30138 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 30138
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF.CTIDFNI'IFICATION
ILDINGADDRBSS: SANITARY NO, APPLICATION SUBMITTAL DATE
0 D ZU ec+n 2c b)
NER'�/.pIAMB:T PHONE: [� C RACTOR'S NAME: LIC NO:
/ ,S 1;a- Ig� O.'15TY Nl C.t J.'k �gC NIC - CONI'ROL0
IffRCHITECT/tNGINEER: LIC NO: - DRESS: er$DR ❑
U A% t'S• . i L
IM cONTAUE PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG %4;d.K PLUMB-
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE ❑ ❑
1 hereby affirm That 1 am licensed under provisions of Chapter 9(Commencing JOft DESCRIPTION
�Z with Section7f)00ofDisuion 3ofthe Business and Profesrions Csdc,and mylicense is S 5� RESIDENTIAL:
0OPERMIT ISSUANCE ,w
WF in full Tome and effect. ❑SFDWL C]KITCHEN REMODEL
�.Uy(U] License Class Lit.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
p
N 6 a Date Contractor
g.Oy ARCHITECTS DECLARATION PANELS ❑MULTI-UNG' (D STRUCTURAL
Z 0 1 understand my plans shall be usrd n public records, MODIFICATION
0Z O UP TO 200 AMPS I ❑INTERIOR • - ❑CHIMNEY REPAIR
I✓4t:LLL Licensed Pofessional 2(11-1qq AMPS - IMPROVEMENT
�+y�_1 OWNER-BUILDER DECLARATION OVERIOI]BAS ❑BATH REMO AR 10L ION
14 S' a 1 hereby affirm that I em exempt from the Contractors License Law for the
p�e,06U following rason.(Section 7031.5,Business and Professions Code:Any city or county' SIGNS ELECTRICAL ❑OTHER
41'3 4,ra which mquires a Permit to conswn,alter,improve,demolish,or repair any strumuly
prinnoi¢issmnce,ilso requires the
epplicmt for such permit m Blew signed smtemmt SPECIAL CIRCUIT/MIS .
ym�} that he is licensed prompt tothe provlsionsnfthe Contractor's License Law(Chapmr9
COO (commcndngwith Seninn7rom.friAsinn3ofthe Bsumossind Prefesubso Cal0or TEMP.METIiR OR POLO(NST. COMMERCIAL: VK j
-
, c K that he is exempt Ihere(mm and the hmis(.,,he alleged exemption,Any violation of ❑NEW BCUG/ADDITION El DEMOLI'f10N
4' Section 7031.5 by any applicam for a permit subjects the applicam we civil penalty of POWER DEVICES
>, not mole than Eve hundred dollars(S5gq. [I TENANT ❑FOODSERVICE
Z
Zi' OTHER IMPROVEMENT
< wihos owner nfthep a pry or myemployas with wages fini fosthei(Sec.compensiness SWIMMING POOL ELECTRIC _
0 will do the work,andtheire Cone not intended License ow does of apply to nor Business ❑OTHC•R
a and Professions Code:The Contmeress License Law does not apply tom owner o UTLFfs-SWITCHES-FIXTURES
property who build,or improver t such i and who does such work himself or through
his own employees,e provided that such improvements ate not intended or offend for NEW RESIDENTIAL ELF,CTR SQ Pit -
sale.IL however,theh-ilJingmimprovemem is sold within one year o(complttinn,the SQ.IT.FLOOR AREA SISQ.IT.
