30501APPLICANTTO FILL IN.INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY sYR CI IPPRTLN(1 BUILDING - ELECTR
BUILDING DIVISION APPLICATION/PERMIT
305011
.ARCHITECT
i GINEER: LIC NO:
A )R SS: /
37011E -41
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CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (initial)
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
❑ E] El
ICENSED CONTRACTOR'S DECLARATION of CON
I hereby affirm provisions 1 um licensed under pvisinns of Chapter 9(cmnmencing
with Station 7") of Division 3 ofthe Business and Professions Code, and my license is
Lnfull force and of t
License Cla s C Lic.M
Date Contxcmr
ARCHITECT'S DECLARATION
lundcmnnd my plans shall he used as public mcoNs
QTY.
F.LECI'RIC PERMIT FEE
JOB DESCRIPTION't"
RESIDENTIAL:
0SFDW1. El KITCHEN REMODEL
❑ADDITION PLUMBING RE -PIPE
❑
El MULTI -UNIT El STRUCTURAL
MODIFICATION
[1 INTERIOR ❑CHIMNEY REPAIR
IMPROVE T
❑B FMODFI/R-PAIR [I DEMOLITION
'
'INER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPT021p AMPS
Licensed Professional
OWNER-BUILDERDECLARATION
1 hereby affirm that 1 un aempt from the Con ow or's Liecuse Law fm the
following fensnn, (Section 91 ..m Business and Professions Code: Any city or county
demolish, fi repair any swdure
which its issuance,
alter. nt for
pdornincensed gvtuantto the thovisio satire Contrach cmiuofile amseLts signed statement
ss a n peroso to lmors the
(col he it licensed pSectionnthep,ovivionn3 oft Contmcmds License (Choriong
(commencing with Section 70)0)of Uivisian3 of the Business and Profession Code) or
that he is exempt theral'rom and the basis for the alleged exemption. Any violation of
Section by any applicant for a permit subjects the applicant to v civil penalty of
t more than five hundred A.Ilors ($5 00).
1, as owner of the property, ter my employ«a with wagesatheir wle compensation,
will do the work, and the structure is not intended muffercd mrsole(Sec.](kW, Business
and Professions Code: The Commands License Law does not apply to an owner of
pmpeny who builds or improves theme , and who does such work himself or through
his own employees, provided that such improvements are not intended m offered for
..I,.If, however,the building or improvement issNd within one yearofcoepleti.nfla,
owner -builder will have the harden of proving that he did oat build or improve for pur-
pnse of wlrn)e
E]1, as r of the pmpeny, am exclusively conducting with licensed contractors it,
onstruat the project (Sec. 7144, Business and Itofe,dans Code:) The Commands Li-
censer Law does not apply toanowner ofpropenywho builds or improves thereon,and
who contracts 1'or such projects with a contractors) licensed pursuant n the Contractors
License Law.
❑ 1 am exempt under See. , B at P C for this reason
201-1000AMPS
OVI'.R LWOAMPS -
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISE.
TEMP. MIiTER OR POLE INST.
COMMERCIAL
❑NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT El FOOD SERVICE
IMPROVEMENT
[]OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
NEW RESIDENTIAL L'LECTR SQ FT.
SQ. FT, FLOORAREA E/SQ. FT.
gi Q
VA
�L 1.�
Gl'T11s/ of VUf LNIINO
TOTAL:
QT'y. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN&VC -WATER (EA7IPIW
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury one of the following dcclamt inns:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compem
index, as provided for by Section 37M of the LuMr Code, for the Perfommne. of the
work farwhichthis permit is issued.
AI have and will maintain Workers Compensation Insurance, n required by Section
11 of the Lobar Code . for tire perforcomcenf the work for which this permit is issued
My Workers Ct Iysumis career and Policy numbs, are:.
Curri1./diw Vww/i Policy Nn: AlAl/N11�{T(IOC-_n
CC I .ATE "EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed Erie pend, is forms, hundreddallors ($]hit)
or less. -
I cenify that in the perlbrmanceof the work for which this permit is issued l shut[
not employ eny pagan in any ..not, so as a become subj«uo the Wake.' Compete-
.sat inn Laws of California. Date
Applicant
BACK FLOW PREM. DEVICE
DRAINS-fLOO :A, OND.
STORIES
TYPECONSTRUCTION
FI%TURES - PE R
GAS-EA.SYS ? INCA '.ET
OCC. GROUP
APN
v!
GAS-FA.SYST ER 1
CREASEBNDUSTEL WA. TEI C PTOR
BUILDING DIVISION FUCS
GRF.ASETRAP
PLANCHECK FEE
SEWER -.SANITARY -STORM EA. 700 FT.
ENERGY FEE
WATER HEATER WNRNITIELECTR
GRADING FEE .
NOTICE TO APPLICANT: IL otter making this Certificate of Exemption, yon should
became subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or thispemrit shall he deemed revoked.
1 CONSTRUCTION LENDING AGENCY
\ I hereby affirm that them is a construction lending agency for the performance of
the work for which this Permit Is Issued Six. 3197, Co, C.)
Lender's Name
WATER SYSTENIGREMING
WATER SERVICE
SOILS FER
PAID
NEW NESIDENTIAI. PLMB. SQ. Ff.
Data Receipt#
1
'TOTAL:
TOTAL:
Lender's Address
BUILDING FEE
I cenify that I hove xed this application trod stem that the above information is
taxes. L agree to comply withal] city and county ordinances and state lawn relating n
building conswction, and hereby author« representatives of this city to enter upon the
above-mentioned property for inspection puryoxs.
(We) agree to save, indemnify and kap homeless the City of Cupertino against
Liabilities,judgments, costs and expenses which may many way arem, ugainstsma City
in ... sapience of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WO 11 ALL NON -POINT
SOURCE REGULATIONS.
-
QTY. MECHANICAL PERMIT FEE
SEI SMIC PBE
PERMIT ISSUANCE
ELECTRIC FEE
ALTERORADDTOMCCH.
PLUMBING FEE
AIR HANDLING UNIT LTO 10.1100 CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,M)CPM)
CONSTRUCTION TAX
Signature of Applican/Cmaracar Dna
HAZARDOUS MATERIALS DISCLOSURE
W II Ne applicant or fmure builJing ocsvpam mort or handlehvvMous material
as defined by the Cupertino Municipal Cale. Chapter 9.12, and the Health and Safety
Cafe. Section 25532fa)?
Ll Yes [:j No
Wi11 the applicant or future building occupant use equipment or devices which
mit hazardous air ca mminants as defined by the Bay Area Air Quality Management
Dlstrict4
❑Yes ❑Nu
I have octad the hnaanlous materials requirements under Choler A95 of the Cali-
4 P
no Scurry Cafet ea ions 25505, 25533 and 25534.1 understand ml that Him
fomite Beirutcars
arrivengdoustems which ormilannam,that Isets'. is.. atter. ritifiete of me (without
arrive txpuixnxnta which muy(�e ted pri�rm issmun�fa Cenificax of (keutuarev.
EXHAUST 11001)IW/DUCT)
HOUSING MITIGATION Mr."
HEATINGUNITOD100.00013TU)
"
HEATING UNIT(OVER 100#41 BTU)
PAID
VENT] LATION PAN (SINGLE NES ID)
Date Receipt #
TOTAL:
ROILP.R-COMP (3HP OR 100,008 BTU)
BOILER - COMP (OVER 107,001 BTU)
A]R CONDI GONER
ISSUANCE DATE
/ ^
/ J
NEW NESIDENTIAh MECH. SQ. PI',
•"'^...I (^ V / ISSUED BY:
OFFICE