30583 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL FERMII N°. 30583
BUILDING DIVISION APPLICATION ERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAII
E� Ms�•e� CT I�09 913 .7
OWNER'S NAME:
PH)NE C TRA R'S E: LIC NO:
Q�
NIC CONI'ROI.M
RCHITECT/ENG EER: LIC NO: A DRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG .. PLUMB MECH
of �}P-S ❑ ❑ ❑
LICENSEDCONTRACTOR'SDECLARA'UON QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won with Section7W fDivisi l of the Buxinoxun ofessiom Code,and my license is RESIDENTIAL:
F,,=O full tone an Y PERMIT ISSUANCE
QE- ire J ..ib GSFDWL O KITCHEN REMODEL
V U Lieeas laza Lic.p
yQi Dat�Comrcmr LACES-RESIDEMIAL ❑ADDITION ❑PLUMBING RE-PIPE,
RCHIlECTS DEC A (� ❑MULTI-UNIT ❑STRUcT L
Z OF y Z I understand my plain Mall be used e.Public records PANELS MOD ' TION
UP TO 200 AMPS GINTERIOR Ih1NBY REPAIR
[F�L'W Licensed Professional 2UI-1000 AMPS IMPROVEh1ENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR CI DEMOLITION
Q I hereby affirm that 1 am exempt from the Contractors License Law(or the
54'
ow V following nmson.(Section 7831.5,Business and Profslaw,Cade:Any city or county SIGNS ELECI'RICA ❑OTHER
nal}+la.y which requires a permit m censwn,alcor,improve,demolish ur repair any arum urt
0 prior to its issuance,also requires the applicant for such Permit o rile a xignN statement SPECIALC C /MISC.
S fyj} thin has licensed punuam m the provisions of the Comment,',License Low(Clep¢r9
LL�00 (commencing with Suction l001B of Division 3ofthe Nminesx and Pmkxsionx Cmde)mr TEM1IP.M OR POLE INST COMMERCIAL:
6 a c C that he is exempt therefrom and the basis(or the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
nLL
Section lO3L5 by any applicum faro permit subjects the applicant mncivil penahy of POWE D� 1
LL^m ❑TENANT ❑FOODSERVICE
t mon than five hundredEiz dolours yempl. IMPROVEMENT
SC
El 1,as owner of the propcny,or my employees with wages as their sole c,an
SWI NG POOLE CTRIC
F will du the work,and the structure is not intended or offered forsale(See A044,Business []OTHER
L3 m and Professions Code 'Ile Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES- RES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RF_SIDENTIAL ELEC IO FT.
sale.If,however,the building or improvement is sold within one year ofcompicamn,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-huilder will have the burden of pnoing that he did not build or improve for parry '
Fine of ea1eJ.
1,as owner of the property,am exclusively contracting with licensed a ntmmors to TOTAL:
cambric,the project(Stt.9(W4,Bmines and Professions Cndel The--a—ii.'s- EP 2 3 1996
.se Law does nor apply In an owner of property who builds ter improvesY,thereon, QTPLUMBING PERMIT FEC
who contracts for such projecd with a carumcmr(.c)licensed pursuatu to the Contractors
License Low, PERMI"1ISSUANCE
El I am exempt under Sec. ,H Pe P C lin fikoaxan L"1 I;Int ._nJD'k.l
Owner ]);airALTER-DRAIN&VENT-WATER(EA) VALUAI9ON
-
WORKERS COMPHNSNFION DECLARA'T'ION BACK FLOW PROTECT.DEVICE
Ihereby aff rude,pw,11,ofpepry l the folloom,J I
� Ih J m Crf t ol'C a II W k .0 pent DRAINS-FLOOR,ROOF,AREA,COND. IFS 'I'YPh:CONSI'RUCI'ION
sadm 'dcall for M1ySeen lllNl of In 1h Code for the Prf a nr the
I or
which hi Escroor d. FIXTURES-PER TRAP
Shaveand 'II maintain Workers Compen al r n In'urmsc,u:required by Settlor
3700mda ahor Code,ft"Ou perforrom s ft he wnrk 'rwhol this Mrmit i:' d. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Wi r and lVrl' arm / 'G OCC.GROUT' AIN
Corti , ata • Yolicy N GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATH OF IiXIiM PITON FROM WORKERS'
COMPENSATION INSURANCE GREASF/WDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ICES
[Tins wOm.need not be completed it the pemrit is for one hundred dollars(Sl W)
or less) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work for which this Permit is issued,l shall SGWER-SANITARY-STORM EA.200 FT.
no,employ any person in any manner se as a bee ne xohjsvu,,the Workerd Compere ENERGY FEE
Z ,Z cation laws of Califrmia,Date WATER HEATER WNEYT/ELECTR
0 Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTF.M/IREATING
become subject to the Workers Compensation provisions of the labor Code,you must SOILS FEE
forthwith comply withsuch provision,.,this pereitehall be deemed invoked. WATER SERVICE
Q
52 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.PL PAID Dae RtteiMM
V 0 Thereby affirm that them is a construction lending agency for the performance of
the work for which this pemit is issued(See.3041.Ci,C.)
Q U Lenders Name TOTAL:
M Lenders Address TOTAL:
Fy I early that I have read this application and crate that the above information is BUILDING FEE
p) cour t.l agree to comply with all city and county ordinances and sure laws inlotingte QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby arborize representatives of this caym enter onetime SEISMIC FEE
above-mentioned Property for inxptttum rurposes.
(WO)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments.costs and expenses which may in any way secure against said City ALTERORADDTOMECH.
inconsequence was,granting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 110,000 CFM) CONSTRUC IONTAX
Signature of Applicant/Contractor Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIAE-9 DISCLOSURE
Will the applicamor future bmldin eopunt smor handle hazardous material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Munnrpa rc,Chapter 9.12,and the Health and Safety
Cade,Scam 25532N)? HEATING UNIT(OVER 180,000 BTU)
❑Ycx VENTILATION FAN(SINGLE RESIDE PAID
Dote Receipt p
Will the applicamor forte ht Win pain use equipment Qu or devices which BOILER-COMP(3HP OR 1110,(100 BTU)
emit hazardous air nmtmninanta as J ' by the Huy Arca Air Quality Mawgemem
^J�DinrimEl Yes No BOILER-COMP(OVER I00.000BTU)
I have adthehazardous at IsAIRCONDITIONER
I t. der Chapter695 Ibe Cali. ISSUANCE DATE
halaHandy
r r C 1 S t 55115 25511 J 25534 1 1 1 I ohm I the NEW RGSNEMIAL MECH. SQ.FThuinfI . pJnrt I Cm t IO pamCy
o t unienll ug'm Date TOTAL: ISSUED BY:
OFFICE