30003 AP?LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 4 BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. O Q O I(�V
BUILDING PROJECT IDENTIFICATION
' BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
0< </O a OLViso Cj,4 r ��a7
O ER' N Mr: PHONE: CyNTRAC9 SNAME:' LIC NO:
i -ureSLLC 9SS--GDO09, tVC� pn� WC CON'TROLa
.stItstaA HI CAINGINEER: LIC NO: ADDRESS: F-1
r .A .r- feats aoaso Acaci S�,J7: a6 D
CONIACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB L�
M�CHw
J�ee Coe err y0� O / r'9
LIC DE
SCDCONTRACiOR' CLARATION QTY ELECTRIC PERMIT FEE
I nereny antrm roar 1 am b«ns«I ander provisions nr,Cri in 9l onmmendng JOB DESCRIPTION
,�0p nim Smrion]001D of Division3of the Rosiness and l'mfessinns Criminal my license is PERMIT ISSUANCE �y�
H full forte and effect.
SN `� DW L El KITCHEN REMODEL
RESIDENTIAL-
.4 U License Class Lic,g
6 APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE+�u) Dam Contractor �/
F.Oon ARCHITECT'S DECLARATION PANELS gMU1.TLUNI'I' [-I STRUCTURAL
Z p v2 Z I understand my plans shall be used as public recon+ MODIFICATION
0,•2;,.0 UP TO 200 AMPS El INTERIOR C3 CHIMNEY REPAIR
F4Iay Licensed Professional 2111-IMIAMPS IMPROVEMENT
gY£� OWNER-BUILDER DECLARATION OVER 10011 AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
C Wst I hereby affirm that 1 am exempt from the Count License Law for the
3 O y U following team .(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W which requires a permit ria co isomel,alae,nnpmve,demolish,or I Pah any saumure
0 pme ntitsi.au..ce,also acquires roeapplicaet furnish permit m file o signal smmmenl SPECIAL CIRCIA VMISC.
GE dun he is licensed pursuant mine provisionsofthc Contractors License Law(Chaptcr9
CO (commencing with Section lo)a)o'Division 3 or the Business and Professions Cone)an TEMP.METER Oft POLE INST. COMMERCIAL:
d ca K that he is exempt therefrom and the basin for the alleged exemption Any violalion of ❑NEW BLDU/ADDITION ❑D17MOLITION
4•
=} Section]0310 .5 by any applicant for a permit subjects the applicant In a civil penalty of POWER DEVICCS
[]TENANT ❑FOODSERVICE
FZZ nal mre man five hundred dollars($500). 61
qO ❑'1,a.+owner of the pfnpeny,or my employees with wages us their sale cnmpenxmion, SWIMMING POOL ELECTRIC IMPROVEMENT
22_ will Jo the work,and thestmcmre is not intended orofered for sale(Sm.701 Business E]OTHER
6'3 m and Professions Cale:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
,his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEMR SQ PT.
sale.If.however.the building or improvement is sold within one year of exmpletionahe SQ.FCFLOORAREA S/SQ,FT.
