30913 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
30913
BUILDING PROJCcr IDENTIFICATION
BUILDINOADDRESS: APPLICATION SUBMITTAL DATE
10494• E. ��� P✓• C �-G"' �a q s� y- SANITARY NO. �t
OWNER'9 E,liftNAME: e PHONE: C Q CO. A OR'SNjME: Lao
Is.a G� kci,:.NQ �ee e;00 Q1 '1^2.•S Yah S C0E`14)V%k tru'S 499(0 NIC CONTROL,
ARCNITECI'/ENGINEER: LIC NO: A`t)k�,o :
SS. 5co(,`l U0. � LL ❑
1 I D 1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL PLUMB MF,CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 hereby infirm Ilial 1 an licensed under provisions of Chapter 9(commencing JOB'DESCRIPTION
QRZ with ScefUrt 7(XNBm Div{sinn3 ofthe Businus.nd Rofessions Cole.and nt I n
WOO y 1fe`f to PERMIT ISSUANCE77;611RESIDENTIAL'
F W in full4orce and cReal.
cul License Class Lisp '0$PDWL ❑KITCHEN REMODEL
Dan _ ConnectorAPPLIANCF,S-RESIDF,M'IAI. ❑ADDITION El PLUMBING RE-PIPE
Fpm ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y Z 1 understand my plans shall be used m public recons MODIFICATION
OZ4—a UPTO200AMP5 ❑INTERIO ❑CHIMNEY REPAIR
F,Irl Licensed Prnfcssionnl 201-1000AMPS IMP :MEET
OWNER-BUILDER DECLARATION OVER 1000 AMT'S ATN REhfODEI/RF.PAIR El DEMOLITION
ts
WQ 1 hereby affirm that 1 am exempt from the Conoaetors Liwnse Law for the
3 t U following Manor(Section 703 LS.Business and Professions Code:Any city or countySIGNS ELECTRICAL THER
4 oo which raga ms a Permit to construct,alter.improve.demolish.or repair any amvtmc
p.,LLOa prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIt'/MING.
f t�V) in.,hei.s IlnmscJ pursuant,the Provisions of the Continuous License Law lChapmr9
1+100 (commencing with Section 709))of Division 3uf rhe Business and l'mfcsaionx Codq or TEMP.METER OR POLE INST. COMMERCIAL'
d 6 a• that he is eeenru therefrom and the basis for the alleged exem,nion.Ad,vidaii n of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 703 L5 by onyapplicant for ape.it subjects me.,Plica.,ton civil penalty of POWER DEVICES
^Nrt mre oman live hundred dollars(5500). ❑TENANT ❑FOODSERVICE
Sp ❑I,as owner of tire pmpait ,Or my employees with wages as their sole Compensa0on, SWIMMING POOL EL IC IMPROVEMENT
p. will Jo the work,and the structure is no,intended or aBined lir sale(Sec.7014.Business El OTHER
13 w and Fmfcaions Code:The Contractor'..License Law does not apply,o an owner of OUtLETS-SWITCHES-FI
pro,rity who builds or improves thereon,and who docs such work himself or through
his we employees,provided that such imp mvameas are sol imended or offered for NEW RESIDENTIAL ELECTR
sale.ILhowever.the building or improvement is sold within(me year ofcontpletlon,the SQ.FT.FLOORAREA $/SQ.ET
owner-builder will have the burden ufproving that he did no,build or improve for par- ;p� A
arse ofadv.). P fed
❑1.its owner of the property,ant exclusively contracting with licensed co encu rs to TOTAL:
• construct the project(Sec.7(44.Busineso and Professions Code:)The Contractor's Li- OR 18 a.VM ..caeca
cense Law docs not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE I'J14WI[
who commas for such projects with o contractor(s)licensed pursuant or the Commtnors
License Low. PERMIT ISSUANCE `l }•
❑ P enlarge ,B&PCatfi-�t-d�it'l,snn QXYUf WrERT O
ner on ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORK. 'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I berehyoffirre uMe,peoeltof perjury one Of,hc following deelatimo: - •
❑Iheve andwillmaimaineCrnif am of Comm�no selGinsure for Workeex Cut DRAINS-FLOOR,ROOF.AREA,COND.
