30770 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PHRMI I'N( e] O 70
BUILDING DIVISION APPLICATIONA'F.RMIT PLUMBING-MECHANICAL J r
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. NI-PLICAI10 SUBM1 I'ALDNIf
LU✓rT- GlZo lv��� G>Uvcp� � � � y. f �
OWNERS N I'HO 1': CONTRACTOR'S NAME: LIC NO:
• / \ . 0 NIC CONI ROL# Q
ARCHI E" LIC O: A RESSi El3� J
COM'ACT: PHONE BUILDING PERMIT INFO
gad) f I�6 16 ❑ Consultant Fees Paid by Applicant(Initial) HLne_ r:L� 1'L�UMyII MECH
y/
t O a LLmC/ LN lH 1/L
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 n<reny acct thus 1 am licensed rneer proni.ian ar Cramer v fcommerung � JOB DESCRIPTION
OKZ with Sermon TXgBofDivisim 3 ofthe ImmuessonJ Profession Cade.and my license is RESIDENTIAL,
WOO PERMIT ISSUANCE —
QFU— Licene full force Classed eRar. OSFDWL GKITGHIiN RIeM0D1iL
UU License Class Conor APPLIANCES-R[SIDGVI'IAL ❑ADDITION D PLUMBING RE-PIPE
NQ a. Dam Contractor
(_,pw AMCall la,
DECLARAI ON PANELS /� OMULTLUNIT GSTRUCNRAO
Z 0 i?Z 1 understand my plans shall he used as public records MODIFICATION
OZ—O UPT0200 AMPS /� ❑INTERIOR ❑CHIMNEY REPAIR
[..r?FW Licensed Professional 201-I(0)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000AMPS GBATH REMODT:L/RCPAIR ODFiMOLRION
IY C
a(Osc 1 hereby affirm that I am exempt from the Contractor's License Law for the
� iV following monsoon.(Section 7031.5.Business and Profesmans Cole:Any Cryor county SIGNS ELECTRIC DOTTER
1+13 LL y¢ which mimics a permit to consumer,after,improve,demolish.or repair any'hucture
F-�mO.] prior to its issuance,also requires the applicant for such Permit to file a signedsmemem S .CIM -
E W y tbar he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 9
Iel Z0 (commencingwith of Division 3 of the Business and Professions Code
COMMERCIAL,
wi )or TES .M' POL
a L O C that he is exempt therefrom and the basis for the alleged exemption,any violation of D NEW BLDG/ADDITION D DEMOLITION
X^, Section 7031.5 by any applicant for a permit subjects the applicant to acivil penalty of POW ES
X=, not more than five hundred dollars(851X)). ANT C1 FOOD SERVICE
IMPROVEMENT
_< DLasowner nfthe property,
estrachimi...Imrrovimthwages fmm1eir moc Si,v.7viBsiness SWIMMING POO ELECT' IC
EFC will dothewark,and the o Cmaisam,Licese].a do far of apply 1.off Business DOTTER
3 m and Profession Code:The Cos there''License w l do ssuc nm apply R,if owner .. )IITLETS-SWITC -FIXTURES
his..property who buil,s or improves thereon,and who arms of ac work himself or through
his own employees,provided that such impnsvnnenu arc not encode,centered fur NEW RESIDEN'114EL691al SQ FT.
