30106 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING-ELECTRICAL PERMITNO. JK^ O1O6
BUILDING DIVISION APPLICKrIONIPERMI•r PLUMBING-MECHANICAL Vh
BUILDING PROJECT IDENTIFICATION
BUILDINQADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE
kiln
OWN R'S NA E; 1'I IL C N RACTUR'S NAME
: 10� LIC NO;
NIC CONTROL«
ARC T,CT/BNGINEER: - LIC NO: ❑
CONTACT: PHONE: L HUII,DING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) — ELPC
4,0 W.1397 PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm mad I am licensed under pmvid irm of chapter 9(commencing JOB DE CRIPTION
WOZ wim Seckian7O(10)ofDivision3ofine Business and PmfcsxianxCWgeW mylimense is RESIDENTIAL'
F- O in full rose and effect. PERMIT ISSUANCE
.wm - ❑SFDWL. ❑KITCHEN REMODEL
<Uf�l License Class Lic.«
y�Rl Dam Convenor APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
p' ARCHITECTS DECLARATION
[-ON PANE" ❑MULTIUNIT ❑MODIFI URAO
Z O y Z 1 understand my plans shall to used as public ueords MODIFICATION
O2^O UPTO 200AMPS [I INTERIOR [I CHIMNEY REPAIR
41 Licensed Psofessionel 20140NIAMPS IMPROVEMENT
J OWNER-BUILDER DECLARATION OVER RKMAMPS
at ❑BATH 10D EP 11 DEMOLITION
Q I hereby.(font met I vat exempt from me Contractors e:Any c Law for the �r
OC.0 following Mason. Fans to IIAl.0.Business and improve.
de ions Code:Any city sanctum
SIGNS ELECTRICAL DOT
1�3 ft FNa which requires a pemmid da nmswd alter.improve,demMish.lir repair my swnurc
o, primas issuance,also requires the applicant for such Permit o file v signed statement SPECIAL CIRCUIT/MISC.
cg that m
shat he is licensed pursuant e provisions of the Committal's License Law(Copler9
GAO (commencing with Section N(1(Baf Division 3 of the Business and Professions Code)or TEM P.METER OR PULE INST. COMMERCIAL,
0)a q m that he is exempt domfmm and the basis far me uileged exemption.AnY emotion of ❑NEW BLDG/ADDITION ❑DEMOLITION
WI Section 7031.5 by any applicant for a Permit subjects she applicant to a civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
LF.. not more man rive hundred dollars($500).
C3Q Las owner ofthe ro e,orm employees widh wa es as theirsole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
22 O ❑ t Pe ct Y8 pens.
will b she work,and structure Cont is not intended slumberedw do for sale
,pl(Sec.to an Business ❑OTHER
L �_ and Pro(essinns Cndc:The Contractors license Law Van nm apply.an owner of OUTL SWITCHES-FIXTURES
property who builds or improves themon,and who does such work himself ar through
his own employees,provided that such improvements um not ouldml or offered for NH [ IAL F.LELTR SQ IT.
tale.If.however.the building or improvement ha sold within one year ofcompletion,the SQ.FT.FLOOR AREA $ISQ.FT.
ownerbuilder will have the burden of proving that he JiJ not huilJ lir improve far par- �
pose of sale). -
1,as owner of me property,am exclusively contracting with licensed conlo ctnrs m T(YI'AL:
construct Be project(Sec.7044,Business and Profcavlons Cala:)7 he Coutmchv's Li1 ,J
cense Use does not apply.an owner of property who builds or improves dherenn,and QTY, PL BIN PE FEE �,/�
q Cr
who contracts for such projects with a comrnmnne)licensed pursuant at the Connector's
License Law. PERMI'TISSUAN E
❑1 em exempt under Sec, B&P C for This rcasan
,. - m ALTER-DRAIN&VENT- A) VALUATION,
Owner Da
• WORKER'S COMI'INSATION DECLARATION BACK FLOW PROTECT DEVIC
I hereby affirm under penalty ofperjury line of the fallowing declarations.
I haveand will common.Ccniticmcof Consenrto self-insure for Worker's Compcn- DRAINS-FLOOR,ROOF,AREA,COND.
