30596 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
GICAG
OWN 'SNA E: t� PHONE Z CONTRACNA! LIC NO:
N/C CONTROLN
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ -
Pco.
CONTACT. PHONE: BUILDING PERMIT INFO
(1/_v /' _ �6�Z�0 El Consultant Fees Paid by Applicant(Initial) BLE ELECT PLUMB MECH
r/( LICLE�N-S/EDED CONTRACTOR'S DECLARATIONmcgz QTY. ELECTRIC PERMIT FEE .
1 hereby affirm that l am licensed ander provisions of chapter 9(commmeing JOB DESCRIPTION
Poo with Section 7a W)of Division 3 orate Business art Professions Code,and my license is RESIDENTIAL:
FOO in full form and effect. \ PERMIT ISSUANCE
EHE �j Zp pt�� - ❑SFDWL ❑KITCHEN REMODEL
V Its' Licmu CI s IJc,g
APPLIANCES-RESIDENTIAL ❑ADD,
ITI
FFZ Dem Contractor ON ❑PLUMBING RE-PIPE
F=y A CHITECTS DECLARATION PANELS OMULTI-UNIT []STRUCTURAL
Z0223 lunderamnd myplans,hall b,usedostmNic ecords MODIFICATION
OZ O UP102MAMPS ❑INTERIOR [I CHIMNEY REPAIR
ros Z.1"u.41 Licensed Professional 201-10WAMPS IMPROVEMENT
0 6 OWNER-BUILDERDECLARATIONCLARATION OVER IOMAMPS ❑BATE REM EI/REPAIR ❑DEMOLITION
O C 1 hereby affirm I ren exempt from the C ssions o e:An u Law for the
Oy U which
nquires aer(Sectioni ]OJLS,Business improve,
Professions Cade:ctsurayohcctureounty SIGNS ELECTRICAL ❑OTHER
LLµ0F which requires a permit m connmcL ehen improve,demolish,or rept..my swcwm
priorto its issuance,also requires the applicant for such permit..file a signed statement SPECIALCIRCUIT/MISC.
h tha he is licensed pursuantmthe provisions el theCionosmr'sLicenseLaw(Chrpmr9o (commencing with Section 7")ofDiision 3 ofthe Rosiness and Professions Code)Or TEMP.METER OR POLE INST.That he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
6• Section 7031.5 by my applicam fora permit mbjecm rhe applicant m a civil perulty of POWER DEVICES
y ❑TENANT• ❑FOOD SERVICE
not more than five hundred dollars(5500), IMPROVEMENT
I. >.
asowner ,mil pm pertymmyemntended withered frtheir sole compensation. SWIMMING POOL ELECTRIC
and do the wons and the sh Cantu rte s Lice s o Law does
s not apply to an Business ❑OTHER
and Professions Code:The oyes trout,
License Law does not apply himself owner of LGfS•_SWITCHES-FIXTURES
6 a^ his O n who builds or improves thereon,tad who does such work dedisor through
his own however,
provided that m sown compass sold w thin not intended ser oRertd for NEW RESIDENTIAL ELECI'R SQ FT.
m1e.If,however,the building arimprovemem is sold within one year of completion.the SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of passing that he did not build or improve for pur.
pose Of ti le.). - c
❑I,as owner of the property,am exclusively contracting wird licensed contrarian,m TOTAL
nmuct Ne project(Sec.7M4,Business and Professions Cade)The Connector's Li-
a came Law does not apply m an owner of pr.Perty who builds or improves theuom,and QTY. PLUMBING PERMIT FEE , �`p A '/
who contracts for such projects with a contractors)licensed pursuant to the Communes Y' /996
License Law. PERMIT ISSUANCE ♦s
❑l am exempt under Sec. ,B& 0I P C for this reason r '4
U,
Owner Data - ALTER-D0.AIN&VENT-WATER(EA) „•a llkk,VALUATION '
WORKER'S COMPENSATION DECLARATION BACKFLOWPROTECT.DL•VICE
I hereby tiMrm under penally offerony one of the following dealmutians:
❑ I have and will maintain a Certificate ofConunt m self-insure for Workers Compen. DRAINS-FLOOR,ROOF,AREA,GOND.
ration,as providd for by Section 3701 of the Labra Cade,for the performance of the STORIES E CONSTRUCTION
TYP
work for which this pemth is issued. FIXTURES-PER TRAP
❑ I have and will mainmin Workers Compensation Insurance,as required by Section
3700 of the Ube,Cow,for the performance of the work for whicbthis permit is issuW. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC GROUP APN
My Workers Compensation Insurance currier and Policy number star:
Carrier: Policy No.: GAS-PA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
ffhis�emtion recd not be completed!if thepemdt is for one hundred dollars I$1e10) GREASE?TRAP
or lcssJ PLANCHECK FEB
I certify thin in the perfemaocc of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
net employ any person in tiny manner so as m become subjecl to the Workers Compen- ENERGY FEE
O Z Sudan Laws, Celi Dam WATER HEATER W/VENT/ELECTR
Applicant /�— f - GRADING FEE
tzt ....r NOTICE TOAPPLICAa 1',t0er making Nis C ndicum of Excuip,1 m,you should WATER SYSTEMRREATING
a � become subject To the Worker's Compensation provisions of the Labor Coda.you must SOILS FEE
IJ•1 foMwith comply with such....isbns or this perota.hall be domed revoked. WATER SERVICE
L �
iU. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff PAID Date R.iptk
U O Ihereby
orwhifBrtnthmthere iso issued
frothsg agmen for the performance of
Lir the work for which this permit is issued(Sec.3097,Civ.CJ
f'+ Lenders Name TOTAL:
V Lender's Address TOTAL:
D+ a '
[..t I certify that 1 have read This application and stem that the above information is BUILDING FEE
sr In correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby auNorize representatives ofihis city to enter upon me SEISMIC FEE
those-mentioned property for is.anion f uryoses. PERMIT ISSUANCE:
(We)agree to Save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way raceme against said City ALTER OR ADO TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Sigoamm of AiSdicanVCmamcm, Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicant.,future building occupant smreorhandle hazmdem,material HEATING UNIT(TO 100,00E BTU)
as defined by the Cepenino Municipal Cade,Charter 9.12,and the Health and Safety
Code,Section 25532fa)? HEATING UNIT(OVER 1041X.BTU) -
❑Yes ❑No PAID
V• ILATION FAN(SINGLE RESID) Data Receipt Is
Will the air cmatm or future building occupant sex equipment itQu or dMm S which
emit haasrdous air conmminants us defined by the Bay Arm Air Quality Management BOILER-COMP pHP OR IW,IKKIBTII) TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have mad the hamrdeus materials requimmemn under Chapter fi 95 of the Cash. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Catc.Sections 25505,25533 and 25534.I understood that if the NEW RESIDENTIAL MECH. SQ.FT.
building does rte cummly have a mount.Nat it is my meponsihility..nattily the oecupmt
of the regyjr`ements which must met prior to isavantt of a CeriRcatc of Occupancy.
�1,c-;..s Zt�I//
Own gem t Uat'e 4 TOTAL I ISSUED BY:
OFFICE