30754 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMUNO. 307,54^
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
LUNG ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAn
3l7 [ c N I I 1-�►�1�7
ER �A
'S NAME: PHONE: COrCTOR'S NAME: LIC NO:
F2r6MdX / t�Fk�6JJIJC F1£latoC: Alf. X31 (oly NIC cath aoLa
ARCHITELTIENGINEER: LIC NO: p URPSS: ❑
CONTACT: PHONE:' . , , I� I E �gTa BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ t�.
LICENSED CONTRACTOR'S DECLARATION viionsfChap QTY ELECTRIC PERMIT FEF.
I hereby affirm Not 1 em licensed under provisions of Chapter 9(commencing� JOB DESCRIPTION
�0Omz with Section]IA01)af Divisinn3of the Business and Professions Cude,end my license is RESIDENTIAL:
0 PERMIT ISSUANCE
W f• m full tome and a ��I� '/s ❑SFDWI. ❑KITCHEN REMODEL
ye UU I ise0 s Lit.p R
of til DuteCa...... PMOtli APPLIANCES-RESIDENTIAL ❑ADDRION C1 PLUMBING RE-PIPE
8Z =oe ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z 1 understand my plans shall he used es public records MODIFICATION
0'Z UPT02MAMPS El INTERIOR ❑CHIMNEY REPAIR
r4 Licensed Professional - 201-I010AMPS IMPROVEMENT
OWNER-BUILDER DE CLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
a C 1 hereby affirm that 1 em exempt from the Contractor's c License Law for the
O tYU followwhich requires
(Section 7031.5.Business our,i prove,Professions Cu dc:Any city or county SIGNS ELECTRICAL ❑OTHER
LL O~ wh{r t requires n issuance,also re canstrct alcor,impose demolish,or e a sig any structure
prior thimhe s acteparm attoithe the
rowlsi dant me Contrach ctors
Lice se signedstatementSPECIAL CIRCUIT/MISC.
cmbescitig itpursuantcome of Domnsof Ne Conadrus sLicense Law(l CWt)9
�OC fconhe is exemit duchafa.]BW)oeBasis for oftheeged exeand Po Any violation
Cdle)or TEMP.METER OR POLE INST COMMERCIAL:
thinSec he is 31.5 b thcrefmm and Nc bass for the alleged exemption.Any violation of ❑NEW BLDG/ADDTI70N ❑F06D SERVICE
Z;i, not
omthan Five
hundrelieomrs($permit subjects the applicem toacivil penalty of POWER DEVICES El TENANT ❑FOODSERVICE.
FZQbat marc ohne Eve hundihe dollars(SSW).
❑1.as owner of she property,or my<mployees with wages solerompemmion, SWIMMING POOI.ELECTRIC a IMPROVEMENT
will do the work,and the sanctum is not inrendeel ce.fbami for sale(Sec.7004,Business ❑OTHER
and Pmemiams Cade:The Contmnce,License Law dues not upply m un owner of OUTLETS-SWITCHES-FlXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL Ed ECTR SQ FT.
sole.If,however.the building or improvement is sold within one year of completion.the SQ.¢Flx(]OR AREA LSQ.F17.er-builder will have the burden of proving that he did not build or improve for par- Ir'� /A�
pose of mic.).
❑1,ux nw r of the pmpeny,em exclusively wnuacsing with licensed conwcmm m TOTAL: ,n
mummer the project(Sec.7044.Business and Pmfers.ns Cade:)The Cmarectnr's Li- JAM a�R REC!f
cense Law does not apply m an owner of pmMny who builds or improves thereon,and QTY PLUMBINGPERMIT E
who comm t;for such projects with a contractors)licensed p romentto the Characters
License Law. PERMIT ISSUANCE CITY OF Lar f
❑1 am exempt under Sec. ,B&P C for this reason CH f ENO
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following Jeckinali s:
❑I have and will maintain a Certificate ofconsem to self-insure for Worker's Coiner- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
anticvd as provided for by Section 37M of the Labor Cede,for the performance of the
work for which this Action is issued. FIXTURES-PER TRAP
T have and will maintain Workees Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this point is issued. 'GAS-EA.SYSTEM-I INC.4 OUTLETS 'OCC.GROUP APN
My Wor ,-Co nsaa n�^mnce comer and Policytgjtpberpprt��
Cartier. Policy No.: L(b_ 3=_4 - GAS-EA.SYSTEM-OVER 4(EA)
/ CERTIFICATE OF EXEMPTON FROM WORKERS'
COMPENSATION INSURANCE GRF.ASCANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This imonn Decd not hewmplemd ifthepermit is formahmarraddollars(Slll(1) GREASETRAP
or IessJ PLANCHP.CK FEE
I cenifythat in the perfmmmm.fdu,.mkfm mach this permit is issued,l shall SEWER-SANITARY-STORM EA.led PT.
not employ any person in any manner so as to become subject m the Workers'Compe
n- ENERGY ME
Z satin.laws of California.Date WATER HEATER W/VENT/ELECTR
O O Applicant GRADING FEE
.~N. NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEMITREATING
a � become subjeettothe Workers Compensation provisionsofthe Labor Cade,youmust SOUS FEE
fottmaidromnlywith such prosmonsor thk,mmitshall hedeemediammul. WATER SERVICE
a Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
r7 z Data Receipt M
L) ^ work
by which this Pemercissued(Sm.00G,Cis,agency for the peAntmanceof
W [[[yrrr me work for waren this Permit is irrnw(ser.3007,civ.c,)
lenders Name TOTAL:
O LU1I Iendeet Address TOTAL:
kiyI,s,,, 1 certify that 1 have mad this application and suite that the above information is BUILDING FEE
i.r to correct.l agree to comply with.11 city end county oMinwces and state lawsfclming to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kmp harmless she City of Cupertino against ELECTRIC FEE
Iiabilities,judgmetnx,costs and expenses which may in any way accre against said City ALTER OR ADDTO MECH.
in consequence of the grunting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,01)CFM) MECHANICAL FEE
SOURCE REGULATIONS. O
!� •�9/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCfIONTAX
Sigmtu Ap omrunnr Dom EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,0)0 BTU) '
as defined by the Cupertino Municipal Code,Chapter 9.12,vnd the Hwhh and Snfny -
Code,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
❑Yes - ❑No VENTILATION PAN(SINGLE RESIDE PAID
Will the applicant or future building'ccupatn use equipmrt or devices which Date Receipt
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100.000 BTU; TOTAL:
Dismnp
F1 yea []No BOILER-COMP(OVER IW,000 BTU)
I have read me hazafdoux materials tequ;remen.under Chapter 6.95 of the Cali. AIRCONDITIONER ISSUANCE DATE
foods Health&Safety Cade,Sections 25505,25533 and 25534.I understand that;f the NEW RESIDENTIAL MECH., SQ.PT.
building does not cumndy haveaouc u,that is is my mspmsibility modify the occupant -
of the maluite rano which must tie met prior to issuance ofa Certificate of Occupancy.
Owner or authorized ager. Dare ISSUED BY:
OFFICE