30496 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT-PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30496
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: e SANITARY NO, APPLICATION SUBMITTAL DATE
R ( O . �
OWNS 'S NAME. HONE: CON ACTOR'S N E: LIC NO:
m .r �dy N/C CONTROL#
09aAR HITS /EN,NEER: LIC NO: ADD F.SS. TT '
/ -44
CONTACT: 'LOG PH�ONNE.E:, - � BUILDING PERMIT INFO
V z C(/J�7 7�7 ❑ Consultant Fees Paid,by Applicant(Initial) BLDG ELECT LUM ME
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
'I herehy affirm thafl am'he Bed under provisions of Chapter 9(commencing JOB DESCRIPTION
QCz with Section 9000 afoivision 3 oflhe Business and Professions code,and my license is ! RESIDENTIAL:
00 in full forceaon /J PERMIT ISSUANCE J
M P: License Claes l.., 1 ❑SFDWL _ ❑KITCHENREMODEL
RuuFz W Dam n'. '� Contrnc!ar_ APPLIANCES-RESIDENTIAL ❑ADDITION r. ❑PLUMBING RE-PIPE
f 7th ARCHITSCPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Ofpp.. I and efstend my Plans shall be used as polder Bards MODIFICATION
Z,-� UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�+ u1 Liewsed Professional. 201-IOOGAMPS IMPROVEMENT ,
k$5 •�.1 / OWNER-BUILDER DECLARATION OVER IUf10AMP5 ❑BATH ftF.MOD (REPAIR ODEMOLITIO
al 1 herehy afSectio nt 1 am aBusin s ba the Contract,
o License Law far the _ -��
%3 F following ioason.(Section]113 L5,Rosiness and Prnfessiom Code,Any city ofcooure $ NS ELECTRICAL ❑OTHER
Qy which requires a permit m noutmet.alter,improve,demolish,or repair any swmurc
ren.�i 6 prior m its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. --
,�s'� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
GO (commencing with Section 9000 of Division 3 ofthe Business and Professions Cnde)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt thefermm and the basis for the alleged exemption.Any viulminn of ❑NEW BLDG/ADDITION DEMOLITION
i� tyi
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OWER DEVICES
q not more than five hundred dollars($50D.
❑TENANT ❑h'OOD SERVICE
2=G ❑1,asnwmerofmm prefatory,or my employees who w,c,.athsi.so]it compensation_ S ING POOL ELECTRIC IMPROVEMENT
WC will do the work,and Heemucwre is not intended oroHerul fruits[,(Sec.9M4,Business El OTHER
and Professions Code:The Comincmr's License Law does not apply to an owner
of OUTL ITCHFS.4 XTURES
pmpeny who builds or improves Hereon,and who does such work himself or through,
his own employees,provided that such improvements are not intmded ter offued for I RE DE L P .CTR SQ CE
sale.BE however,the building or improvement is sold within one year of completion,the SQ.FT:FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par-- -
Ease of sale.). r. r '
❑ I,as owner of the property,am exclusively contracting with licensed contmaBrs to TOTAL'
onswmthe project(Sec:'9044,Business and Rufesdons Cale:)The Contractor's Li-
cense Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY. PL ING PERMIT FEE ,`K�i
who contracts for such projects with a conlmetimus)licensed pursuant to the Contrecom's VRs �� ����
License Law. PERMIT ISSUANCE .� 'd``P
E]I am oxempt under Sec: ,B&P C far this reason
Owner Date - ALTER-DRAIN&VENT-WATER(EA) - f,ftI U, l.Ut.�IrVALUATION
• _ WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of peduD one of the following declarations:.. ,
❑I have and will maintain a Certificate of Consenuo self-insure for Worker's Co.,,,- DRAINS-FLOOR,ROOF,ARE OND ' STORIES TYPF.CONSTRUCTION
wnrsanon,as provided for by Section 3900 of the Labor Code,for the performance of the -
forwhichthispermitisissued. FIXTURES-PER TRAP
l have and will maintain Worker's Compensation Insurance,as no dinctiby Section
300mfthe Labor Code.fm the perfonnunce nfthe work farwhich Hispermitis issue]. GAS-EA.SYSTEM-1 INC.4 OUTLETS DEC.GROUP APN
My Worker' Co�Pcry"m1I ent Pol cl Ptin ober arc / GAS-EA.SYSTEM-OV ER4(EA)
Cather: be anll {�y
149
CERTIFICATEOFYEXEMPTIONYFROIN WORKERS'
COMPENSATION INSURANCE' - GREASVINDUSTRL WASTE INTERCEPTOR -
BUI4DIN0 DIVISION FE S;
(This section need not be completed if the permtis for one hundred dollars(51Oda
or les.) GREASETRAP
PLANCHECK FEE
Loy any that int he city pmancenf the work for wobe this permit rkers Cmmlprall SEWER-SANITARY-STORM EA.200 FT.