sale.If,however,the mildin,mimprovement is sold.,thin one year ar completion,the S .B6��'''//0YR61EA E/SQ.Im
owner-milder will have the harden of provingdon hedld not buildor improve bitpun ��JJ
,Puled. n
1,as owner rf the pmryny, it,exclusively rnntmating with licensed cnva'emrx to ArR
c tact the project(Sec.9(Wq Ilusmesx and Pmfcsxioos Ccmc:)T eContmcto8s Li- ef(I1f�
cess Low don not apply to an owner or propeny who milds or mproses themon,and QTY, PLUMBING P E jy, /I[(I(II/
who rmntmetxl'o ,uch pr,,jatx wimaanntmctor(s)licensed Pursuant to the Comments '/I
License Law, PERMIT ISSUANCE urf.M I'As
D lam eauup der See. .B&1'C for this reason
ALI ER-DRAIN&VENT-WATER(EA) VA LUA'1'ION
W( KFR'S CUMP.NSAI']ON DECLARSDON BACK FLOW PROTECT.DEVICE
affirm /if oOO�
.,i4`1 In I
• hereby arm under penalty ofp,rjury one of lie lidlowing declarntionx:
havennJ will rminmin.a Certifcmcrf Consent In self-imme for Wrrker'x Conmco- DRAINS-FLOOR,ROOEAREA.COND' S'1'ORIE 'I'YPECONS'I'RUCTION
action,II.provided for by Section 1700 of the Later Code,for the pc,I name ol'the
work fm which(his lw..it is Issued, FIXTURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance,-.rcyuircd by Scaion
3700 ofthe Labor Code,for the l,rhammnce ofthe work for which this pennitisismN. GAS-EA.SYSTEM-I INC.Y OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cameo Policy Na:
GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE,OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE G0.LASl%INUUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Ofiis section need not be mnsplaalifthe permit is Tonne hoodoo(dollars($10(a GREASE TRAP
or less.) PLANCHECK FEF;
I certify that in the performance ofthe work for which this permit is Issue,,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to hsubject e:ome subjeco the Workers'Compen. ENERGY FEC
0 Z scion Law'af C.1 forma.Data WATER HEATER WNENT/ELECTR / GRADING EEE
Z 2 Applicant
y NOTICE TO APPLICANT.IL after making this Cmtheme of Exemption,you should WATER SYSTEMOREATING
a ? become subject to the Workers Compensation provision of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or all,permit shall he deemed revoked. WATER SERVICE
a �
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ,FT PAID Date Rettiptp
U 0 (hereby affirm thatthem is a construction lending agency for the performance of
LL F-' the work for which this permit is issued(Sec.3092.Civ.C.)
0 U Leader's Name l TOTAL:
Lender's Address
0. I verify that 1 have read Nis application and stem that the above information is BUILDING PER
F+ to correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building i,manue,im,ond Imicla mmdse apremintives ofthis city m eructation the SEISMIC FEE
alcove-mentioned pmpeny(a,inspection purposes. PERMIT ISSUANCE
(We)egme to save,indemnify and keep hmmlcss the City of Cupertino against ELECTRIC FEE
babilities,judgrnrms,cons and expenses which may in any soy accuse against said City ALTER OR ADDTO MECH. fit PLUMBING FEE
in con,"mace of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM(
SOURCE GU ONS MECHANICAL FF.F.
�\ M //q,e /t lI ���/�� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCDONTAX
Signature oofA IirmuVoteacor y Vie/ EXHAUST HOOD(W/DUC) HOUSING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Scctirn 25532(a)'I HEATING UNIT(OVER 100,000 BTU)
D Ye. FI No PAID
VENTILATION PAN(SINGLE RESID) Umc RcwiptIf
Will the applicant or future building occupant use eti ipmem or devices which B01LE0.-COMP GET OR 100,(100 BTU)
mit hazardous air contaminants as Jelined by the Bay Arca Air Quality Management
fU 1'Ah:
'Dlstrictl '
❑Yes Cl No BOILER-COMP(OVER 100.0(1(1 BTU)
I huvc mud tbnmmrJnux mumri:Jx reyuirnncntsnndcr Chapinr(i95o1'he Cul, AIR CONDITIONER
ISSUANCE DA'I'fi
forma Health&Solely Code.Sections 25505,25533 and 25534.1 midcrxtand(hut it'the NEW RESIDENTIAL MECH. SQ.FL
h11Id Jr not curz¢ndy have umnnnt.ohm it h'nry rcxpunviM1llhyanality lbc ruupmn
of the 4 mems whlchn et rte amt unu ismance nl:r n "eco ul Ocau,aney.
Owner nr out r rngcn ata ALI BY:
OFFICE