30689 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.-MECHANICAL 30689'
BUILDING PROJECT'IDENTIFICATION
BUILDINGADDRRSS:'7 7>� Lot a
SANITARY NO. APPLICATION SUBMITTAL DATI
i urn r Gs' SOL l
o
OWNER'S NAME: PHONE: CONTRACI'OR'SNAME: LIC NO: I 46
N/C p CONTROL g
lopRCHITECDENGINEER: LIC NO: ADDRESS: ❑ /�7 �H
CONTACT: - - PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF�CH/
Lm thatIDCONnsed and,,
Pro DECLARATION
of chapter
QTY. ELECTRIC PERMIT FEE I�
I hereby arum that 1.m licensed ander proviatmna or enapmr 9 teamm=n=i a, - JOB DESCRIPTION
�OZO with Section]O(llp of Division3of the Business and Pronasions Code,and mylicense is in fail force and effect. pERMITISSUANCE S RESIDENTIAL
WULicense Class Lie,p r :
jXCFOWL ❑KITCHEN REMODEL
UZ `
�QW Ume Contract APPLIANCES-RESIDF.M'IAL CADDITION ❑PLUMBING RE-PIPE
F.Dvai ARCHITECT'S DECLARATION CMULTI-UNIT []STRUCTURAL
CZ-Z Iunderstandm I ^ PANELS MODIFICATION
- my shall he used as public records °' UPT0200AMPS ❑INTERIOR CHIMNEY F, C Licensed Pefic,ional 201.1"AMPS IMPROVEMENT
�O that I a exempt
DECLARATION CouTION OVER I000AMPS C BATH REMODEUREPAIR 0 DEMOLITION
d' � I hereby affirm that I am exempt from the Commctors License Law for the
3aFVF following reasnn.Section]OlIS,Business and Pro(essiom Code:Any city or county SIGNS ELECTRICAL COTHER
y which requires a permit to construct alter,improve,demolish,or repair any swctum _
primo its Wastricc,nlsciax,mrca the applicant(or such permit m fileusigned statement SPECIAL CIRCUIT/MISC.
ya that he is licensed pursuanuo the provisions of the Convector's License Low(Cmpter,9
^G£0 (commencing with S¢tion]OW)of Divixion7af the Business and Professions Code)or TEMP.METER OR POLE INTT.
a
that he is exempt therefrom and the basis Qor the alleged exemption.Any violation of NEW BLDG/ADDITION ODEMOLITION
5rolim1701LI hyany applicant forapermitsubjects mcupplicantowcNilpenahynf POWERDEVICES
y not lure than five lmndrcd dollars(8500); ❑TENANT ❑FOOD SERVICE
❑ 1.ae owner of the progeny,or my employees with wages os their sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
_ will do the work,and thesvucmo is not imemfeduroEbred for sale(So,.)044,Business ❑OTHER
6 3 and Professions Code:The Convectors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES S
property who builds or impmves thereon,and who does such work himself or though
his own employees,provided that such improvements urn not intended ar offered for NEW RESIDENTIAL ELEMR SQ FT. I
sale.IL however the building or improvement is sold within one year ofcompletion.the SQ.FE FLOOR AREA 5/SQ.PT.
adder will have the burden of proving that he die not build or improve for par-
N"up
post upside.).
I,as owner of the property,ran exclusively contracting with licensed contractors to
conmmct the project(Sec.](W4,Nosiness and Professions Code:)The Contractor U.
who coew doesnoteppri roan ownerofpropeny whobuaAarmantroves thereon and QTY. PLUMBING PERMIT FEE
who commas for such projects with a commnorts)licersscd pursuant lathe Convecto6
License Law. PERMIT ISSUANCE
❑ 1 mn exempt under Sec. B&P C for rhix natant, ,
ALTER-DRAIN&VENTEA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICE -2--g. �A[�
1 hereby aRrm ns:under penalty ofperjury one of the fallowing declaratio - J-1`
onion, =and will maintain Il- u Cenilicate nfCnnsum to self-insure for Wnrkrrs Compete DRAINS-FLOOR,ROOF,AREA,COND. $TORIES TYPECONSTRUCTION
ration,ar provided Bir by Section 77M of the Labor Code,or the performance of the
work for which this la m it is ismad. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section' -
37M fthe Labor Cure,for the performance of the work for which this parrot is issued. GAS-EA.SYSTEM-I INC.4 OUTLEfS W. ROUP APN
My Workers Compensation Insurance carrier unit Policy number ate: LLI l 11X�
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4EA) V( U
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section aced not N completed if the permit is for one hundred dollars(S I IX)) BUILDING DIVISION FEES
or loss.
l GREASETRAP
1 Iccnify mot in the perfmtnonce of the work for which this permit is issued,l shall PLANCHF.CK FEE
rot employ an SEWER-SANITARY-STORM EA.200 FT. O_.
p y y person in any manner so m to become subject m the WorAerw Camper- ENERGY FEE
Z sation Lawsof California.Dam
O A licont WATER HEATER W/VENT/ELF.CTR -
PF GRADING FEE
r h NOTICE TO APPLICANT.If,atter making this Certificate of Exemption,you should WATER SYSTEM/1'REATING
become subject to the Worker's Compensation provistons of the Labor Code,you must SOILS FEE
W ti forthwith comply with such provisions or hi.s permitshall bo deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB. SQ.FT. - PAID
U kfarrby which'his.iti issued(Sec.30 lending agency nnhe performance
of Dt eceigp
W 17" the wok for which this perms is issued(Sec.309],Civ.CJ
O U Lender's Name - TOTAL:
W Lender's Address
F. I certify that 1 have read this application and state that the above ifloor mien is BUILDING FEF,
In correct.9 agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
U Z building construction, th
ction,and hereby auodm repasenmtives ofthis city to enter upon the SEISMIC FE
above-mentioned politely for inspection purposes. PERMIT ISSUANCE 4a�
(We)agree to sever indemnify and keep harmless the City of Cup,mmc against ELECTRIC FB LO
liehilities,judgmems, .,,,.ad expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in cmmeamenee of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14(1(10 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
- AIR'HANDLING UNG(OVER 14(XNCPM) CONSTRUCTION TAX
Signature of Applicant/Conuacmr Date EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant storeor handle haeadhow mmeriul HEATING UNIT(TO 1040(X)BTU)
' as defined bylhe Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Cade,Section 25532(.)4. HEATING UNIT(OVER 100,010 BTU)
❑Yes r1No
- VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building twcupont use equipment or devices which Date Receipt If
min hazardous air comuminad.,us defined by the Bay Arca Air Quality Management BOILER-COMP(311P OR 1110.00)BTU)
District? TOTAL:
❑Yes ON. BOILER-COMP(OVER 100.0001TU)
1 M1ave rcuJ the M1aaardnus materiels rcquircments under Chapter bJS nr the Culi- AIRCONDITIONER / 'gSS ATE
fomia Hc.11K&Safcty Cade,Sections 25505.25533 and 255 W.I understnnJ that if the HEM RESIDENTIAL MECH. SQ.FT,
building dims net currently have u anneal,that it is my responsibility to ratify the occupant
of the requiamenu which most be met prosto issuarm of a Cenificam of Occupancy.
Owner or authorized agent_ {' DoteISSUED BY:
OFFICE