30132 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE.BALL POINT PEN ONLY
CITY OF CUPERTINO. BUILDING-ELECTRICAL PERMIT NO. 30132
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL '
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAT ION SUBMITTAL DATE
O E: CO R CT(]R'S ME: LIC N NIC COWR".
�J f VOrOs a��"�`-9332 vro�Co,.T T 30 3 [�/VIg1
RCHITECDENGINEER: - LIC NO: AODRIiS E3
r-
CONTACT: -�/'N��0/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) .BLDG ELECT PLUMB MECH
C roS �'S3- 3 z
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
I hereby amort that I an licensed Ba under and
Professions
of Chapter 9 my license is )OB DESCRIPTION
UZ with Section10effecDivision Sof the Business and Professions Code,and my licensees RESIDENTIAL _
_O in PERMIT ISSUANCC
fall force end cffKl.
�a.U I" License Class Lie.# ❑A DWL ❑KITCHENRE-PIPREMODEL
N<M Date Conlruvaor APPLIANCES-RESIDENTIAL �ADDITIGN ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL'
F O r/� PANELS
rZ O�2 I uMerslnnJ my plans shall he used as public remNs MODIFICATION
Oy O UPT0200AMPS El INTERIOR [I CHIMNEY REPAIR
wx� Licensed Professional 201-1000AMPS IMPROVEMENT
. OWNER-BUILDER DECLARATION OVER IOQ]AMPS El BATH REMODEVREPAIR [I DEMOLITION
8C Oil 6I hereby affirm that I em exempt from the Contractor's License Law for the
3 0.V following reason.(Section 7131.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL El OTHER
W LLO which requires a permit to conswn,nlmr,improve,tlemnlish,nr repai......ure
{n EE
primmhs issuance.alsorequires the applicant forsuch Permian Bleu signed statement SPECIAL CIRCUTUMISC.
{vv{saff��y Net bets licensed pursuunitothe Provisions ofihe Corbusier's License Ldw(Chapler9 _
CQ� (commencing with Secti,m70DOof Division 3 ofthe Businessund Professions Code)or TEMP.METER OR POLE]NST. af COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemptinn.Any violation of EI NEW BLDG/ADDITION ❑DEMOLITION
>4C1 Ir•
Section 71131.5 by any applicant for a permil;objects the applicant a civil penalty of POWER DEVICES
^'rn []TENANT ❑FOOD SERVICE
not more than five hundred dollars(ESfp). IMPROVEMENT C�
INS
wi 1 usowmer of the the immune
isnot werabsi ithfeed batiste
Sole 04,1.8 sines SWIMMING POOL ELECTRIC
yCO will Bothe work,and Neswcmreis not intemleJ oroRercJ fnrsele lSecJ014.Business ❑OTHER- V
6 dF S and Professions Gtle:The Conlmnols License Law does at apply to an owner at ' OUTLETS-SWITCHES-FIXTURES v
propcny who builds or improves thereon,and who does such work himself or through
his own employees.provided that such improvements Ort not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If,however.The building in improvemem is said within one ycaob completion.the S - RAREA ,IJ Q.FT
$/S .
nee-builder will have Ne moven ofpmving that he did not build or improve for par- Jt �y(Sk II
pote of sate.).
❑1,as owner of the property am exclusively contracting with licensed contmam,to `Y^ Ltt C)� V
construct the project(Sec.]044,Business and Professions Cale:)The Contractors Li. r� y T ••
cense Law does not apply in an owner of p operty who builds or improves memon,and QTY PLUMBING PERMIT FEE
who connotes forsuch projects with a co Cantons)licensed Pursuing to the Courectors
License Law. PERMIT ISSUANCE
1 am exam under SK. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(CA) VALUATION
Owner TIO � !� - �•
WORKER'S COMPENSATION DECLARATION BACK Fl.OW PROTECT.DEVICE '�V v.LJ0 g g/0C
10,10 I hertby a1Hw under penalty of perjury one of the fallowing dedar4tinns: ����`�w Kv J
I have and will maintain o Cettificam of Consenno self-insure for Workers Compen- TDRAINS-FLOOR,ROOP,AREA,COND, STORKS TYP GONSTRHLTIQN
cation,o provided for by Section 3]011 of the Labor Code,for the performance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation w Insurance,ss required by Scotian
My Warke Labor Code,
nsatifor the
surancmaneeaf the work forwhichthis permit is issued. GAS-EA.SYSTCM-I INC.40l1TLET5 OCC.GROUP APN
My Workers Compensation Insurance cartienli Policy number ort: _
Certiec Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTE'RCEPT'OR
BUILDING DIVISION FEES
(This ction neW mol t ermn,lelW if the pewit is fmone hundred dollars(E 100)
se
or less.) GREASETRAP PLANCHECK FEE
I certify that intheperformmmcofthe work for onchthis permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any peon in any mmner sn as to trareeyp m 1pyy Workers'Cinnow- ENERGY FEE
G Applicant sof famia pv p4� IO i �'(y WATER HEATER WIVENT/ELECTR
J7 J/ Ute— GRADING FTE
NOTICE TO APPTICA97p.IL after making this Certificate of Exemption,you should WATER SYSTPREATING
abecome stibject .,the Warkers Compenwion provisions of the La)ror Cash.you must SOILS FEE{iI fonhwitheomply with such provisions or thus permit shall be deemed revukul. WATER SERVICE
aQ
r7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.FZ PAID Dae Receipt a
U O ]hereby affirm Nm Them is ucatmnion lending agency for the peRwun
oce of
file F the work for which this permit is issued(Sec.3097,Civ.C.)
O U Lenders Name TOTAL'.
{EI Lenders AJNess
Iy cer ify that 1 have read this application and stow that the above information is BUILDING FEE 0-
LO) correct.I agree to comply with all city and county ordinances and slate laws Winning to QTY, MECHANICAL PERMIT FEE
U building contraction,and hereby nmhorine repcwtualives of this city to enter upon Ne SEISMIC FEE
above-memiormd progeny for inspection purposes.
(We)agree to save,indemnify suit keep harmless the City of Capone..gaiPERMIT ISSUANCEns, ELECTRIC FEE O
liabilities,judgments.costs and expenses which may in anywayaceme agonstand Chy eI ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of this pewit. /+
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO]0.011(1 CFM) -
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX -
Signature of ApplicanVContmam Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willow appliertrom boom building occupant smreor handle intonations material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12•end the Health end Safely
Cade,Section 25532(.)? HEATING UNIT(OVER UMOCXT BTU)
❑Yes 5QNo - VENTILATION FAN(SINGLE RESID) PAID
Will Ne a Ilam ar future building cu 1 use c ui 1 or devices which Data Receipt g
,
pp gK the
q Amen BOILER-COMPOHPOR 10TOWBTID mil Intention air contaminants as defined by Ne Bay Arca Air Quality Management,
TOTAL:
District!
11 Yes JLNo BOILER-COMP(OVER 100.000 BTU)
real the Taormina,materials AIR CONDITIONER
1 have
requiremcros under Chafer 6.95 of Nc Call- ISSUANCE DATE
fomes Health&Safely Cade,Sections 25505.M533 and 25534.I understand unit if the NEW RESIDENTIAL.MECH. SQ.FT.
building does not currently have v mount,Nat it is my responsibility to notify the o cupnl
of the miuiremems which must be met prior to issuance of a CeNticac of Occupancy.
Owner or vmharieed ngem, Dale V&W1 IF ISSUED BY:
OFFICE.