30661 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: t SANITARY NO. APPLICATION SUBMITTAL DAPI
?3 l"�-
OWN 'SNAME: PHONE:, CONN pNgCTOH:S NAME: ' �L�Cs�
NIC CONTROhp
iRC IT Cf GIN[ER: LIC NO: ADDRESS: ❑
t -trnv.
CON ACT-M PHONE: BUILDING PERMIT INFO
!!'' W A0,40 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT TUM MECH
A,* ❑ ❑
.LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PI7RMIT FEE
1 hereby affirm that l um licensed under pm,olu s of Chapter 9 wommm�cing JOB DESCRIPTION
Q=Z with Section of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL
0p in fullfome and effe PERMIT ISSUANCE
=UV -icenm Class - Lic.N A6-C? ❑$FOWL ITCHEN REMODEL.
Z APPLIANCES-RESIDENTIAL [)ADDITION ❑PLUMBING RE-PIPE
Dale Contract
ARCHITECTS DECLARATION PANii1S ❑MULTI-UNIT ❑STRUCTURAL.
ZOrnZ I island my Inns shall used ns publ. . MODIFICATION
OZ—� UP TO 200 AMPS
h+4 ❑INTERIOR
❑CHIMNEY REPAIR
r edErolessimiall 0sIMPROVEMENT
Y OWNER-BUILDER
DEC RATION
yy C 1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER["AMPS ❑BATH RF.MODEI-REPAIR ❑DEMOLITIO
pc a 0.V Rdlowing r,tsun.(Section 0031.5,Business and profession,Code:Any city or county SIGNS ELEC'I'RICA], ❑OTHER
Y LL
Is. which reclaims a permit m construct.alter,improve,demolish,,r repair any structure
ONa prior to its issuance.also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUTOMISC. IJ-�
that he's licensed purswnIt,the provimmsnf the C,nnic,unx Licensee Law(Ch.pmr9
pZO� (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP MEILR OR POLE INST. COMMERCIAL
that he is exempt Nercfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil peraltynf POWER DEVICES TENANT ❑1'OODSERVICE
-
nmmore than five hundred dollars(SSW). IMPRO
p�O
E)1,as owner of the property.or my employees with wages as their side compensation. SWIMMING POOL ELECTRIC MINT
22 tiGG'!! will do he as k,mddc,uuct.misnot intendod m aliened insole(S..]044.1bouness
6 3 and Professions Cade:The Contractors License Law does not apply to an owner of 17.OUTLETS-SWITCHES_,IXTURES 1./47
W
property who builda or improves Roman,and who does such work himself or through
his own employees,provided that such impoormenm are not Immoded or.,Tenser for NEW RESIDENTIAL ELEGfR SQ FT.
sale.IL however the building or impmvermntis sold,flumine year of cnmplalnnthe SQ.FT Ff.00R AREA LSG.FL
owner-builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
❑ 1,m owner of the pmpeny,am exclusively contracting with licensed contractors to TOTAL:
comm the project(Sec.7H4,Business trod Professions Cut....The Contra.........
