30381 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING molitiC•1'IDENI'IFIDAITON
BUIJILLDIINNG ADDRESS, SANITARY NO. APPLICATION SUBMITTAL DATE
C� r4ln - ICU
OWN E / PI10 E: CONTRACTOR:4 AME: �LI NO:
X / NIC CONTROL4
kKCHLTE /ENGINEER: LIC NO: ADDRESS:
JQ ❑
CONTACT. PHONE: 07`Y`+HJT BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB •MEC
❑ ❑ ❑ OE
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby et7mn Nat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
y�y100 with Section 7000)of Division 3 of the Business d Professions Codamd my license is PERMIT ISSUANCE.
RESIDENTIAL:
�FUS mfull force and e(fec( m��g 7y ❑SFDWL ❑KITCHEN REMODEL
UU LICCnse Lm.d 'T
Fzw Dere s r Contreror�( � APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE-PIPE
oe Q d as "
ARCHITECTS DECLARATION
F.,7 usARCHITECT'S ,.O MULTIUNIT ❑STRUCTURAL
ZO[ Z I understand my plans shall be used as public records MODIFICATION
O Z J UPT0 200 AMPS
u01 Lmensed Prnfcsnonel [I INTERIOR C1 CHIMNEY REPAIR
OWNER-BUILDER DECLARATION CiannON OVER
M IMPROVEMENT
11 m I hereby eflirm that 1 oro exempt from rhe Commetnr's License Law far me DVER 1000 AMPS ❑BATH REMODEUREPAI)R ❑DEMOLITION
�a$06U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER / •^
W lZ(y F' which requires a permit m C.nxuucr,.Iter,improve,demolish,or repair any sanctom
�� prior to its issuance.also requires the applicant forsuch Permit o file a signed statement SPECIAL CIRCUIT/MISC. I TQ
�. Ihm he is licensed Pursuant m the provixions of th.Cnntrannr's License Low(Chapter 9
X00 (eornmrnmng with Section 700T.Mivision 3ofthe Business and Professions Code).r TEMP.METER OR POLE INST. COMMERCIAL:
L oC that he is exempt therefrmn and the basis for the alleged exemption.Any violation of
�on Section 7031.5 by an ❑NEWBLDG/ADDITION ❑DEMOLITION
any permit subjects the epplicemmacivil penalty of POWER DEVICES
ZC} not more than five hundred dollars 15500). ❑TENANT [I FOOD SERVICE
� C O I,us owner of the property:arm 1.us with wa Cgassheir sole core IMPROVEMENT
ycmp y g Inosines SWIMMING POOL ELECTRIC
will do the work,and the structure is not imendedoroReml Tarsale(Sec.]004,Business 1:1 OTHER
G m
-. and Prolessions Code:Thu Contnmtors License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES _
pmpeny who build,or improve.thssam,and who does such work himself.,through
his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL ELECFR SQ FT
aide.IL however.the building.,improvement is sold wimin.ne yemofcomplitum.the SQ.14.FLOORAREA $/SQ.ET.
owner-builder will have the hufden of pmving that he did not build or improve for pur-
Ense.lsole.).
1,as owner of the property,am exclusively contracting with licensed mnaoctors to TOTAL:
.nsuuct the project(Sec.7044,Ba,mvs,and Profession,Code:)The Conmtemr's Li- s
cams law does not apply to an owner of property who builds or improves(thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a conaacluds)licensed pursnunuo the Comman''s Cr 6 q 1996
License Law.
E] m 1 aexempt under Soc. .B&P C Sothis mama S
PERMIT ISSUANCE v
Owner Data ALTER-DRAIN&VENT-WATER IRA) III �VALUATIONIV
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE
I hereby aBirm under penalty of perjury one of the following declarations:
•�L have and will maintain a Certificate ofCousem nt xelEmsom l'mi-Worker's C.mpen DRAINS-FLOOR,ROOF,AREA.COND.
Sado.,as provided for by Section 37M of the labor Code.for the performance of the STORIES TYPE CONSTRUCTION
n winch thix permit is issued. FIXTURES-PER TRAP
X"
hav and will mainwin Workers Compensation Insurance,as requited by Section
. Mof the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INCA OUTLETS OCC.GROUP APN
My 'a Compensation Insurance carrier and Policy number are:
Carrier: Policy So: GAS-G.SYSTEM OVER 4(EA)
CERTIFICATE OF EXIIMP'rION FROM WORKERS'
COMPENSATION INSURANCE GREASMISDUSTRL WASTE INTERCEPTOR
(This section need oat be compined if the permit is nonce hundred dmi.rs($1(x)) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK PEE
I cenify that in the performance afthe work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA
3W FT.
not employ my person manrrcm in Say r as Wrote om .
e subject to the Workers'Co.,.. ENERGY FEE
0Z Satinn Laws of California.Data WATER HEATER W/VENT/ELECIR,
O Applicant GRADING FEF.
N NOTICE TO APPLICANT If,after making this Cer ificare of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions or the Labor Code,you must SOILS THE
W '.r fima ithcomply with such provisions or this permit shall be deemed resulted. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW R[SIUEMIAL PCMB. SQ.FL PAID
V Q work
which
Pe there isaemta.n3097,lending agency fora,perf.nnancc of Data Receipt
OF the work for which Nis permit is issued(Sec.J09],Civ.C.)
L) lenders Name TOTAL:
Lcndcr' Address 'TOTAL:
1
I c<nily that 1 have real this application and scam that the above nomination is BUILDING FEE
fain comet.l agree to comply with all city and county ordinances and sum laws relating to QTY, MECHANICAL PERMIT FEE
U 7building construction,and hemhy autha rampresemativeso(this city menmrupon the SEISMIC FEE
ahovnmcumned Pmpeny for inspection purposes, PERMIT ISSUANCE
(We).9.to save,indemnify and keep humdes the City of Cupertino against ELECTRIC FEE
Iiubilities,judgmems,cost and expenses which may in any way.ccme against said City ALT'ERORADDTOMECH. PLUMBING PCE
in consequence of the gmming of this permit.
APPLICAn UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING I.El to,"CFM)
SOURC 'ULATIONS. MECHANICAL FEE
Six1
o—L '• AIR HANDLING UNIT(OVER IQfgp CFM) CONSTRUCIONTAX
S' reoI ApplicanUContmct Dam EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
BAZAR US ALS DISCLOSURE
Milthe...heart.,fmmm building oecupam St.. rhondle humedous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)] HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VCN]'ILATION FAN(S INGLE RESID) PAID
Data Receipt#
Will the air ctromorfumre building occupby
nt By Am
ent or uality .nage ant BOILER-COMP GET OR 100,000 BTU)
•emit hamNous air cnm.minanb as Refined by the Buy Arta Air Quality Management TOTAL:
Dntrin. BOILER 100,0011 BTU)
F1 Yes ❑Nn •
I have read the hmnNous materials Aquiroments under Chapter 6.95.fthe Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Secdu 25
m505,255]3 and 25534.L understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building da.mu cummly have a tenon..thar it is my mspomibility,to notify Ne occupom
of the requirement which must be met prior to issuance of a Cer ifeam of Occupancy.
Owner or.ulbonred agent Uma TOTAL: ISSUED BY:
OFFICE