owner builder will have the burden of proving that he did not build at improve for put-- e�
pose of sale.). _ / SP
�'!a N a+ 7
❑1,.a ownerof the poapery,am exclusively emumcllng vilh licensed comacloc+to TOTAL: �� J�
construct the project(Sm.]014.Business and Prof essions Calc:)The Contractor's Li- 3 Q MT]a/ 9/l a/c
rix law does not apply to on owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE Ota[
who contracts for such projects with a cnmractons)licensed pursuant o the Contractors
License Law. ' PERMIT ISSUANCE
❑lent exempt un rSm. ,tl&PCT rthis(enwn
O n,�. ALTER-DRAIN&VENT-WATER(Ids) VALUATION
WORKER'S MI'CNSATION DECLARATIONl' " BACK FLOW PROTECT.DEVICE
I hereby affirm under petalry,of perjury,one of the following dealararions:
❑ I have and will maintain a Certificate of Coment to self-imme for Worker's Compsn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
onion,as provided for by Section 370X1 of the Inbar Cale,for the paffermance of the
work for which this permit is issued. I FIX]URES-PER'IRAI' - d
❑I have and will maintain Worker's Compensation Iru menet.as required by Section
3700ofine laborCode,for the per(amwceofilm week for which this permit is issued. GAS-Hp.SYSTEM-I INC.4 OUTLETS OCC.,Q06 2 8 APN
My Workers Compensation Insurance carrier and Policy number are: pul\4
Cartier: Policy No.: GAB-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
- BUILDING DIVISION PEE$
(This secion need nut hcconsplated if the pcnnit is Tonic hundred dollars is 110) GRCABE TRAP
or leas.) PLANCHECK FCC S8s3T�
toy modifythatint he anyreammaceo as
work for suich ject to are W is issded,[,hall'Compr- SEWC:R-SANITARY-STORM LA.2Ip FT.
wr employ any person in any ionone so as to become subject m the Workers'Cumpen- ENERGY FEE
ZZ ration laws of California.Uma WATER IIEA'I'I7R WNENVELF,CTR
Applicant GRADING FEE
try
NOTICE TOAP.due Worker's
aftC. mn.,,.w sCisions of the
Labor n.Core,
is.
WATER SYSTEM?REATING
become subject y it Worker's Comas or this provisions of rhe Labor Code,you must SOILS PER �-
✓,.a
forthwith comply with such provisions or this permit shall 6e JcemeJ revoked. Wp'flilt SERVICE a
f� Q
]z CONSTRUCTION LENDING AGENCY NEW RFSIDF,NIAL PLMB. SQ.FT PAID
V l hereby affirm that there i......wction lending agency for the pertmmance of Date Rcceiptp
U. — me work for which this permit is issued(Sec.3097,Civ.C.)
Q U Lenders Name b TOTAL:
Under.,
Address TOTAL: ,aa Oa r
L4 1 certify]hut 1 have read this application and state that the.lwve information is BUILDING FEE
V) coram.l agree to comply with all city and county ordinances and state laws relining to QlV, MECHANICAL PERMIT FEE
(.J ,z building contraction,and hereby authorize eeprescmatives of this city m enter upon me SEISMIC FEE
aMvomentowed primary for inspection purposes PERMIT ISSUANCE AAp
(We) g.to rove,indemnify and keep hnfmleea the City of Conamms ngainea ELECTRIC FEB �M14a
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR At)])TOMECHax.5p r
asequence of me granting of this permit. PLUMBING. FEE d�W
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,000 CFM)
SOURCERE LATIONS MECHANICAL FEE
`� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX 013.yb
Signd cera wApplicant]Contracmm /rte EXHAUST HOOD(WMUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Wall meapplicam orfmrclimliingmatuara manhandle hazardous mated.] HEATING UNIT(TO 100.0X10 BTU)
as defined by me Cupertino Municipal Cade,Chapter 9.12,and use HaWth mW Safety
Code.Section 25532(x)'! HEATING UNIT(OVER 100,000 BTU)
[I Yes ❑No PAID
VENTILATION FAN(SINGLE RESID) Date Rcceiptp
Will the applicant or future building occupant use equipment or devices which
is em it hazardous air contaminants a%defined by the Bay Arca Aar Quality Management BOILCR-COMP(3HFOR 100,00i /a y/f
DictrictP TOTAL: I+ Vs/+
❑Yes []NoBOILIiR-COMP(OVF:R 100,000N'VU) -
I haveudthc hazardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
feat.Health&Safety Calve,Sections 25505.25533 and 25534.1 understand that if the NEW RES]DF,NTIAL MECH. SQ.FT.
Wilding does not emrendy have a tenant.mat it is my responsibility to notify me occupant
.(,he requirements which must he at Her to issuance of.Certificate of Decapvte,
Ownwintumodredagem Data TOTAL: 'a ISSUED DY:
OFFICE