owna-buildevwill have the burden of pmving that he did not build or improve for par- 4 R11
pose of rale,. G'
❑1.as owner of the property,am exclusively communing with licensed amurmtors to 1i ise
construct the project(Sec.71,4,Business and Professions Code:)The—hrustors
cense Law does not-pply to an owner of propcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Frojwn with a conlcactogs)licensed pursuant to the Cmnmctors U
License Law. IPERMIT ISSUANCE J U
❑lam exempt under Sec. ,B&P C for Its..an �ktt
ALTER-DRAIN&VENT-WATER(EA) yl VALUATION
71t
wntt Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 handy affirm under penally of perjury one of the following Workers
bo--androvidsdiforbinwim37M ofCeLabor Code.for the
Worker's Compen- DRAINS-FLUOR,ROOR AREA,COND. STORIES TYPE CONSTRUCTION
1('Aprovided for.i Section 37(X1 of the Lahr Cagle,for the perfammce ofthe
er which this permit is issued. FI%TURES-PIR TRAPhave and will radintun Worker's Compensation Insurance,os required by Section
of the Lahr Cade,for Ne performance of the work far ouch this ermit is issued. OAS-EA.SYSTHMd INC.4 Of1TLETS OCC.GROUP APN
y Worker's Compensation Insurance carrier and Policy number are:
artier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE Op EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE CREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISIO MS
(Thi,satioo necdnot becompdal ifthe Permit is far..hundred dollars(SIM) OREASETRAP - - -
or less.) PLANCHECK FEC
I certify that in the performance ofthe work for whichmis permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any marnsr e�?W KbjecOo the Workers'Compen- ENERGY FEE
Z cation Laws pm —// ��77bb WATER BEATER WNENT/ELECTR
7OO Applicant ✓.b GRADING FEE
q y NOTICE 'AN'C If,a ler making this Cenifeme of Exemption,gnu should WATER SYSTEM/BEAI'ING
become suhjcct m the Worker,Compensation provisions of the Lahr Code,you on SOILS FEE
W forthwith comply with such previsions or this porous shall be domed revoked. WATER SERVICE
Cis Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ,W. PAID
U O (hereby affirm that hem is a construction lending agency for the Performance of Date R ciptB
f~ the walk for which this permit is issued(Sec.3097,Co,CJ
Q LJ
Lender's Name _ TOTAL:
de
(11 Lttbeic Address TOTAL:
ns 1 certify that I have read this application and state that the above information is BUILDING FEE
N correct.l sane to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V huildinB conarvction.and hereby authorise rcpmenmtivcs nfthi,try n enmrupon the S[ISMIC FT:E
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agate pi indemnify and keep hornless the City of Cupertino Haman ELECTRIC FEE
liabilities.judgments,coststudexpanses which may in any wayaecom-9-1-11 said City ALTER OR ADD TO MECH.
inconuqucresofthegrmtingofihfspermh. - PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY LTH LL NO T AIR HANDLING UNIT(TO 10,(X1)CFM)
MECHAMC LFEE
SOURCE EGULATIONS.
AIR HANDLING UNIT(OVER IO,OW CFM) CONSTRU TIONTAX
Signature o' ppl 'ia omwtor late EXHAUST IIOOD(W/DUCq HOUSING MITIGA FEE
HAZARDOUS MATERIALS DISCLOSU
Wil the apPliant or form building occupant store or handle hurardoua material HEATING UNIT(TO 100,000 BTU)
es defined by Me Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cate.Section 215320)? HEATING UNIT(OVER 1gLOW BTU)
❑Yes
No VENTILATION FAN(SINGLE RESID) PAID
- ReceiP
Will the applicant or future building use equipment or devices which
Data
mit ruination til com
nminan¢as retired by
by me Ne Bay Area Air Quality Management BOILER-COMPOHP OR I00,000 BTU) AIL:
omot^ BOILER-COMP(OVER I(IIt"BTU
❑Yes Fl No ,
5 ALR CONDITIONER'
I have mist the hauNsms mamost,re mmur ams under Chapter 6.95 of the Cali- / ISSUA .DAT
fomin Health&Safety Cade,Sections 25505,25533 and 25534.1 undemand thm if the NEW RESIDENTIAL MECH. SQ.IT.
building doe nm cmrcnd,have a mount,that it is my respotlibility to notify the acupml
of the requirements which must he met prior to issuance of a Ciumficate of Occupancy.
Owner or authorized agent Data 1' ISSUED BY:
OFFICE