30627 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -BUILDING-ELECTRICAL PERMIT NOL.
. OBUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
627
UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
'T,'1 Q6
N 'S NAME fHONF:� CONTRACTOR'S NAME: LIC NO: N/C CONTROL»
zkm- )-u--a-- K /s SING Sao
aRCHITGCT?:NGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
• ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION - QTY. ELECTRIC PERMIT FEE
1 hereby aboard drat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�a'Z with Section 700()of Division 3 of the Business and Professions Code,and my license is
00 y PERMIT ISSUANCE RESIDENTIAL'
in full force and effect.
❑SFDWL [I KITCHEN REMODEL
6 Uy U License Class Loc.M
y6F Date - Contractor APPLIANCES—RESIDGNTIAL ❑ADDITION [_1 PLUMBING RE-PIPE.
'prp ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z i,2 1 understand my plans shall be used as public records PANELS
OZ UP TO 200 AMPS MODIFICATION
P E'tp�i Licensed Professional El ❑CHIMNEY REPAIR
a OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
¢c�• '� OVER AXX AMPS ❑BATH REMODEUREP IR ❑DEMOLITION
F W Q I I hereby affrm that 1 um exempt from the Cial stirs License Law far the
O y U following rwson.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELCCfRICAL ❑OTHER
k
kit b• which admires a permit m commit,alter,improve,demolish,or repair any structure(y.�, prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
2 y that he is licensed pmsmmt to the provisions ofthe Contractor's License Law(Chapter 9,
QD (commencing with Swdon](N10)mf Division 3of the Business and Professions QWe)or TEMP.METER OR POLE INST COMMERCIAL:
0. that he is exempt duarf out and the basis for the alleged exemption.Any stalatbn of ❑NEW BLDG/ADDITION [I DEMOLITION
as Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more than Five hundred dollars(35110). ❑TENANT ❑FOOD SERVICE
�Q I,as owner of the n,mrm to ees with ata es us theinole cont IMPROVEMENT
Q ❑ pipe y damp y g penmtion, SWIMMING POOL ELECTRIC
willdmhe work,unJ theewcmre is nmtimended or offered fnrsale(Sec9044,Btsiues. ❑OTHER
a]3 ro and PCombatssions Code:The CombaLicense Law forearm apply m an owner< U'1'LETS—SWITCHES—FIXTURES
6 property who builds car improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ IT, "
aide.If,however,the building or improvement is.sold within one year of completion the $gIT.FLOOR AREA 3/SQ.FT.
nwhip,builde,will have the burden of Finding that he did nut build or improve for par-
osJ�.h
pe of salol. //IT
I,as owner of the n am exclusive) TOTAL:
❑ pipe y, y contracting with.....sed eanuatom to �.' (�
construct the project(See.70004,Business and Professions Code.)The Commctnr's Li O
1/i
se Law docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE U/
sense
eammea far such projects with a oomracumb)licensed pursuant to the Coateaemr's
License Law. PERMIT ISSUANCE
❑Owner
I am exempt under Sec. ,B&PC fonhis rc3san
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Date
WORKER'S COMPENSATTbN DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby off m under penalty of Perjury one of the following declarations:
Fl have and will maintain a Ceniticate of Consent it)self-insure far Workers ComPen- DRAINS—FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 37M of the Labor Code,for the suchimmacc of the STORIES TYPE CONSTRUCTION
work for which this perme.it is issued FIXTURES—PER TRAP '
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Coda forthe performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP MIN
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy Nei: GAS—EA.SYSTEM-OVER 4(PAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FPES
(]bis section need not he completed if the pdrot is formic hundred dollars IS 100) GREASP.TRAP
or less.) - PLANCHECK FEE
I cenify that in the perfornmnceof the work far which this Permit is issued,Ishall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject no the Workers'Camper- ENERGY FEE
0 action Laws of California.Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
ry ti NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
f't , become subject to the Workers Compensation provisions of the"her Code,you most SOILS FEE
Qforthwith comply with such provisions or this permit shall be decarea evoked. WATER SERVICE
CONSTRUCTION LENDING AGENCYPAID Date Re t
Q I hereby affirm that there is a construction lending agency for the performance it NEW RESIDENTIAL PLATE. SQ.FT
f
{ks F the work for which this Permit is issued(See.3107,Civ.C.)
O lender's Name %. TO Al.:
WLender's Address TOTAL:
1 cenify that I have read this application and state that the above information is BUILDING FEE
i..t
LI) coact.l agree no comply with all city and county ordinances and state laws relating in QTY. MECHANICAL PERMIT FEE
V z building conswetion,and hereby vuMorize represemmivex of thin city icier upon tM1e SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep minicar Ne City mf Cupertino againu PERMIT ISSUANCE ELECTRIC F
liabilities,judgments,costs and expenseswhich mayinany way accrue against said City ALTER OR ADD TO MECH.
to consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,11fg1 CFM)
SOURCE REGULATIONS.' MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CUM) CONSTRUCTIONTX
Simulate of ApplicantlComfacmr Date EXHAUST HOOD OODUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicammr future building occupant store or handle hazardous material HEATING ON]'T(TO 100,00)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cala Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Yes 7 N VENTILATION FAN(SINGLE RESID) PAID
Will then applicant or future building t use equipment or devices which Date Receipt N
pp g by the BBOILER—COMP(3HP OR 100,010 RTC)
emit hazardous vin contaminants as defined by the Bay Area Air Quality Management
District? TOTAL:
❑Yes -. ❑Nm BOILER—COMP(OVER 100,000 BTU)
I have read the houdous materials requirements ander Chaptar 6.95 of the Cali+ AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT
building does not currently have a tenant,that it is my responsibility to notify the cecupant
of The requirements which must be met prior to issuance of a Cenifcom of Occupancy.
Owner or i athorized agent Date ISSUED BY
OFFICE