30488 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. ^ O / ^/N
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. JK 4}80X!
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APP (CATION SU ITTAU DATE
108All
`OaxNER'S NAME: �I - a ` PHONE: CONTRAC`OR'SN ME: LICNO:
Lam% 1/iGL •IJ` NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
l FoxG(ovE �
CONTACT: ,. PHONE: BUILDING PERMIT INFO
-' ❑ Consultant Fm.s Paid by Applicunt(Initial) LDG ELECT PLUMB MEC({
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby e1 LIC Nat I am licensed under provisions of chapter 9(commencing DESCRIPTION'
oaz with Section]a1NBnf Division 3 ofshe Business and Professions Code,.nd my license is PERMIT ISSUANCE RESIDENTIAL:
O in full force and effect.
�UI ❑SFDWL ❑KITCHEN REMODEL
Liceme Class oCntr APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DE
in G Date ARCHITECTS
Contractor
DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
z O n Z I understand my plans shall bo used as public records MODIFICATION
O Z�.. UP ID 200 AMPS
e 1c4[❑[❑-++IJ Licensed Professional [I INTERIOR [3 CHIMNEY REPAIR
ga-� OWNER-BUILDER DECLARATION OVER201-I
IMPROVEMENT ,
yoo fall I hereby offnm that 1 am exempt from the Common,',License Law for the
OVER IINiO AMPS BATH REMODEUREPAIR 0 DEMOLITION
S6 a all d V following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER Lr6w T l Qf ,
u1=1a, which requires a permit to contract,alter,improve,demolish,or repair any mancwre
Our to its issuance.also raciness theapplieum for such permit to file a signedmamem SPECIALCIRCUIT/MISC.
thin he he is licensed pursuant m the provisions of the Commaor's License law(Chapter9
I„ C, (commencing with Section 7000)of Division 3 of the Business and Profassiom Code)or TEMP.MIUER OR POLE INST, COMMERCIAL:
s e of shat he is catnaps therefrom and rhe basis for the alleged exempfion.Any vim.ima of. ❑NEW BLDG/ADDITION ❑DEMOLITION
la• Section]031.5 by any applicam fomi
ra pert stems the ii,liceso a civil pcmilly of POWER DEVICES mrd m ❑TENANT ❑FOOD SERVICE
not more^�< five hundred 1.
G I,osowoerofNe proselconmycampla
sea with we esss their soe cotepman. SWIMMING POOL ELECTRIC IMPROVEMENT
uturn
ed
will do the wons and the a o Contr...t s License Licas does r auto tapply to an Business []OTHER
and Professions Code:The Contractors License law does nos apply s if owner of OUTLET'$-SWITCHES_FIXTURES
his o
awfully who builds or improves thereon,and who dors such work
te himself or Nmugh
his awn employees,srovidal Nat such mentis old Whitmore nm iyear ofd m offered for NEW RCSIUENTIAL ELECTR SQ
owns L bowevea ll have are bur en of pemntt is s t hediyurrdcompletfor the t SQ.fT.FLOOR AREA LSQ.FT.
pose.builder will have are burden of proving that he did not build or imprme far sur- - s
pate a sole.).
❑er az ownerof the property,an,B exclusively contracting wird licensed cnntmema i- . TOTAL:
cansrmcuhe es not (Sec.o an Business rop Profusions Codel)The Comracmrs Li- SEP c se Lawes forssapplyman with
who theHereon,and QTY PLUMBING PERMIT FEE 1J pnzaes
Lha canvass forsuch projects with a conuacuar(s)IicensW sinuate m 1M Commcmrs 1 J eco
License Lew. t
❑lwar ixcmps under Sm. .B&PCfor this reason PERMIT ISSUANCE
Owner Dote ALTER-DRAIN&VENT-WATER(EA) VALUATION/
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I bereby M.under seamy of perjury one of she following declarations:
I hosannd will maintain.Cenitieseeof Consent to self-insorc for Worker's Camper- DRAINS-FLOOR,ROOF,ARPA,COND.
STORIES TYPE CONSTRUCf10Ni
tion as provided hi for mi Ss issued.
37W of the Labor Cade,for the cerfotrtmnce of the
work for add this permit is issued. FIXTURES-PER TRAP s
❑ 1 have std will maintain Workers Come of the
n Insurance,for which
h required by Section
MyW Workers
Labor Cadnfonhsurance emari ofshewlic farallem Nis cermet is issued. GAS-EA.SYSTEM-I INC.40I1TLfi I'S
OCC.GROUP APN
My Workers Compensation Imumnce carrier and Policy number are:
Carrier. Policy No.: GAS-FA.SYSTEM-OVER 4(EAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be compined ifthepernmis foranehundad dollars(SUKE GREASF.TRAP
ar IcsaJ PLANCHECK FEE
Ic%fthmin.theamfinn ceofthe work(..whi'lido madisissued.lshall SEWER-SANITARY-STORM EA.200 IT.nasten er ecoasmbecomesubjest to rhe Workers Compen- ENERGY FEE
O zs Lar tersE - WATER HEATER WNENT/EI.fiR
Arlolicanr ( GRADING FEE
Z y NOTICE TO APPLICANT:IL sifter making a Certificate of Exemption,you should WATER SYSfEMI1'REATING
become subject to the Workers Compensation Provisions of the Labor Cale,you must SOILS FEE
{il forthwith comply with such Provisions or this permit shall he decimal revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V 0 l hereby affair that hem is a construction lending agency for part.... Dau;L
ipta
W. E•+ Ne work for which this permit is issued(See 31197,Civ C.) -
0 Lenders Name - TOTAL:
U
ULender's Address TOTAL: -
I certify that I have read this application and atm.Nm the shove infor mrum is BUILD( G E
°VS correct l agree to comply with.11 city and county ordinances and seam laws miming re QTY. MECHANICALPERMIT FEE
V Z building construction,and hereby authorise representatives ofthis city to enter upon the SEISMIC PEE
shave-mentioned pm,my for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmleth
ss e City of Cupertino against ELECTRIC FEE
tiex L rems,com.vandexpen.spe which may in any way accrue against said City ALTER OR ADD TO MECH.
usnce (the greening of this permir. PLUMBING
APPLI:ANT INDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO 10,0011 CFM)
SOUR ERE( CATIONS. MECHANIC FEE
AIR HANDLING UNIT(OVER 10,00( CFM) CONSTR ONTAX
Signature of Appli di(omacmr De EXHAUST FOOD(WIDUCT) HOUSING ATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
ss defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety as
Cale,Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
Dyes ❑No - PAID
V[NTIfAT10N FAN(SINGLE RFSID) Data ecciprp�—
NTII Ne applicmt or future building occupant use equipment or devices which
'mit hazardous air contaminants as defined by the Bay Ares,Air Quality Management BOILER-COMP OHP OR I0LD)0 BTU) -
TOTAL:
atom( BOILER-COMP(OVER 100.0010 BTU)
❑Yes ❑No
I have readthe hazardous mirequirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 undcomnd Nm if the NEW RESIDENTIAL MECH. SQ.IT.
building does no,correctly have.report.Nm it is my responsibility annually the..par
mthe requiremems which most be met prior In rsmnce or.Cmificme of Occupancy.
s Owner or authorized ager - Date - TOTAL: . ISSUED BY:
OFFICE