSUANCE
U License Class m M
❑SFDWL El KITCHEN REMODEL
F� D
Dote Cnnwnnr AI'PLIANCIiS-kIiSIUENTIAL [D ADDITION [I PLUMBING RE-PIPE
FOh ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z c n� I understand my plans andl be used ru i nhlic recoNs MODIFICATION
_ UP'T0210AMPS
h 41`_ Licensed Professional [D INTERIOR [I CHIMNEY REPAIR
ej sy � OWNER-BUILDER DECLARATION 2111-IOINIAMPS IMPROVEMENT .
CC CCG 1 hereby affirm that 1 um exempt from the Contractor's License Use for the OVER hall ❑BATH REMODEL(REPAIR El DEMOLITION
06 U following rmsnn.(Section 9031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑LITHEI
which requires a permit to ronsmsct,alter,improve,demolish,or repair any structure
pdrnolts ismaner,sborequires theapplicare Lnsuch Hermit to rile a signed statement SPECIAL CIRCUIT/MISC.
Ny
that he is licensed personal to the provisions of the Contmemfs License Law(Chapter 9
<p (commencing with Section 70(10)of Division 3 of the Businns and Precisions Code)co TEMP.METER OR POLE INST. COMMERCIAL-
that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
B•
Section 703IS by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES
�m ❑TENANT ❑FOOD SERVICE?
not marc owner
five hundred ty,or
y employees
f�G ❑I,as owner of Ne property,er my employeeswiN wages ustheir sale cnmpenemian, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and Ne etucture is net intended mefimed fortune(Sec.7Bw,Bailouts ❑OTHER
a� and Professions Code:The Comoro License Law Nes not apply 1Tm owner of OUTLETS-SWrrCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are wt intended m offered far NEN'RESIDENTIAL FLECTR SQ PT.
sale.If,however,the building orimpmvcmem i,sold within ane year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the human of proving that he did net build or improve for put.
pose of sale.). P A 1
1,as ewer of the property,am excessively contracting with..I...ed centre...s m TOTAL: /1
nsuoct Noese p not appl(Sitey
to an Business and Professions Codr impro Commdols Li- ��
who
inch plytoan with
a cofpropeny who
sednor improves thcreomatd QTY. PLUMBING PER T FEE •/I
whonse Use PERMIT
such projects withattmtmnnr(s)liwmed pumtwm to the Contractor's j
License law. PERMIT ISSUANCE?
❑ m
Inexe pt nder Se ,B&P C for this reason u -
Owner Dare�l-3e•Y-Q.� ALTER-UkA1N&VENT-WAT131i (��ALUATION
E 'SC TION DECLARATION BACK FLOW PHOI'F. .UCVICE V
I hereby affirm ua pe dtyofpmjury one of tire following coronations:
❑Ihaveand will mninwineCmifieareuc Conserv mself-insure far Worker's Cempen- DRAINS-FLDO ,R P,A .A,COND. STORKS 'TYPE CONSTRUCTION
saloon,as provided fee by Section 3700 of the Ubs r Code,for Ne perform.....of the
work fill which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain W'orker's Compensation bromm nce,es requited by Satian
3700.f the Labor Code,for the performance of the work for which this permit is issued. GAS-G.SYSTEM-I INC.JO EC OCC.GROUP APN
My Worker's Compensation lnsumne.citric,and Policy number- m:
Cartier. Policy No.: GAS-PPA.SYSTEM-OVER 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
Old, It.neednot the completed if the permit is for one hundred dollars($IOff - BUILDING DIVISION TRES
or lesrJ GREASETRAP PLANCHF.CK FEE
Ic,nily that in theperform..sc of he work forvehich thixpetmit is issued,I shall S17WER-SANITARY-STORM LA.200FL
not employ any person in any manner so as to become subject to the Workers'Contrym- ENERGY FRE
O z soden laws of California.Dote WATER HEATER WNENT/ELECfR
z Applicant - GRADING ITH
N NOTICE TO APPLICANT:If,after making this Cenifica¢of Exemption,you should WATER SYSTEMITRATING
E
become subject .nb
o the Worker's Compensation provisions of the Ior Code,you must SOBS PER
Lai) forthwith comply wilbsuch I, visinnxer this permit shall be deeper]revoked WATER SERVICH -
a0
� z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ.FT. PALO
V khandbyfarw .Dinmbauhmeis..Id( es.30lending ageimy lin No perinmsoncem' Date ke,eiptk
C) F
the work for which Nis permit is issued(Sec.31197,Civ,C.)
Q U Lender's Name TOTAL
D.1 Izndvr' Address TOTAL:
f9111 1 certify than I have rcaJ this application and ,are tha the above information is BUILDING PEE
&n correct.1 agree to comply with all city and county on insures and state laws relating to QTY. MECHANICAL PERMIT [ZEEU 7— building consrmelarrmullimeby amhorinen,nescroaftes of thisrhymemer upnothc SEISMIC FEE
above-mentioned property for inspection prognoses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PhUMBING FEE
I.consequence of me gmmi..g of this pearm
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,DO CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFMI CONSTRUCTION TAX
• Signature of Applicant/Contractor Data EX HAUSTI IOGD(WMUCD CONSTRUCTION
UCIONTAX PP,Ii
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building command Bion,or handle torturous material HEATING UNIT(TO 100.000 BTU)
as defined by We Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
a Code,Section 255321a)2 HEATING UNIT(OVER 100.00)Bi'U)
❑Ye. 0N VENTILATION PAN(SINGLE RESID) PAID t
Dam Receipt a
Will the applicant or future building by the B use equipment lily Management
which DOILER-COMP(3HP OR 100,011(1 BTU)
•emit District? us air contaminants as defined by the Bay Area Air Quality Management TOTAL
Dixtrict2
❑Yes ❑No BOILER-COMP(OVER I00,0(t)BTI)
I
I have teal Ne hzs
ardrailroads aterials requirements under Chapter 6.95 of the Cali- AIR CONDITIONIiR ISSUANC A
f sad.Health&Safety Code,Sections 25505,25533 ad 25534.1 understood that tithe NEW RESIDENTIAL MECH. SQ.FT. /I J
building does ton eurenny htfo. rom,Nat It is my mspensmirty to n,my the oeapam r
of Ne requirements which musbemet pdnrtoi.xsuunce ofa C<nifieam of Occupancy.
Owner rr ouWmiud agent Dat TOTAL: ISSUED BY:
OFFICE