30370 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30370
S O IA3 I
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: � SANITARY NO. APPLICATION SUBMITTAL DATE
76 es 1 \\ Pr I-- 2\-`lG
OWNER'S NAME: PHONE: CONTRACTOR'SN ,IC NO:
Q N/C CONTROL#
IRCIITECT/ENGINEER: LIC NO: ADDRESS: ❑
mosellit
CONTACT. PHONE: BUILDING PERMIT INFO
S` ❑ Consultant Fees Paid by Applicant(Initial) BLDG' ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affims that I Am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
„D,aZ with Section 7")of Division 3ofthc looiies,and Professions Cndgend my licenscis RESIDENTIAL
��❑ in full force ande PERMIT ISSUANCE?
aUtl License ,e _ I,iap 6233$9 ❑SFDWL ❑KITCHESIREMODEL
Res. Dam
Contra cmr�.P Qn1 tf6 r'v APPLIANCES-RESIDEN'PAL ❑ADDITION ❑PI.UMBINGREPIPE
ARM TI'=S DECLARATION J PANELS
E8F..7ra/+ ❑MULTFUNIT ❑STRUCTURAL
OZ p J1 a 1 undetslwJ my plans stroll be usetl as public rccoNs IFlCATION
:! UPT02W AMPS
F'.reJ F'W Licensed Pmfc atonal ❑INTERIOR 1HIMNEY REPAIR
q� OWNER-BUILDER201-1 WIIAMPS IMPROVEMENT
•y��r-
p, I hereby affirm that am,acornet
exempt DECLARATION fmm the Convector's Licensee Law Emma OVER 11x10 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
x a d F following reason.(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELEC17tICA1. EJ OTHER
F O which requires It Permit te conswct,often improve,MmofiM,or repair any stmdurc
prior to its issuance,also requires the applicant fm such permit to file a signed statemem SPECIAL CIRCUIT/MISC.
!!alp+
that he is licensed pursuant o the provisions ofihe Contracmr's License Law(Chapter9
y00 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)m TEMP.MITER OR POLE INST. COMMERCIAL,
E1.2o yf that he in exempt therefrom end the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [IDEMOLITION
my Section 703LShy any applicant fur a permit subjects the applicant too civil penaityaf POWER DEVICES
> not name than Eve hundred dollen(8508. _ []TENANT ❑FOODSERVICE
`�6 11I,as owner ofthe properly,or my employees with wages as their vole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
C will do the weak,and the structure is Outimendedoroffered for safe(See 70W,Rosiness El OTHER
Gand Pmfeaionv Code:The Contractor's Liecom Law does not apply to an owner M OUTLETS-SWITCHES-FIXTURES
property who builds or impmers thereon,and who dues such work himself or through
his own employees,provided that such improvements are not intended or nffercd for NEW RESIDENTIAL BLF,CTR SQ FT.
salt.If,however.Ne building Orimprovement is sold within one yemof completion.Ne rSQ,FT.ILOORAREA WSQ.FT.
owner-loilder will have the burden of proving that he did not build or improve for pun
ptrse of sale.). !}
❑ 1,as owner of the property,um exclusively contracting with licensed connactorx m TOTAL:
construct he project(Sec.70,14,Business and professions Code,The C000_,s Li 966 l 'a
cense Law does notapply to an owner Of property who builds or mpmves thcomm,and QTY, PLUMBING PERMIT FEE �L �-
whoaontractsfor such p le Projects with a contractorho licensed pursuant to the Convectors
License Law' PER ISSUANCE
❑1 am esempt under Sec. B&P C for this reason �y
Owner Dam ALTI7R-GRAIN&VENT-WATER(EA) L- VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm..on,penalty of perjury one of the following dechunio e:
❑I have and will maintain a Cendicate of Comem to self-imute for Workers Compcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
salion,ax provided for by Section 3700 of Ne Labor Cade,for the performance of the
work for which this permit is issued. FIXTURF,S-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance.as required by Section
37M of the Labbe Code.far the pedoaance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Cogtpensalion t mu cgqcurrier and Policy n Lg� -
Canler, S1atFC a#1 Q Policy No.: flt a7 9�I GAS-FA.SYSTEM�OVER 4 IEA)
CF,RTI FICAM OP IAEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed ifthe permit Is for One handle collets($100) fi UILDING DIVISION FIES
or less.) GRkiASE TRAP PLANCHECK FEE.
I certify that in the performance of the work for which this permitis ismed,I thall
SEWER-SANITARY-STORM EA.200 IT.
oat employ any person in soy manner vo as to become whject m Ne Workers'Compete ENERGY IZE
salmon Laws of California.Date WATER HEATER W/VEPID iLEC R
z O 'Applicant GRADING FEE
try NOTICE TO APPLICANT.If,eller making this Certificate Of Exemption,you should WATER SYSTEM/I'REAI'[NO
a ; becmne subject to the Worker's Compensation provisions of the Labor Code,you must SOUS FER
Lkl forthwith comply with such provisions or this permit shall In,deemed revoke, WATER SERVICE
LL A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.17. PAID
L)0 l herebyunionrat theuhcrc isued(Seeconstruction lending agency for the perfntmoaenf Date Receipt#
W. f'+ the work fur which this permit is issued(Sec.3097.Co.C.)
O U Lenders None TOTAL:
y Lenders Address TOTAL:
L, a 1 viol ify that I have read this application and state that the above information is BUILDING FEE
N correct.I agree to comply with oil city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction.and hereby authorize representatives of this city to emerorym the SEISMICrUR
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)am aNm
gree ave,indemnify and keep nlea the City of Cupemno againvt ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acemeegoinst mid City ALTER OR ADD TO ME CH.
in consequence Of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTAN AND WE] .COMPLY WE A LNON-P01 i AIR HANDLING UNIT(TO 10.000 Cnn
JOLLUCH RF,GULATIOt /� ` MECHANICAL FEE
AIR HANDLING UNF(OVERROXECI-N) CONSTRUCTION TAX
Signa ore of ApplicanUContracmr Date EXHAUST HOLD oODUCq
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplimmt or future buildingapuntsmre orhandle hazardous meteriul HEATING UNIT(TO IW,OW BTU)
as define by the Copra ino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Section 25532(a)q HI?ATING UNIT(OVER 100,000 BTU)
❑Yrs ❑Nn VENTILATION PAN(SINGLE RESID) PAID
Will the,applicant or future building occupant use equipment or devices which Dame Receipt a
emit ham dous air conwminams as defined by the Buy Area Air Quality Managentem BOILER-COMP(3HPOR 1 W,IIf1011TU)
District? BOILER-COMP(OVER 10u0k)BTU) TO
❑Yes ON.
L have read the hmuNnos mororials nifarcmemsmnder Chapter 6,95 of the Coh. AIR CONDITIONER ISSUANCE DATE
Forma Ilcalth&Safety Cole,Sections 25505,25533 and 25534.1 understand that a the NEW RESIDENTIAL MECH. SQ.Pf.
building does not eutrendy have aa
teat.Nat h is my respsnsibility w notify the wcupant
of the mquiroments which must be met prior in issuance ofa Certificate ofosea ey.
Goner Or authorized agent Dale TOTAL: ISSUED BY:
OFFICE