30925 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: J SANITARY NO. APPLICATION SUBMITTAL DAPI
az IIS— C ( qvo a- L*%_
O ' NAPHONE; ACTOR'S NAM P LIC NO:
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t6\1 /vtc • lr 4" `( L N/C CONTROL#
A ITECf/F.NGINEE I,IC NO: A SS: ❑ -
✓ / orVe (0F 5,x6 PA Pio NOor a✓Ie
CONTACICO7r f< 7v r'PHONE:�g1 5Q5-O BUILDING PERMIT INFO
P 1 D ( ❑ ConSdfent Fees Paid by Applicant(lnllinl) .BLDG EL PLUMB MECH
ID
LICENSED CO ACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nm I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWOC wEh Sec Run 7000)of Division 3 of Ne Business and Professions Cade,road my license is' PERMIT ISSUANCE RFSI� DFNTIAL•
C S L= L en a Claaca effect. ❑SFDW L ❑KITCHEN REMODEL
1, U Dat rose Class Contractor
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
al/ t% Date Contmnor
ARCHITECT'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
Z O n Z I understoM my plans shall be used m public records PANELS MODIFICATION t
OZ—p UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
�4FMS Licensed Professional 201.1000AMPS IMPROVEMENT
e9+ .•...411 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR [3DEMOLRION
�+ Q I hereby affirm that 1 1. exempt from the Contras,Coo License Law for the
k3 6 U fallowing¢awn.(Senian 703 1.5.Business and Professions Calc:Any city-,.my SIGNS ELECTRICAL ❑OTHER
41 0.e which requrtex a permit to ennstrvcL ober,impmvq demnliaM1,nr repair any nwewm - A—tom
��h.] pri�rm its issuance,else tequircs Ne applicant for such permiuo tilts signed stammem SPECIAL CIRCUIT/MISG. `
} that he is licensed pursuant to the provisions of the Contractor's License law(Chaper9
�pO (imomencingwith Se,ion70(f.f Division Sof the Bmincasand Professions Code)or 3'BMP.METER OR POLE.INST. COMMERCIAL: .
e y then be is exempt dounfmm and the basis far Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Lc Section]031.5 by any applicant fnr a permit subjects the upplicant to,civil penalty of POWER DEVICES
ern ❑IMPROV ❑FOOD SERVICE
t main than eve hundred dolor y employees
FZ} IMPROVEMENT
Q 01,as owner of the property.or my employees with wages mtheir sole compensation, SWIMMING POOL ELECTRIC
O will do the work,and thestimeam,is not intended oroRered for sale(Sm.7044,Business OTHER
rod Professions Code:The Comba toh License Law does rot apply to an owner of OUTLETS-SWITCHES-FIXTURES
D.
a.. property who builds or improves thereon,and who fres such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. Alh
p�
side.If.however,the building or improvement is sold within one your of completion,the SQ.PT. OO F� $/SQ.PT.
caner-builder will have the burden of proving that he did not build or improve for put. e
Nor of sale.). P���
El 1,us owner of the Properly,am exclusively connecting with licensed contractors to TOTAL:
eommre do Project(Sec.7a44.Burincasand Pmrersians coder The cantrolm's Li. (f/ vF U 1
cense Low does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
wh.co6actsfarsuc1i projects with a conuactor(s)licensed pursuant tothe Conorno's
License law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this Mason �I
Owner Dam ALTER-DRAIN&VE R ) VALUATION .
WORKER'5 COMPENSATION DECLARATION BACK FLOW PROTECT.
I hereby aRrnt made,penalty of pedu,one of the folluwin6 decleretions:
❑ I have and will nommain a CertiOcme ofConacn to selFcclimfor Worker's Crimper. DRAINS-FLOOR,RO .GOND. STORIES TYPECONSTRUCION
anion,os provided for by Section 37M of Ne ISM,Cole,for the performance of the I
work for whichthis permit is issued. FIXTURES-PER TRAP 3
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this Permit is issued. GAS-BA.SYSTEM-(INC.4 OUT,- S OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thissecarm need not be complaint Hite Name is foronahundmd dollars($100) GREASETRAP
or less.) PLANCHECK FEE
I certifythat in the performance ofnhe work forwhich this perah is round.I&bull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mau
manner so as to become subject the Warkeri Compen. ENERGY FEE
',Z cation Laws of California.Dr¢ WATER HEATER W/VENT/ELECfR
z� O Applicant GRADING FEE
�•+ VJ NOTICE TO APPLICANT:If,after making Nva Certificate of Exemption,you should WATER SYSTEMffREATING
became subject o the Worker's Compensation provisions of the Labor Code.you most SOILS 17EE
[WL7 G forthwith comply with such previsions or this permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FL PAID
U O Dam Receiptp
Iherebyaffmnthauheri isaadl(Se 30landing agency forthe performance of
Nc work for which Chia permit is issued(Sec.309],Civ.CJ
Dr(~ Lenders Name TOTAL:
{U lenders Address TOTAL:
Q. 1 certify than 1 have reed this application end scorn thauhe above information is BUILDING FEE
ulcorrect.l agree to comply with dl city and county ordinances and state laws relating in Qry, MECHANICAL PERMIT FEE
U 4 building construction,mrd hereby authanor representatives of Nis city to enter upon the SEISMIC FEE
ubovobourah ted property for inspection P.,act, PERMIT ISSUANCE.
(We)agree to save,indemnify and keep hmmleas the City of Cupertino against ELECTRIC FEE
Iiabilities,judgmenm,costs and expenses which mayin Any way Brant against said City ALTER ORADDTO MECH.
n consequence of the greening of this permit. - PLUMBING FEE
APP 'NDERSTANDS AND WILL WITH ALL Nq1-11W—
ON- OIN' AIR HANDLING UNIT(TO ROOD CFM)UT MECHANICAL FEE
///
ZI AIR HANDLING UNIT(OVER ILD00 CFM) CONSTRUCTION TAX
gnewrea licarmConlramor Dart EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store on handle xmdomnu,terad HEATING UNIT(TO Ifln"BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,andNe eahh end Safety
Code,Section 25532(a)' HEATING UNIT(OVER 101,000 BTU) ,
❑Yes []No - VENTILATION FAN(SINGLE RESID) PAID Dote Receipts -•
Will the applicant or future building occupant use equipment or or devices which
innumerous,eve contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,1)00 BTU) TOTAL
Drstnc@ BOILER-COMP(OVER 100,000 BTU)
❑yes .FIN.
I have mad the hauudous materials requirements under Chapter 6,95 of Ne Cali- AIR CONDITIONER ISSUANCEDA
(omits Health&Safety Code,Sections 25545.25533 and 25534.L understood Nat if the NEW RESIDENTIAL.MECH. SQ.FT.
building reuas eats rrentlywhich must avea hi,
Nato ismymapf a Ccrvry to Oiteofy Nepancy.nt -
fth rcquiromcnu which mustbemd pdmmissuame oraCmifiwte of Occupancy. -,
Owns or iadmared agent Date TOTAL: ISSUED BY:
OFFICE