30407 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 30407
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION[PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT n ENTLFIcATiON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DX
O AME: PHSIIONE _ Sa CON'fJ{�C70N'�NpM{'�.n LIC NO:
At
(_f `� �O�+Y`./�1/[/_Jam_ NIC CONTROL p
RCHITECT/ENGINEER: LIC NO: ADDRCSS: ❑
CONTACT: PHONE: EDConsultant
PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ;F,- PLUh11} ME
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby affirm ma l am tire it under prnvision,of chapter v(comcnaing JOB DESCRIPTION
WOO with Section V000)ofDivision 3ofine Buslneaand Pr..fcsaiom Code,and my inmamseis RF ID NTIA -
FOO in full force and eBcO. PERMIT ISSUANCE 22
F
aUU License Class Lic.N ❑SPDWL El KITCHEN REMODEL
F Z Doe Cantonal, APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING R&PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p H z m
I undersnd my plans shall be used ex Public records MODIFICATION
O Z 4
F,N.Lw Licensed PrUP TO 2(Nl AMPSofessional [I INTERIOR El CHIMNEY REPAIR
�a4 N-I OWNER-BUILDER DECLARATION 201.1000AMPS IMPROVEMENT
C C Q 1 hereby affirm that I am exempt from the Contractors License Low for the OVER IDOAMPS ❑BATH REMODELIREPA R DEMOLITION
XO i U following reason.(Section'/03L5.Business and Professions Cede:Any city m corny SIGNS ELECTRICAL ❑OTHER
LL a
LLC)y which requires a permit to construct,alms improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
C
V) prior
he is licensed pursuantto no provisions of the Contractor'sLicense Law(Chapter 9
W C) (commencing with Section]000)ofDivision 3 o the Business and Professions Cole)or TEMP.MLTER OR POLE INST OMM R CIA
E E c C char he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
X.nLL Section 703 1.5 by any applicant(mePermit smbjecu the applicant t0.civil penalty of POWER DEVICES
FZY ^ than five hundred dollars(S500). ❑TENANT ❑FOOD SERVICE
SSD sowncrofthe property.or my employees with wages es their sole compensation. SWIMMING PCXXLELECTRICIMPROVEMENT
L
ill do the work,and the structure is not Intended or offered formle(Sec.7044,Business ❑OTHER
W m d in Cods:The Couractoe%Lions Law does no apply to an owner of OUTLETS-SWI'MHIS_FIXTURES
�'•. property who builds m improves thereon,end who don such work himself m through
his own employees,provided that such improvements are nae intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If.however,the building or improvement is sold within one yearofrnmpletimi the SQ.FT.FLOOR AREA 5/$Q.pT.
er-builder will have the burden of proving that he did not build or improve fur cur- n
pose of sale.).
❑1.as owner of the prolixity,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Cods:)The Contract .Li- ,/� sCj
�
cense law does not apply to an owner of property w ho builds or improves thereon,and QTY. PLUMBING PERMIT FEE /n^
who contracts for such project with a Imaracmr(s)licensed pursuant m the Contractor I/s /J y
License Law. PERMIT ISSUANCE i", le,
❑lam exert er Sec. ,B&P C fur this recon k.y is
Date ALTER-DRAIN&VENT-WATER(FA) VALUATION
WORXERSCOMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following decimations:
❑Ilameand will mm'ntaina Cenificam of Consenuoself-Insure for WarkcYs Cnmpen- DRAINS-FLOOR,ROOF AR G,COND.
ration.. rovidW for by Section 3700 of the(tabor Cale,for the performance of the STOHITS TYPE CONSTRUCTIO
omrk for which this permit is issued. 'FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3]0)of the Labor Cage.for rhe performance of he work far which this .it is.sued. GAS-EA.SYSTEM.I INC.J OUTLETS
M Worker's Com OCC.GROUP APN
My Compensation Insuantt Cartier and Policy number arc:
Cartier: popsy Na.: GAS-FA.SYSTEM-OVER 4(FA)
CERTIFICATECOMPENSATION
ON FROM WORKERS'
COMPENSATION INSURANCE GkEASFIINDUSTRL WASTE INTERCEPTOR
(This.vation nein not be completed Bum permit is forone hundred dollars(SIM) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Loy any than in the performanymannce ro theas
work for which this permit.ers Colshall SEWER-SANITARY-STORM EA.200 FT.
nm employ my perforin any manner so ns m bacmme subject the Workers Conflict- ENERGY FEE
z cationanwn of C.lifomia.Dae
O WATER HEATER W/VENT/ELECTR GRADING FEF,
Z Applicant
y NOTICE TO APPLICANT:If,after making this Cenifi<ate of Exemption,you should WATER SYSgEM/TREATING
become sxibjecno the Worker's Compensation provisions of the Lahr Cafe,you most SOILS FEE
[k7 fnumah comply with such provisions or this permit shall he deemed revoker. WATER SERVICE
lY
'] z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ IT. PAID
UO (hereby affirm that them is a contraction lending agency for the wrfomunce.f Date Receiptp
4. F the work for which this permit is issued(Sec.3097.Ci,CJ
C) U Tender's Name s
Lenders Address TOTAL:
t}•' 0. 1 certify Nm 1 have read this application and loom that the above niformaion is BUILDING FEC
y correct lags to comply with all city and county ordinances and state laws relaingm QTY,EER
MECHj('R)
ERMIT FEE
U .Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection pugmses. SUANC
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FF.
liabilities,judgments,costs and expenses which may i n any way accts against said City ADD TPLUM B ING FEF.in onsqucne of the granting of this permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT LING U000(1 CFM)SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCr10NT
Signature of A,pIh.m Ccmmcm, Date IIHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATI FEE
Will the oppliwm or future buildo,oecuPunt ooreor handle har^rdouv mmenul HEATING UNIT(10101.g0 B'IU)
as defined by the Coconino Municipal Code,Chapter 9.12,and the Hcahh and Safety
Code,Section 25532(.)' HCA'1'ING UNIT(OVER 100.000 131 Of
❑Ye. DNm
VIiNI'ILA'DON PAN(SINGLE RMI Of PAID
Will the applicant or future building occupant use equipment or devices which Dae Receipt 4
emit hazardous air contaminants as defined by the Bay Arose Air Quality Management BOILER-COM('(3HP OR 100,00 BTU)
L
s F-1 No BOILER-COMP(OVER 10,010 BTU) TOTAL:
rend the h.zadnus materials mquirecients under Chapter 6.95 of the Cali- AIR CONDITIONER
&Safety Calc,Sections 25505.25533 and 25531. undeno n l thnt a the ISSUANCE DATE
nm¢'nrrently have amnanl,into itiemy lexponsihilily Innnlily the tacupanl NI:W HESIDIiN'1'IAI.MACH. SQ.IT.
ments which must bo met prior m issuance of u Certificate of0ccupancy.
horizedagnnt Dote T AI
ISSUED BY _
OFFICE