30007 ,.APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 30007
BUILDING DIVISION APPLICATION/PERMIT PLUMB NC1-MECHANICAL.
BUILDING ADDRESS:
BUILDING PROJEM-IDENTIFICATION
SANITARY APP8LICATaIQN SUBM AL DAT[
atq ao Cad �__ � 1
U f
e/Iiure / n
PHNE:�+ L CONTRA .0 y
OR' pME: i yL.IC NO:
F �JGUC'/C INQN/ NIC CON RO x
.HIT iCf/ENGINIiER: LI NO: ADDRESS: ❑
Isis
mA, fees a?D d`D eac�e�Si.#t ,260
CONTACT: G PHONE: BUILDING PERMIT INFO
e e C'oo er ��6 p�Oo�' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT
ErLr-EE#CC�T PLU�MBB MECHH
LX, La. Ld ICh
LICENSED CONTRAC'FOR:S DECLARATION QTY ELECTRIC PERMIT FEE
I herchy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION -
{O{a��Z with Section 7")of Division 3 Of the llusirtess and Professions Code.and my license is
FBF in Poll tome and effect. PERMIT ISSUANCE AWL KITCHEN REMODEL
�UU License Clash Con APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
W Dem _ TS )Err 94A
F.
ARCHITECTS PANELS (�MULThUNIT ❑STRUCTURAL.
20 7, Iundcmland my plans shalibovud as puM1lic rtroms MODIFICATION
.5n2
ZQ UPT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
� y{N Licensed Pmfessinnuh 201.100TAMPS IMPROVEMENT
WaS raj OWNER"BUILDER DECLARATION Contractor's
OVER]Bob AMPS ❑BATH RF.MODEUREPAIR [I DEMOLITION
1 hereby affirm that 1 em exempt Is sit
the Conaacmr's License Law for the
O y V fallowing reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL El OTHER
ss+LL Owhich requires n penis to uirest a ober,improve,h Permit
t or repair any swment
gz.y thwheiOiaua.ce,aleo rcqulres the of for Contractors
Licensle a e
signedstatementSPCCIALCIRCl11T/MISCO
XW� @m M1e is licensed purnuam mthe provisions of the Conwctnrs Licence Law(Chaper9
(i((WYYYY g p O (cin he is in NSeneirson and
the
alleged
exemd An,
vi9lmm r COMMERCIAL:
gwi )o
TEMP.METER OR PULL INS
6 o C Net he is exempt)any cep li and the basis lits the alleged exemption,Any l Pen lty of ❑NEW BLDG/ADDITION ❑DEMOLITION
t°• Swtion]N L5 by any applicant for a permit subjects the applicant to n civil Penalty of POWER Of VICES
r" not mare than Eve handled dollars($500). []TENANT ❑P0011 SERVICE
ham IMPROVEMENT
Q 1,as own"ofan,pmpeny,army employees with wages as their sole cnmpensmim, SWIMMING POOL ELEMIC
d. wdldod.work,andthe strucmmisnot immusim rolfered fmsale(Scc.7014,Business []OTHER
a and Profession Cade:The Contractors License Law does not apply man owner,of oun. I'$-SWITCHES-FIXTURES
property who builds or improves ftmon,and who docs such work himself or through
his own employees,provided than such improvements um not intended m offered for NEW RESIDEN'T'IAL ELEC'TR SQ FT.
sale.If.however.the building or improvement is sold within one year of completion,be ,CSI SQ.FT.FLOOR AREA $/SQ.IT.
comer-mild"will have the home.efprnving that he didme build nr improve for par. p1 �G(µT y�
pose of.sowne t��a al/ / (��V`i0 �7 x q /
❑1,as owner of the pmpeny,,B exclusively convecting Cnd licensed)noCannranrtss . TOTAL:
en,c La the es not appl(Secy
]040.Business rop Professions ds or improves The Conmeton, nd
c mLawdoesnmapplymmownerofpropenywhosedportheCocon,end QTy, PLUMBING PERMIT FEC
whence Law
for such projects with avonaamnr(aniemaed pursaml mlhe Q,ntruem,r.
