30966 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^^
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. v V
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. v
` BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SU
B
MITTAL DATE
OWNIJPSNAMII:, - I CONTRACTOR'S NAME: LIC NO'.
2 ` N/C CONTROL#
1J ARCHITECr/IiNGINEER: IC NO: ADDRESS: _ t385�-1 � El
/1 CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECE PLUMB MECH
S R FSG fC RAT
LICENSED CONTRACTORunder Prostitutes
QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 oat licensed under pmvixinnx pt 9 as clog JOB DESCRIPTION
O0Z with Section]IXN))af UivixinnlaDhe Business and Prole.inn. c nil my'ense is PERMIT ISSUANCE:
00 RESIDENTIAL.:
fill force an effect.
WP Li
Np
❑SIDWL ❑KITCfFN REMODF1,1UULicense Cl... Lln.
.. APPLIANCIS-RESIUPNF <LD3Cortrecar UAL
EIADDITION ❑PIUMBINGRE-PIPE
py ARCHITECTS DIECLA AT El MULTI-UNIT ❑STRUCTURAL
l understand my plans shall be used as publi co Ls PANELS
GZ � MODIFICATION
G 2014 2fAMPS ❑INTERIOR ❑CHIMNEY REPAIR
(Q-,`3�IY Licanctl Professional 2014"AMPS IMPROVEMENT
CY , OWNER-BUILDER DE 'ION
yy C U I hereby affirm that I am exempt from the Contmciors[.area.Law for the OVER 1gIB AMPS ❑BATH REMODEUREPAIR OLITION
p(a 4 F following reason.(Section 7011.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
{{�i11 O y which requires a Permit to construct,alter,bounces,demolish,or repair any stmeture
prior to lssiolormee,dim requires the applicant fonuch permit o fileasignedstmenmm SI'IICIAh CIRCUIT/MISC.
�} that heir licensed pursuant)the pervisionsof Ne Contmcmrs License law(Chapterit
�GOQ (commencing with Section]O00)of Divixion3 ofthe Business and Professions Cade?or TEMP METr:R ORPOLE INST COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Secdon'/113 LS by any oppliwnt fora permit xuhjecte the applicant to civil penally of I'UWBR DEVICES
net more than five hundred dollars($500f
?TE0TIiNANT ❑FOODSERVICE
Q0Lasownerof the property,or my employees with wages sstheir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENTwill do the work,and the structure is not imendedoroffemsl forsale(Site 7(W4,Business ❑OTHER
and Professions Cade.The Contractor's l.iccnse law does oat apply to an owner of OUTLETS-SWITCHES-PICTURES
Fmpeny who hands or improves thereon,send who dues such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however.the building orimprovement is sold within one year o(complecon,the SQ.ErrFfxO R1IHA $JSQ.f.7.tuner-builder burden have the huen of proving that he did not build or improve for pur- P (.'{ V
rase of sole.), ,
❑1,as owner of the property,am exclusively contracting with licensed contmnors m TOTAL: p
construct the project(Sec.]DW,Business and Professions Cade:)no Contractors Li-
cense law does not apply to an owner of property who huilds or improves thereon,and QTY. PLUMBING PERMIT FEE FEB IlII[pLv
who contracts for such projects with a comructor(s)licensed pursuant o the Contractors
License Law.
