30687 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 30687
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRISSn:
r� l 940 T0n7a,C/ C! SANITARY NO. APPLICATION SUBMITTAL DATE
OWNCR'g AME' O ACTO 'S L
Gj NIC CONTROL
litp N R: kLIC NO: ADDRESS: ❑ V�l
CONTACC PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB /MyEECHH
ELECT '
LICENSED CONTRACTOR'S DECLARATION - ;<
1 hereby m1fmt thin I am licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
IIz�00 with Section 7000)of Division 3 o0he Businessand Professions Axle,and mylicenxc is -
F� full forestal effect. PERMITISSUANCF.
JUV Licencc Class - Lick _ WL ❑KITCHEN REMODEL
F �W Date Comment, APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
FF D on ARCHITECT DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
O z p^o� 1 undersmnJ ns y p(ons shall he used as public records
QQ UP TO 200 AMPS MODIFICATION
F W Licensed Professional - ❑INTERIOR ❑CHIMNEY REPAIR
< ; 201.10AAMPS IMPROVEMENT
C a OWNER-BUILDER DECLARATION Cmu em OVER TWO AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
—y W 6 I hcrehy affirm that I am exempt from the Cammcmr's License Law for the
x 36 U following reason.(Section](131.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
I-=WO which requires a permit m co ndowl,alae,improve,demolish,or repair any structure
rn prior to its issuance,also requires the applicant for such permit to file a signed stmemem SPECIAL CIRCUITIMISC.
f;!(} that he is licensedpursuam an the pmvisionsofhe Contactors License law(Chapur9
W OO (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE(NST. '
6 m yy that he is exempt the¢fmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by an /ADDITION [I DEMOLITION
y y applicant for a permit subjects Ne applicant to a civil penalty of POWER DEVICES
FZi^ tat more than Evc hundred dollars(S50% ❑FOODSERVICE
�p 01.as owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
e will do the work,and the strucmm is not intended or offered for sale(See.7044,Business _ OTHER
G3^ and Professions Code:The Cmunume,License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
S his own employees,provided than such improvements the not intended or offered bar NEW RESIDENTIAL ELECIR SQ PT.
sole.ILM1awcver,thehuildingnr improvement issold within awyemrrsompatian,the w SQ.FT,FLOOR AREA sftiq Pf.
owner-builder will have the huNcn of proving that he did am build or improve far par- V w^
} P-ecomle'). �R�
❑h us ow er , the Properly,,l exclusively contracting with licensed cnnhmlrrx i.
news the r of th(Scop 7W4,Rumness vad Professions Code:)The d countdrrm to
cense Law docs not apply loan owner of Property who builds or improves thereon,and QTY PLUMBINGPERMIT FEE
who contruats broach pmjcots with o contmclons)licensed pursuvntto the Connector's -
License Law, '
❑I am exempt under Sec. B&P C for this reason PERMIT ISSUANCE
Owner ALTER-DRAIN&VE ER(EA)
` Date VALUATION
WOHCOMPENSATION DECLARATION
1 hcrehy efWurundercr Penalty of pe jry BACK FLOW PROTECT.DEV( -uone of the following declarations: `
❑Ihavaand will mainainaCerifictteof Consent to selFamet,for Worker's Compen. DRAINS-FLUOR.ROOF,AREA.
motion,m pmvj�r l for by Section 3700 of the tabor Code.forte performance of the TQIfIFS TYPE CONSTRUCTION
work for sable this permit is issued. FIXTURES-PER TRAP CS u
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3710ofthe Libor Costs,bards,perirmnncc ofthe work for which this permit is issued. GAS-E.SYSTEM-1 INC.4 OUTLETS �fl�pQDUP APN
My Worker's Compensation Insurance carie,and Policy number are: 1
Carrier: s Policy ban, GAS-E.SYSTEM-OVER 4(E) ukJC
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRESMNDUSTRLWASTE INTERCEPTOR
(This senum need not beemopleled ifthe permit is borrow hundred doll ars(5100) - . BUILDING DIVISION FEES
or Ices,) OR ESE TRAP PLANCHECK FEE
I Loy any that in the Performaany
nce reu as t become
for subjech ct to
themit is Workers'
Cmaro. SEWER-SANITARY-STORM EA. PI'. ass—
not,,.piny any person in any moaner en as to become subjen to the Worked'CnmPen-
,� Applicant
of Calil'arniu.Dam ENERGY FEE _t
O WATER HEATER W/VENT/ELECTR GRADING FEE
O Applicant
h NOTICE TO APPLICANT:If,after making this Certified¢of Exemption, on should WpTL'It SYSTCM/I'REATING
h 5 become subject m the Worker's Compensation provisions of the Lubor Code,you must SOILS HE
uQ fnnhwilh comply with suctip000kimis or this permit shall be deemed revoked. WATER SERVICE
7z CONSTRUCTION LENDING AGENCY n NEW RESIDENTIAL PLMR. SQ.14, PAID
V O L hereby affirm that here it.construction lending agency for the performanceof Date R ptp
L4 F-' the work for which this permit is issued(Sec,3097,Civ.C.) -'
Lenders No.
U Lenders Address TOTAL'
yI certify that 1 have,sail this application and state that the above information is BUILDING FE 1
TA correct.l agree m comply with all city and county ansinarect and mute laws relating as QTY MECHANICAL PERMIT FEE
V z building construction,and hereby outhrdec represemouves Muds city to enter upon the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE ^
f We)egtee m save,indemnify and keep harmless the City of Coprnino against ELECTRIC FEE 6 `
Imbilitics,juI cuts.cnnsand expenses which may in any way accrue against said City
ALTER OR ADD TO MECH.
in conscquetme of the gaming of this permit. - PLUMBINGME ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ID 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signature,of Applicam/Commetor - Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle baallous material
HEATING UNIT TO 100,80 BTU)
- as defined 1,the C.Imino Municipal Code,Chapter 9.12,vad the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,000 BTI!)
El Yea ❑Na
VENTILATION FAN(SINGLE RESID) PAID
Will the it comm or furore building occupant theBuse equipment of devices which Dale Receipt p
miner? nus air ntmmninams as Defined by the Bey Area Air Qualify Mwagemem BOILER-COMP pHPOR IW.000 BTU)
Disain7 TOTAL:
['j Yes ❑Nn BOILER-COMP(OVER 100.000 BTU)
I have at the haaallous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER / ISSUANCE DATE
forms Health&Safety Code.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.ff.
building does not currently have a tenant.that it is my c,pmobday maant to madly the occupI
of the requirements which most he met prior to ho merofa Cerificate of Occupancy. I
Owner or author eed agent Dam ^T Q
ISSUED BV:
OFFICE