,.act.as provided for by Section 3700 of the Lahr Cudc,far the Performance.11he - ASTORIES 'TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP Jlljl/ ��
❑I have and will maintain Workers Cmnpcnsmion insurance,us required by Section
3700ofshe Lubar Cod..forthe perlormarteof the work for which thispermit is issued. GAS-EA.SYSTEM-I INC. OUTLETS f OCC.G1 APN
My Worker's Compcnsm inn Insurance currier and Policy number arc: I yVz,
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) �^Ur- -
CERTIFICAB'E OF EXEMPTION FROM WORKERS' Lr t I IIHI)
COMPENSATION INSURANCE GREASEANDUSTRL WASIE INTERCEPTOR
(This section need not be completed Bthe permit is forone hundred dollars($lab BUILDING DIVISION FP.0.S
or less) GREASETRAP -
PLANCHECKFEE
Toy an,that'por mom druanycalmance of the work far whicM1 mit permit is issuW,lshall gEWIiR-SANITARY-STORM EA.200 PT.
not employ eny person in any manner riles/pJpCt�e�gjga/o the Workctd Cmnpcn- ENERGY FEE
,� cation Laws f lifym'{a Dam I / / VN 1�
z0 Applica 1 141 I WATER HEATER WNENT ELECfR GRADING FEE
kn NOTICE TO PPI ICANT:If,all pairing this Canificall,of Exemption,you should WATER SYNTWGREATING
abecome subject.the Workers Compensation Provisions of the Indo Cade,you must SOILS FEE
boom.int comply with such pfrvisim,mmis Not shall bo deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDINGAGENCY NEW RLSIDpNT1AL PLMB. NQ.FL PAID
V -a hereby which thi mauheu isaconswcti30 lending agency fanhe performance of Date Raeipt«
� the wah for which this permit is issued ISec.3097.Civ,CJ
O F" Landers Name TOTAL:
LViI Lenders Address TOTAL:
y 1 minify that 1 have read this epplicmion and arum mat the above iifunmtion is BUILDING FEE
Vl correct.l agree to comply with all city and county ordinances and state laws ranking to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby authorize mptesentatives ofthis city to enter upon the SEISMICFEE t
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ague.save,indemnify end keep hamde.the City of Cupertino vg.into ELECTRIC PEE
aiabilities,judgmems,costs and expenses which may in any way vccme against said City ALTER OR ADD TO MECH.
in consequence of she gmmmi
ing of this pert. PLUMBING FEE
APP O IUNDERSTANDS�� AND L COMPLYdsf.L NON-POINT AIR HANDLING UNIT(TO IR IBN FM)
SPURT-NT U '1'1 NS. /UI NON MECHANICAL FF.E
AIH HANDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
h�ig mfApp1wgrmU.mTmto, Data EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theapplicant or future huilding.ceopantmme or handle huzardnur material HEATING UNIT(TO 100,000 BTU)
as defined by she Capsicin.Municipal Cods,Chupmr 9.12,and the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 1 MOOE BTU)
C]Yes Ug No VENTILATION FAN(SINGLE RESID) PAID
,` Dam Receipt«
Will the applicant or Palaa building ecoby the Bl use co Air
Qualor ity
Management
which, BOILER-
emit ict? us air c.nmminame as defined by the Huy Arrau Air Quality Management COMP(7HP OR 100,000 BTU)
Disvict1TOTAL:
❑Yes p�`'Nn BOILER-COMP(OVER 100,00)BTU)
I have re:td the he...dousmudcritif,m amnarms under Chapter 6.95of dam Cali- AIR CONDITIONER ISSUANCE,DATE.
rami.Ileal.&Safety Calc,Sections 25585,25533 and 25534 1 undcrma ld that if the NEW RESIDENTIAL MECH, SQ.FT.
b ]it duesnat ome tlyhay.aten mat itismyor".o mility set ramify dile occupant
fd yuiremLetl11sw Imus he 't r 1�suwm�'r1II ertif/ty�//,1�Oke{�m�j� /y _
��al O,, AIA agent
inr VJ A Q l f lY 41/�lnl
O�Yoiu s orTZcl'a6 m me - TOTAL: ISSUED BY:
OFFICE