License Low. PERMIT ISSUANCE
❑tum exempt der SIhisrc
O n^- - ALTER-GRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FL OW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: ./
•7 I have and will maintain a Cenificme of Consent to aelf-inscre for Workers Compete DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE C(lN5'TRULTION
carman,as Provided for by Section 37M of the Larval Code,far the performance of be
work for which has permit is issued. FIXTURES-PER TRAP -
Cl 1 have and will maintain Workerrequ
Worker's Compensation Insurance,as ired by Section `..s
3700.17tbe Labor Cedc.fonoperfurmance of the work for which @is pennil is ismed GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am: GAS-EA.SYST1iM-OVF.RGIEA), A
Cmriee Policy Nn: IlguG'�y $ 19. 6
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR A
COMPENSATION INSURANCE BUILDING DIVISION FEB.S
rices.) y per one hundred dollar($100) WA' ER HEATER RY-STORME . PTA
(This section need native completed if the permit is for GREASETRAP - y`�•�
NCHECKFEE- 6 33 Jx�
Loy an that in the fsooner olThe became
which this mkems aed.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person m my manner w m m become subjecuo Ne Wnrken.'Compen- ENERGY FEF.
O z smion l.awsof Culifumia.Dam GRADING FEE
z Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING ^
F+ became aobject o the Worker's Compensation porsWons of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall bedecmed revoked. WATER SERVICE
Q PAID
5 z
CONSTRUCTION LENDING AGENCY NEW RF:SIDIiNT1ALPLMB. SQ. T. hate Receipt#
L)Q I for
rwhich his ponnere issed(Se 30 loading agency for the peRonnana of
f-t the work for which this permit is issued(Sec.3097.Civ.CJ
u" Lenders Name � TOTAL:
(J Lenders Address TOTAL:
�rI x 2 BUILDING FEE
[r I rectify that 1 have read this application and state that the above inl'ormution is xfx Ni
rA cortect.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
U
building conenotion,and hereby authorize representatives ofthiscity toenter upon the 1363.44
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)vgme to save,indemnify and keep harmless the City of Cupertino against ELECfRIC FEE
Iiahilities,judgmenn.costs and expenses which may in my way accme against said City ALTER OR ADDTO MECH. q f/
in consequence of the granting of this permit. PLUMBING FEE as C
APPLICANT U DBRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGJ/IL�ATIONS. MECHANICAL FEE g
// G/�//1/ AIR HANDLING UNIT(OVER 10.11011 CFM) CONSTRUCTION TA% L
/iR // C�-��1.[.t-/ II 7-�7fi—
Signal of Applicant/Cmaracmr a/vete EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE Q+
HA%ARDOUSMATERIALSDISCLOS li
Will the applicant or future building Occupant store or handle hatimno;material HEATING UNIT(TO 000.000 BTU)
as defined by the Cuprom Municipal Cale.Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)] HEATING UNIT(OVER FOR"BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dane Rtteiptx
Will the applicant or future building occupant uao e.Ail Qu or dcyiees which BOILER-COMP(HIT OR 1a0,(NIO)ITU)
emit hnxamous air communities os define)by the Bay Arte Air Quality hfanagemenl TOTAL:
District'! BOILER-COMP(OVER I00.000 BTU)
❑Yes []No
I have teed the hmarm
dous remodels repti menm under Chapter 69AIR CONDITIONER5 of the Cali- dl ANCE D E
forma Health&Safety Code,Sections 25505,255)3 and 25534.1 eadmaund Thal if Ne NEW RESIDENTIAL MECH.. SQ.FT.
building does tmtcurnmely have a mount,that iI is my responsibility to notify the oecupam
of the requirements which must be met pdnr to konamem.CeniticmeofOccupancy.Oweoramthnrind again Date TOTAL: pISSUED
OFFICE