not employ any person In any manner so es to became subjee adds,hWorkers'Comlmm ENERGY PEE
Z nation Laws of California.Data
O Applicant s WATER HEATER WIVENT/ELECTR GRADING FEE ,
y NOTICE.TO APPLICANT If,after making this Ceniticam of Exemption,yon should WATER SYSTEMRREATING -
f~ ; beemne subject to the Worker's Compenwtion provisions of the Labor Code,you mast SOILS FEE
WQ forthwith comply withaoch provisions or this Immulshall be deemed revoked. WATER SERVICE
VCONSTRUCTION LENDINGAGENCY NEWRESIDENTIALPLMB. - SQ.Up PAID Q I hereby affirm that hem is a construction lending agamy for performance of Dem Receipt
W !-t the work for winch this permit Ls issued(Sec.3097,Cls,C) -
V Lorder's Ne
amh:
U L ndmSAddress -r TOTAL:
L4 J certify that 1 have read this appllwtlon and mise fl at the above information is O BUILDING FEE f
y corect.I agree to comply with'sll city and enemy ordinances and store laws relating to QTY, MECHANICAL PERMIT FEE
V building construction,and herehy authorize representatives ofthis city to color upon the SEISMIC FEE sic
above-mentioned property far inspection purposes' PERMIT ISSUANCE
(WO agree to save,indemnify and keep hnmtless the City of Cupertino against - ELECTRIC FEE
liahilitics,judgments.costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING PER
osegomw Of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MGCHANICAI.FEE
SOURCE REGULATIONS.' b
AIR HANDLING UNIT(OVER 10,000 CFM) zo
CONSTRUCTION TAX
Signature of ApplicedUContmctor Date.,tv EXHAUST HOOD(WMUCT) - HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantof future building occupant sore or handle hazardous normal HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Ca_le,Section 25532(1)4 - HEATING UNIT(OVER 100,000 BI U)
❑Yes 7 N VENTILATION FAN(SINGLE RESID) PND
Date Receipt
will the it cintaminants r building racby the
hpart eByse Area
Air Quality
Management
BOILER-"COME LUIP OR 100,000 BTU)
:mit hazardous air contaminants as defined by the Buy Arca Air Quality Managmnent TO L: O
District? ILER-COMP 100,0011 BTU)
❑Yes '❑Nu BO - ,
ISSUANCE DATE
I have read the hazardous materials reuirements under Chapter 6495 of the Cali- AIR CONDITIONER r�
wI
9 P
fomia Health&Safety Code,Sections 2550.5,25533 trod 25534.1 understand Hm if the NEW RESIDENTIAL MECO - SQ.ET.
buildil gd aqpof wnenply have a tenant,that it is my respommil ity to notify the occupant
oP requi but wide .a he map tri uoissmres nfa Certificate of Occupancy.
kovirep �
ror authorize y.1
g T'Date TOTAL: ISSUED BY:
OFFICE