❑I am exempt under Sea. ,B&I'C fur Be,reason PERMIT ISSUANCE V111 lslr'sr ser uurr-K I INV
Owner Dem ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORK RIt:S COM PENSATIONDECLARNMON � ✓
Ihere# affirm under pcnAtyef BACK PLOW PROTIECT.DEVICE
y ofCoyeneafthefnsumior Workers
❑lhuve provnd ide for
inection 37Mficale ofConsent ode.sure for Worker'sce of the
DRAINS-FLM)R.BOOP,AREA,GOND. STORIES TYPE CONSTRUCTION
ration, r provided for io Ss issued,
l]00 of the Labor CtNe,for the performance of the
for which this pemdt is issued. FIXTURES-PER TRAP
w 1 have ad will maintain Wmkers Compensation Insorxn hi ns his parr by Seaton
1]IN)of Ne Lelwr Code.far perfarmann of the work for which this permit is issued. CTAS-EA.SYSTEM-I INC.40UTI,ETS OCC.GROUP qPN
M Worker�sC mpe� ani¢ al cr and Polley pe
Cm'cr:s51 RITE "Fs/NVt Policy NuY Imo_ 10-4-+g GAS-EA.SYSTEM OVER4(EA7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAT ION INS U RANCE GREASE/INDUSTRI,WAS TE INTERCEPTOR BUILDING DIVISION J-11 IS
(Thissectianncedhothecomplci difthepertrdtisforanehundreddollars(Sled) CREASETRAP or less.) PLANCHECK FEF.
I codify that in the performance ofthe work for which this permit is issuod,l shall SEWER-SANITARY-S'THEM EA,200 Fr.
not employ any person in tiny manner so us it)beaomc.vahjccr)o the Workers'Comfort. FEB
s7. whom lawfom
Lass,of Ciliit,Dec
Z Q A - WATER HEATER WNPN'1'/ELECIR
pplicant GRADING F'EC
y NOTICE TO APPLICANT IL utter making this Certificate of( Exemption,you should WATER SYSTEM/IREATING" !�
become subject m the Worker's Compensation previsions or the hntwr Code,you must SOILS FEF.
N !ti
forthwith comply with such provisions or this permit shall ha deemed revoked. WATER SERVICE '
w
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U l herebywhich irm
that issed(See,30 len ding agency fnnhe Performance of Dem Rweiptb
the work for whiett Ihis permit ix issued(Stu.909].Cie CJ '
Q U Lender's Name TOTAL
Lender's Address TOTAL:
Iy I utility that l have read this application and state that the above information is BUILDING FEE
N correct.I agree to comply with all city and county insurances and state laws relating m QTY. MECHANICAL PERMIT FEF. S
U Zbuilding construction,and hereby carbonic mpreserufivcs of this city to enter upon the SEI SMIC FEE
F-m shove-mentioned property fn ' lion P on"wes.
(We)agmet ,mdemni aril keep harmless the City of Cupertino against PERMIT ISS DANCE ELIICTRIC FEE
liabilities,judg "mucx so which may in any way accmc against sail City
n canxeque of gmmmilid ispcmtit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLIC sRSTAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNfr(TO 10.000 CFM)
SOUR C R ATIO M17CIIANICAL FEE
.aa AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
Sign net App anbContructor T Date EXHAUSTHOOD(WIDUC) HOUSING MITIGATION FIiE
HAZARDOUS MATERIALS DISCLOSURE
WE theap nein or future building occupant store orhandle huartlous material HEATING UNIT TO 100.000 BTU)
s defined 't 'upertino Municipal Coto,Chapter 9.12,and Ne Health and Safety
Yes
5532(a)] /No
1 HEATING UNIT(OVER 100.000 BTU) PAID
VENTILATION FAN(SINGLE RESI)) U Receipt#
Will the applicant or future building uncertain use equipment or devices which BOILER-COMP LINE IOO,OW BTU
:it hazardous air contaminants as defined by the Bay Area Air Quality Management ( )
)ImrlaEY. No TOTAL:
BOILER-COMP(OV ER 100,000 if rut
❑
I have re the n dons roam aH ne Chapter AIR CONDITIONER ISSUANCE DATE
quiremems under Che fi.95 of the Cali-
Health of tsde,Sodit 25505,15533 and 25534.1 understand that afire NF,W RESID ENTAL MECH. SQ.EL
nothingness ntlyhave nant,tmtitismYrealx'nsibilitytonndfythesxcuanl'
of Nerequi which met psiorm issuance ofa CeNficmenf Occupancy.
K(r Pp
Own at are TOTAL: ISSUED Y.
OFFICE