30922 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PER VU r NO. 0 9^^Z
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL L
BUILDING PROJECT IDENBEIr CATION
BUILDING DDSANITARY NO. APPLICATION SUBMITTAL DATE
14
eTW-ACONTR R'S AME: L �1 �•
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UtCHITECP/ENGIN' . LIC NO: ADDR Xi �`/G_l/O ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION CON QTY. ELECTRIC PERMIT FEE
1 nereby arFmt,Nm 1 on licensed ander pravLvions of Cords. 9 anmmereng JOB DESCRIPTION
i-wZ with Section and efofDiviaiunJuflM1e Buxinesa and Pmfcssions Code.and my license it RESIDENTIAL,
F O in full force and cf ct PERMIT ISSUANCE
L'"F rcas., ���T 1.#7-- " -( mL. ❑SFDWL ❑KITCHEN REMODEL
FGVW Licca. Lin.p
NGS Dae Contra sC� e�ll�0... APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING R&PIPfi
1„ ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z_ 1 r mY plans eh I he used ac{mhhc recme%
OZ— n _ - Q UP'1'0200AMPS ODIPICATION
F -a Uccnsed Pmfeavonal -1 ❑INTERIOR IMNEY REPAIR
�,'.�1 OWNER-BUnUI?R DECLARATION 201-1000AMPS IMPROVEMENT
C dd C 6 I hereby arfinn um,I am cxempt from the Contractors License Law for the OVER REVAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
°' a V following reams.(Section]031.5,13otlness and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
'3
CW h which requires a peril to con,nucl.alter,improve,demolish,or repair any sarmure
F�•ffnna prior to its issuance,also requires the applicant for such perino file a signed statement SPECIAL CIRCUIT/M ISC.
pa that he is licensed purstamuo the provision,of the Contractors License Law(Chapter 9
pGpO (commencing with Section 91100)of Division 3ofthe Business and Professions Cone)or TEMP METER OR POLE(NST. COMMERCIAL
6 y o K that he is exempt therefrom and the basic for the vlleged exemption.Any viulminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^h Section 903 L5 by any applicant for a perit subjects the applicant to a civil penally of POWER DEVICES
not more than five hundred dollars($500) TENANT FOOD SERVICE
=Q (] I,nowner of the properly,or my employees with wvges as their rale compenwtion, SWIMMING POOL ELECTRIC IMPROVEMENT
p. will do the work,and the saeture is not notarial araffcred for sale(See.lUW,Business ❑OTHER
a 3
at and ProlieWonn Code:The Contractors License Law does not apply to an owner of OUTLETS-SW ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employe.......aded that such imp...entemv are not intended or offaad for NEW RESIDENTIAL ELEC'rR S I .
oth.If.however,the building or improvement is soldwithinone yearofcompletion.the PAG
St '1' A�RGA gISG.FT.
er-builder will have the burden of proving that he did not build tar improve for pur- Q+ .FLUOR
pax of sale.).
[]L a.owner of the property,am exclusively contracting with licensed contractors to TOTAL: n I��
construct the pri(Sec.7(00,Business and Professions Code:)The Contractor's Li- Pg�
remo tawdoes not eppl,...n...vrofpropeny who builds is,impmvcsffienun,end QTY. PLUMBING PERMIT F EX A •L'I REnff�
who contracts lot such projects with u conrat
or(O licensed pursuant the Contractor's {!u
Licrnx Law'
I]I am exempt under See. ,B&PCho NisrePERMIT ISSUANCE ason TMUh CUILH Illy()
Owner Date ALTER-DRAIN&VENT-WATER BEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
l L hereby affirm under penalty of perjury nnc nf1ha following declarations
❑ Ihaveund will neinmin a CrinicateofConsenuoself-inure fur Worker's Cionva- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
s ition,as provided! N
for by Section 37W of the Labor Cale,for e performance of me
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the perfarrome,ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker' Inm s ncecaand Policyn
Cartier: a �E�Policy Nn: YmplrLj o't0 k=" GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASMNDUSTRL WASTE INTERCEPTOR
or I<ss.)
(Thin inion need not he completed if the permit is forone hmJreddnllas($I W) GREASETRAP
BUILDING DIVISION FL'ES
-
PLANCHECKEEE
Loy any that int he Perforanymannrof the work for which this permit irkers om,sell SEWER-SANITARY-STORhf LA.200 FT.
not employ any person i a any mannerso,a to became subject u,the Workcri Compen- ENERGY FEE
O ,'� Ap,ficaws of Cnlifomia.Dam WA'1'I7R HEATER W/VENT/ELECTR
Z O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making that;Certificate of Exemption,you should WATER SYSTEMITREATING
baume subject n,the Worker's Compensation provision of the Labor Code.you mail SOILS FEE
foMwith comply with such provisions or this .it shall be deemed revoked. WATER SERVICE
5Z CattherRUCTION LENDING AGENCY NEW RESIDF.NTALPLMB. SQ.ET, PAID
V Q lfor by affiran which
ether,isacd(Sec.30 len ding agency fonhe perfnmmnac of Dam kcceipt#
� r' Ne work for which this Permit is issued(Sec.3119'1,Civ.CJ
Lenders Name TOTAL:
W Lender's Address TOTAL:
FIL 1 certify that 1 have read this application and state that the shove information is BUILDING FEE
CZ) comet.Iagree ,,comply with.11 city and aantyordinances andante lows relating,. QTY. MECHANICAL PERMIT FEE
) Z building mnshuction.and hereby authorize mpmsenwtives of Nin city to enteruprm Ne SEISMIC FEE
above-mc )alone
Mm
property for inspersion purposes. is
PERMIT ISSUANCE
(We)agrcc to save,innif y and keep harmless the City o(Cupenino against ELECTRIC FEE
liahilities,judgmems,cos¢and expenses which may in any way accrue against said City
in msequence of the granting of this perit. ALTER OR ADD TO SUCH. PLUMBING FEE
APPLICANT (NDE ANDS AND WILL COMPLY WI NON-POINT ALR HANDLING UNIT LTO 10,100 CFM)
SOUItCE1 UL NS. MECHANICALFEE
AIR HANDLING UNIT(OVER IBM)CIM) CONSTRUCTIONTAX
Slgvatgac l'ApplicanUC HAZA—RDOIOUSr MATERIALS DISCLOSURE Date EXHAUST HOOD(WNUCI HOUSING MITIGATION FEE
RDO
Willthe applicaao fiutum building circulated store orhandle hazardous material HEATING UNIT(TO 100,100 BTU)
as defined by do Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Sector 25532(n)'/ HEATING UNIT(OVER 100.000 BTU)
I]Yis ❑No PAID
VENTILATION I-AN(SINGLE RES ID) Dam Receipt#
Will the Sir co am or future building occupant y A coni it Qu or devices which BOILER-COMP(3HP OR 100,000 BTU)
.mit haarJnu.c vis amnminams as defined by Om Buy Arco Air Quality Manugemmnl TOTAL:
Uiarict9
Fl Yes ONo BOILER-COME(OVER 100,000 BTU)
I have recall the haardaos materials mens under Cha AIR CONDITIONER ISSUANCE DATE
ml2rt and rsta mine if Cali-
Heolils, Salm Code,ea Moen 25505,25533 wJ 25534.1.a try the
Nal if Im NEW RESIDENTIAL MUCH. SQ.ET.
buildi doe currency haveatenanL Nm it m bility to notify the wcurym
of menuw ichman M:met poor to menu mail met pooroartificumof Ocemaneof Gcemanc.
autlmolld agent Date TOTAL: ISSUED BY:
OFFICE