30655 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
O1 ,1PHONE: CON7Rf.CfO AME:y 71 / � C O
/Y` C/.�� WC CONfROLN
W
ARCHITECf/ENGINEE LIC NO: AD RF ' ❑
CONTACT. PHONE: BUILDING PERMIT INFO
' / . . „v 1 /�+',�f Qom/ slA�7/1 ❑ Co [ani Feud Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hertby vHinn Ihn 1 am licensed under provisions of Chm -
prer,9(cn amar ng JOB DESCRIPTION
�4'Z with 5ec1am7r1011)0 lviourlofthenuclides Professions Code and my lianscis
µµII O O PERMIT ISSUANCE
'PHI,
P in fu41derstu§d
c, � V 71 g SFDWL ❑KITCHN REMODEL
jukkJ LiceLIf.M gpPL1ANCLS—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
0. atCr,nuacmARCHITECTSD PION _ ❑MULTI-UNIT ❑STRUCTURAL
ZO .Zr i plans ehnll beuxcJmprddrmcurds PANELS MODIFICATION
vJUPT02MAMPS
OZ?� ❑INTERIOR - ❑CHIMNEY REPAIR
Pw(_' Licensed Professional 201-1000AMPS IMPROVEMENT
�Y OWNER-BUILDER DECLARATION
Contractors
OVER IIXIUAMPS ❑BATH REMODEUREPMR [I DEMOLITION
C W 1 hereby.Cham that l am exempts a the Cnnsares Co License law for the
dU whichfolloingfcsson.Permit
]onstru t.idnessand Pr a,demolish.or
Any city or county SIGNS ELECTRICAL C2 OTHER
3 0.y
which rtquirts'e permit m romwa,eher.improve,Jeanelish,or repair anY structure
��m� prionoils issuance,aim requires the applicunl fr,r such penniun NeaxigneJ xtammrnl SPECIALCIRCUITIMISC.
} thnl he is license)puasoum to the provisions of the Cenwcmr's License taw(Chnpmr9
Goo that he
engwithherefrom(KK))of basisnn3 aft he Business exemption.
Any
violation
of TEMP.METER OR POLE INST. COMMERCIAL:
o y that he is exempt therefrom and far..psis for the ct, be
cxempat ran
Any violntion of ❑TENANT /ADDITION ❑DEMOLITION
'n0. Section]m LSby aandledicamfmapertnit subjats the applicant toucivil penviry of POWER DEVICES
y []TENANT ❑FOODSERVICE
1„ } not more man Five handled dollars(ESIXp. IMPROVEMENT
E) SWIMMING work,
pestructre myemntended wiawagesed rtale(Se.compensation, SWIMMING POOLELECTRIC []OTHER
will dolhework,andlheswcontisnot torimrndes Law,does
apply to a,nvite,ss of
W -adpro erty who
Cndo:The Contractors theme's License law,dac w apply s if owner aC OUTLETS—SWITCHES—FIXTURES
�' .. his own who builds or improves thereon,and who nts such work himself or Through -
his own employees,e provided that such improvements is arc not intended or offered for NEW RESIDENTIAL ELECfR SQ IF.
ovioneLhowevalt have
bur improvement isat he did noneildori improve
Ne SQ.FT.FLOOR•�RE s i s k SJSQ.FT.
nor-huilJer will have the burden of proving that he did not buil)or improve for por-
pose of sure.).
C]1,as exactor the property:am exclusively contracting with licensed contractors to TOTAL: DEC 11. 1 6
construct the 044
e project(Sec.7 ,Business snit Professions Code:)The Commences Li-
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT 71 FEE
whoemmictsfar''such projects with.a conercmgs)licensed pursuant tmhe Contractor's LILY Ur VUrtIiNU
License law. - .
❑I am exempt under Sm. ,B&P C feamis reason PERMIT ISSUANCE
Owner
ALTER—DRAIN&VENT—WATER( VALUATION
Dart
WORKER'S COMPENSATION DECLARATION HACK PLOW PROTECT.DEVICE
1 hereby affirm under Family of perjury one of the following declamlions:
171 I have and will maintain a Certificate of Consent an self-insure for Worker's Camper. DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 37110 of the Labor Code,for the Performance of the
work for which this permit is issued FIXTURES—PER TRAP '
❑1 have and will maintain Worker's Compensation Insurance,as requmed!by Section
37M of the Labor Cade,for She performance of the work for which this permit is issued. GAS—CA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's tet tion Ins., came and Policy number :
Carica. tire
Na: 6� pF GAS—EA.SYSTEM-OVER 4(PAJ
FI EO E%E ION FROM RS' r
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEPS
(This section need notbe completed iftbepermit is foronehundrcJ Jolles(SIM) GREASE TRAP
or less) PLANCHECK FEE
Icersifytha inthe perfrnmrncaafthe work for whichlhis limit is issued,ishan SEWER—SANITARY-STORM EA.AXI IT.
not employ any person in any manner so as to become subject to the Worker:Cooper- ENERGY FEE
,Z setin oLows of Califomis.Dam
WAFER HIiATER WNENT/ELECI'R
z Applicant GRADING FEE
NOTICE TO APPLICANT.If,afar making this Certificate of Exemption,you should WATER SYSTEMRREATING
6F5 S become subject .,he Warkees Camrmation provisions of are Labor Code,you must - SOILS FEE
forthwith comply with such provisions or this permitshall be clamed revoked. WAFER SERVICE ,
O Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID Date Receipt It
LJ 0 I for herebyaffirmthat them is ed(Sec,i30len ding agency for the performance of P
W Newark for which this Permit is issued(Sec.I(N7,Civ.CJ
(~ fender's Name TOTAL:
Wlandet1 Address - TOTAL:
11, 1 certify that 1 have read This application and state that the shove Information is BUILDING FEF.
(4 coned.i agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
G.� building commuctica,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEF.
above-mentioned property for inspection purposes. PERMIT ISSUANCEy
(We)agree to save,indemnify and kap hannleav the City of Cupertino against ELECTRIC FEE
Iiabilifies,judgmats,costs and expenses which may in any way acme against load City ALTER OR ADD TO MECH. -
in consequence of the granting of this pernm. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HLXXI CFM) MECHANICAL FEE
SOURCE REGULATIONS.
` AIR HANDLING UNIT(OVER IgIXO CFM) CONSTRUCTION TAX
Signature of'ApplicantaConlmcmr Data EXHAUST HOOD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant state or handle hnzaduue merorinl BEATING UNIT(TO I MM0 BTU) . .
as defined by the Calendar,Municipal Cade,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)T A, HEATING UNIT(OVER I W."BTU)
❑Yet
VENTILATION FAN(SINGLE RESID) PAID
Data RaeiptY
Will She applicant or future building t use equipment or devices which BOILER—COMP(3HP OR 11X1,(1(0 BTU)
mit haxallous air contaminants as JdinW by by the the BBay Arca Air Quality Management TOTAL:
Disaict7
❑Yu BOILER—COMP(OVER 100.006 BTU)
I have mad the hazandous rtmterials on,moments under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE _
feria Health&Safely Calc.Sections 25505,25533 mad 25534.1ondcrs d if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoesn arcntl h nnsihilit the rupees
e realonce u a Canonical a Occ M.
wholihiu dzed.gent Data TDTpL: ISSUED BY: AL,
OFFICE