cense law does notapply to an owner of pmpeny who builds or improves dmam,and QTY, PLUMBING PERMIT FEE
whomntmcty forsuch pmjecwwith aconuactodi licensedpursuam mthe Commcmrs
License Low. , PERMIT ISSUANCE
❑I am exempt under Sec. ,B&YCfordisreason
Owner Unm ALT17R-DRAIN&VENT-WATER(EA) 'VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE DEC ���
1 hereby affirm under penalty of perjury one of the following declarations 12
01 Hum,im will maintain aCenificomof Cnnsenun eclLinsurc for Workers Cnmpem DRAINS-PLOOk,kO(3P,AREA,GOND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor CWe,for the performance of the
work for which this permit is issued. 3 FIXTURES-PER TRAP o CITY Ur m_MIINU
❑ E have and will maintain Worker's C,mpensntion Insurance,as'rcyuired by Section
37W ofthe labor Cal,forthe performance ofthe work for whichdis permitisiyi al. GAS-EA.SYSTEM-1 INC.4 OWLETS OCCGROUP APN
M Werke''' Con�t tion canner and Policytyt�](r �j I7N fT
Carrier: �L��/YY,(l arts Policy No. Ue/6-7 C CZL GAS-EA.SYSTEM OVER 4 LEA)
CERTIFICATE OF EXEMPHON FROM WORKERS'
COMPENSATION INSURANCEGREASE/INDUSTRI,WASTE INTERCEPTOR
(Thissection need not be completed if me is mrit is for one hundred culls.(SIM) BUILDING DIVISION FIRES
or less.) GRF.ASETRAP
PLANCHECK FEE
Ired eym,tpersa mato n,nrmuc,sx fahe,ork Soordr whijethis the Wirrkes Cmalhu'I SEWER-SANITARY-STORM EA.2M In
sol employ any Coven is cry manner m tu In become subject m de Workers'Cumpem ENERGY IsIEIE
,� Applicant
ant of Cali(nmia.Dam
O Applicant WATF.H HEATER W/VfiNT/IiLECTR GRADING PEE.
y NOTICE TO APPIJCANT.If, ou
after making this Certificate of Exemption.you shld WATER SYSTEM?REATING
a �" become subject to the Workers Compensation provisions of the Labor CWe,you must SOBS FEE
W�ryy forthwith comply with such provisions or this permit shall he deemedrevoked. WATER SERVICE
Uz CONSI uum,hureRUCTION LI!NDlNCAGENCY NEW NESIDIENTIAh PLMO. SQ.FT. PAID
V l for whihthi thauhere isned(Seconstructionlen Jing agency for do performance of Uam ReceiptN
{L -+ Le work for which this permit is issue.)(Sec.J09],Civ.CJ
f-s Lenders Nmnc 'I'UTAL:
L) Lcndcrs AJdress TOTAL:
Fy 1 certify that I have motion,application and nate that the move information is x BUILDING THE
V) correct I agra to cnntply whh all city nnJ county nnlin.ncex vnd cum lows roln0ng m QTY. MECIIANICAI.PERMIT FEE -
,(� , building conswdinn,anJ hereby amhoriz<rtpresemmives a(dis city mercer upon the SEISMIC FEE
shove-mentioned prupeny for inspection purposes. PERMIT ISSUANCE
(WO.,rase to.sove,indcmnily and keep Iinrndcv.do City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in my way seems,against said City corALTER OR AIIUTO MECH,
in re9ucnce odds gmming of this permit PLUMBING FEE
1s'E RE UNDERSTANDS AND WILL COMPLY WITH DLI.NON POINT AIR IIANDLINC,UNIT(TO IO,pW CPM)
( tICANT UNDERS S. MECHANICAL PEG
AER HANDLING UNIT(OVER 10,000 CFM( CONSTRUCTION'I'AX
omreof Applican/Cnntmctor ate EX fIAUST 1400D(W/DUC13 HOUSING MITIGATION FEE '
HAZ RDOUS MATE I.S DISCLOSURE
Will the applicant or future building occupant store or handle infamous materialHEATING UNIT(TO I00000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heald and Safety
Code,Section 2553210)] HEALING UNIT(OVER 100,000 BI'U) GG3 3
❑Yes ❑Nn VENTILATION FAN(SINGLE RESID) P
ReceiptN
Will do app. m infuture building naw a nt use Area
Air m or devises which
mit hazardous air ronmminomx as Defined by the Bay Arca Air Quality Management BOLLEN-COMP(3Hp OR I0I,(X1118TU)
t District? ❑Nn BOILER'-C(ME(TVCR 100,00E BTU TOTAL:
❑Yus
I have read the hazaNeusmaterial.requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.F T.
Willing doe not curtendy haves mnant that
his myre,immihiloymnmifydeoceopant
of the na,ircnenn which most be met prion,{...ace of a Ceni Ic vs,of Oce....c,
Owner m aathorind.gent Dam TOTAL: ISSUED BY
OFFICE