30399 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3 0 3 9 9
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITTALDATE
/03/V_ T� ,nr '15C 3
OWNER'S NAME: PHONE: CU CTOR' N ME: LIC NO:
,(Ja G c. 2 QQZ NN/-C� CONTROL
4 RCHITECT/ENGINEER: LIC NO: A U SS: � _
CONTACT: PHONE: J 77 V BUILDING PERMIT INFO
❑ Consultant Fees Paid 1,3Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR derp DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby 10)of that I am of Me
under provisions of Chapter 9 commencing JOB DESCRIPTION
WZ with Satrecandon Off.,,
3nfthe Rosiness and Professions Code.and my license is PERMIT ISSUANCE RESIDENTIAL
W in full force end eRat
U U License C s — Lic.a U d ❑SFDR'L [I KITCHEN REMODEL
Qa Da¢ C`Z DECLARATION r APPLIANCES-RESIDENTIAL CADDTf70N [I PLUMBING RE-PIPE
A CHITECTS DECLARATION
1 understand my plans shall be used as public records PANELS ❑MULTI-UNIT ❑STRUCNRAL
MODIFICATION
FW Licensed ProfcsuDPT02MAMPSonnl [I INTERIOR [I CHIMNEY REPAIR
W< OWNER-BUILDER DECLARATION
201. )A pROVEMENT
6 1 hereby affirm that I em exempt from theeContrConvenorIII
's License law for the OVER IIXAMPS BATH REMODEUREPAIR C DEMOLITION
=U following reason.(Section]031.5,Business and Professions Cade:Any eery or coumYSIGNS ELECTRICAL C OTHER
OyaF which requires a permit m constaMet,r,improve,demolish,or repair any structure
mJ prior to in isousece,also requires the applicmm for such Pemtit m file a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant in Me previsions ofthe Contractors License Law(Chapter 9
73� (commencing with Section 7")of Division 3ofte Business and Professions Cmde)or TEMP.METER OR POLE(NSTCOMMERCIAL-
Ma
e he is exempt therefrom and the basis for the alleged exemption.My violation of
^� Section 703ISb en applicant for f pp CNEW.BLDG/ADDfI70N EI DEMOLITION
y Y Y PP permit subjects Ne applicant m e civil Penalty of POWER DEVICES
Z} rot roma than Dve handled dollars($500). [D TENANT [I FOOD SERVICE
_? (]Las Owiimaf the property,or my employes with wagesmtheir sole compenxetion. SWIMMING POOL ELECTRIC IMPROVEMENT
will do Ne work mid Ne structure is not intended oruffered foraile(Sec.7614.Business C OTHER
3 and Professions Code:The Conactors License Law des not apply m an..,,if OUTLETS-SWITCHES-FIXTURES
prmpmy who builds Or improves thereon,and who does such work himself or Nmugh — i
his own employee,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
We.If,however,the building-improvement is said addim rte yearaf.ropledon,Ne S .FLOOR AREA E/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for put-
pose of sale).
C I.as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL:
construct Ne pmjat(Sec.Tans,Business and Professions Code)The Convectors L �A�+,,
censelawdasnmapplyto no arofpropertywhobuildsorrmpmvesthereon,and QTyF t•I;"§'"Y`�PLUMBING PERMIT
whoconuecu forsuch projau wit a convactons)licensed pursuant in Ne Contactors ^ +tiez,a, ran.+,_ 4
I.J.Law.
C 1 em exempt under Sa. ,B&P C for this reason PERMIT ISSUANCE
Owner ALTER-DRAW&VENT-WATER(EiQ
Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE �s,.�s
I hereby etBrm under Penalty of perjury one of the following dalantions: 74:!0
(have primo wBl I.by
Section
37M ofCmn-ntm-Ide.fore a Workers Co of Me DRAWS-FLOOR.ROOF.AREA,CORD.
-tioq u provided for by Satimn 3]00 of the Inbar Code,for Ne pMormence of Ne STORIES TYPE CONSTRUCTION
wort for which this Permit is issued FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne labor Code.for Ne perform¢neer of Ne work for which this pemut is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP qPN
My Workers Compensation Insurance canner and Policy number tie:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thiy;, ,�.;tr BUR.OWG DIVISION FEES'Ti�;k'if•p i,;,r
Olds section nand not be comPlned Ran,Plan is for one hundred dollars(5100)
or less.) GREASE TRAP PLANCHECK FEE
1 certify Nu in Ne performance of the work for which this permit is issued,l shell
not employ any person in any manner-as to become subject Ne Workers' o pen- SEWER-SANITARY-STORM EA.200 pp. ENERGY FEE
0 Z cation Lew I(omla.Dap WATER HEATER WNENT/ELECTR
Applicant M1 GRADING FEE
lA NOTICE TO PLIC : ,aft "'ids, ifrcam of Exemption,you should WATER SYSTEM,TREATING
become subject m Ne Worker's Comp -tion pl� isi,as of the Labor Code,you must SOILS FEE
Qforthwith comply with such previsions or this permit shall he deemed revoked. WATER SERVICE
Z) z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ.FT. PAID
-) Thereby aH;rm Net tart isaconswction lending agency for Ne performance of Date Receipts
L E•" Ne work for which this permit is issued(Sc,.3097,Civ.C.)
Lenders Name
UTOTAL:
a. Lkl Iander'a Address TOTAL:
4 I certify Nat 1 have rend this application and stem that the above information is BUILDING FE£
Vd come( I agree to comply with all env and counry md'manros and star,lases relutinp m` QTY MECHANICAL PERMIT FEE
Z building conommlmm.and hereby authorize representatives ofmhls coy in error upon the SEISMIC FEE
abnee-memmned pmpany forinspection purpose. PERMIT ISSUANCE
(We)agree m scree,indemnify and keep harmless Ne City of Cupemmo against ELECTRIC FEE
liabilities judgmems.cows and expenses v:bich may m any way accae agamq said C r,
in consequence of the pmainp of Nis permit ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPO WITH ALL,NON-POINT AIR HANDLING UNIT(TO IU.OIXI CFM7
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER Ill."CFM) CONSTRUCTION TAX
Sigiwum cLApphcmNContactor Dam EXHAUST HOOD(WMUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant smrc or handle haardous material HEATING UNIT(TO IW."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Cade.Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
.pYes CNO
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant Or future building occupant use equipment or devices which Dae Receipt a
:mit literature nit contaminanu as defined by the Bay Mee Air Quality Management BOILER-COMP DHP OR 104000 BTU)
Disuim? TOTAL:
r_1 Yes CNO BOILER-COMP(OVER 100,00)BTU) _
1 have read the hi ashous mammals requirements under Chapter 6.95 of 0r,Cali- AIR CONDITIONER ISSUANCE DATE
forma BOOM&Safety Code,Secrimns 25505,25533 and 25534.I understand Net if the NEW RESIDENTIAL MECH. SQ.PT. �
building does nm Monday have a RMOCdim it is my responsibility m rod the occupant Or^ ,4 ` p
of Bie requiaaenu which must beret priorto ismmce of a artificer Of Occupancy, C
Owner or authonsed agent Data "NOTAL: f
1 LED BY
OFFICE