action,as provided for by Section 37W of the Labor Code,for the performance of the STORIES TYPECO ION
work for which,his permit is issued FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,it,required by Section
37M of be Labor CMc,for the performance of the work for which this pefmiris iaaed. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Compensation Insurance carrier and Policy number are: OCC.GROUP APN
Cartier: Policy No.: GAS-EA.SYSTEMAVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
Mix.section need no,be completed if,he,emu,is far me hundreddollars(5100) BUILDING DIVISION FEES
or less.) _all,forGREASE TRAP PLANCHECK FEF,
lay any that in the any dealer ceof
bjeais tire
Cooper-mall SEWER-SANITARY-STORM EA.20014.
--'..Play any person in any manner so as m hemme xubjcm m the N'orken'Cooper- ENERGY FEE
O Z Mien Lows of California.Date WATER HEATER WIVENT/ELECTR
O
Z r Applicata GRADING FEE
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/fREATING
E , bennnc subject to the Workers Compensaion provisions of the Labor Cotlee you mus, SOILS FEE
forthwith comply with such pookiowor this pormil shall be deenadmvoked. WATER SERVICE
d 0
EJ Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
L)O I herebywhich thi ilia thenis.
sue (Se309 .Cing agencyfar the perfnrm:mcc of Dae Receipt,
the work for which this pcnnil is issued(Scc.7097.Civ.CJ
B.
O L)U L salves Name
Leadds Address *TOTAL1 certify that 1 have read Phis applicalum z d smte that rhe above information is BUILDING FEEto carrier.I agree to comply with all city and county entrance.and state laws ramdng to QTY MECHANICAL PERMIT FEE
Z building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEEabove-mentioned Property for inspection purposes. PERMIT ISSUANCIi(We)agree to save,indemnify and keep harmless the City of Corpsman,against ELECTRIC FEEliabilities.judgments coos and expames which may in any way attic again%]laid CitgLTGR OR AUU TO MECH.in sequcnceof the 6rmid,of this perna. PLUMBINGFEEAPPLI i 'T UNDERST NDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UND'(TO 10,(X]0 CFM)SO' C EGF' ATION. MECHANICAL FEEAIR HANDLING UNIT(OVER 10.0000 CFM) CONSTRUCTIONTA
'ignand FfApplican C tractor ate EXHAUST HOLD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will,he appliwm orfuarc building rcntp,alooreor handle hazadon,material HEATING UNIT(TO 100.04(,0 BTU)
az JefnW by]he Cupertino Municipal Code.Chapter 9.12,and the Health and Safety,
CMc.Swoon 25532(al'! HEATING UNIT(OVER 1 W.0(I0 BTU)
❑Yes nNo
VENTILATION FAN(SINGLE RESID) PAI
Will ted applicem or primea building by the n y A equipment or devices which Dae It ccipt N
emitict? air umaminanla as defined by the Bay Arca Air Quality Management BOILER-COMP(3NP OR 100.00(1 BTU)
District? TOTAL:
❑Yes ED BOILER-COMP(OVER 100.000 BTU)
1 have read the has dour materials AIR CONDITIONER
my M533 na undo Chapterrsta ofthe CWi- NUANCE DATE
fomia Health&$ufcry CMc,Swoons 25505.8537 and 25534.I umlenmM tha if the NEW RESIDENTIAL MECH. SQ.IR.
building Jr .not cnnen0y exananl.Ihat i,is my resrymsibilWfif, ��.pn,ofthem whit n, rprimmissnanmofuCeuthorrzedr tun TOTAL:
ISSUED BY:
OFFICE