30415 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OP CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION "
415
BUILDING ADDRESS i - SANITARY NO." APPLICATION SUBMITTAL DATI
O ! 0 VAIIlcRtes ?J
OWNER'SNE: 1_ PHONE: CONTRACTOR'S NAME:' LIC NO:
Cl �za-)(ITJ PVj .1s3-bo33 oar I CONTROL#
� n S Yl
RCHITECMUNGINEER: LIC NO: ADDRESS: - - ❑
60, x 36Z SAPo✓u A °1'567/,.
CONTACT: PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r+l G b ❑l 1:11 X ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT PEE
I hereby affirm that I ant licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0Z with Section 9000)of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE RFC�[p.�NT[JO
G" m full fame end affect.
� AL
Uz�" License Class [—�e Lic.# 4119 1 - CSFDWC C KITCHEN REMODEL
yQG Date-_-�—aI �1q(y Cnntrector a APPLIANCES-RESIDENTIAL ADDITION -„ 0PLUMBING RE-PIPE
> ARCHITECT'S DECL TION CMULITUNIT 4 ❑STRUCTURAL
ZO0�er I understand my plans shall he used as public records a PANELS, / MODIFICATION
UPT0200 AMPS
Licensed Professional ❑INTERIOR' '[I CHIMNEY REPAIR y
OWNER-BUILDER DE C201-I WOAMPS IMPROVEMENT
1
G Centr ON hereby affirm that 1 um exempt from thee Comrumor's License Law for the OVER 10IXIAMPS El BATH REMODEL/REPAIR ❑DEMOLITION
t•+a04 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
D I"' which requires a Permit to construct alter,improve,demolish,or repair any structure � L
�y prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
<� thathaislicensedpursuant16theProvisionsoftheCommencesLicenseLaw(Chapter9
00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
4 o that he is exempt therefrom and the basis for the alleged exemption.Any violation of -
w Section 70315 6 an applicant for 3 pp pens y o ❑NEW HLOG/ADDITION' (]DEMOLITION
y y PP permit subjects the applicant to h f POWER DEVICES
yyyy} not more than five hundre ❑TENANT CFGGD SERVICE
ddoilem(8500). IMPROVEMENT '
Q 0m0Zwnerofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the stmcture is not intendedoroffered for sale(Sec 7044,Business C OTHER
4 and Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES"
property who builds or imp rovas thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for
NEW RESIDENTIAL EMCTR SQ PT. - '
sale,If,however,the building or improvement is sold within unarm,
ofcompledon,the SQ.FT,FLOOR AREA 8/SQ.FT
wner-builder will have the burden of proving that he did not build or improve for put- - 6
pose of sale), .:.� /
C,Las owner of the property,amexclusively contracting with licensed commctors to TOTAL: „J-
.normal the Project(Sac.70ckL Business and Proleions Code:)TTe Comracior's Li- �(// 9
cense Law does notapplyto anownerofproperty who builds or improvas thereon,and QTY. PLUMBING PERMITFEE
who matmem file such projects with a con occandsn
)licensed puoant w the Cc mraetoes I+O'
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
!4
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
❑I have and will maintain a Certificate of Consent o self-inscm foo-Workers Corrigan- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is Nsued.' FIXTURES-PER TRAP.. -
C.1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS - OCC GROUP APN
My Worker'sC yetiyyyp000o�lnsuj�t�a��-n��a carrier and Policy number me - r
Carrier: 4.CGsd Polic No.:9(. 4Q74Q7 GAS-EA.SYSTEM-OVER 4(1
CERTIFICATE OF EXEMPTIONFROMWORKERS' � -
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissectia.needom bo completed if the permit E for one hundred dollars O l 00) GREASE TRAP
vilest.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,i shall SEWER-SANHARY-STORM P.A.200 FT.
not employ any person in any manner so as to become subject to the Workers'Cooper- ENERGY FEE
,`4 sation Laws of California:Date.
0 Applicant WATER HEATER WNENT/LLECTR GRADING FEE
' y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMIIRP.ATING
become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT / PAID -
Ihereby affirrnthat there is a construction lending ugency for the performance of Date Receipt#
O the week for which thin Permit is ismed(Sea.3097,Cie.C.)
Lender's Name - - TOTAL:
Lender's Address A :
I canify dra I have rend this opplicmion and suite that the above information is BUILDING FEE
F.i V1 correct I agree to comply with all city and county ordinmcas and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction,end hereby matimire representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection Purposes. - . 'armPERMIT ISSUANCE - ”
(We)agree,.save,indemnify and keep brimless the City of Cupertino against ELECTRIC FEE
liabilities,judgmeins,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. - PLUMBING HE
in consequence of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITN
SOURCE REGULATIONS. LL NON-POINT AIR HANDLING UNIT(T010,000 CFM) MECHANICAL FEE
y Z� AIR HANDLING UNIT(OVER IO,DOO CFM) CONSTRUCfIONTAX .
antic of plicantsContractor I .DmL EXHAUST HOOD(W/DUCT) ''•' HOUSING MITIGATION FEE'
HAZARDOUSMATERIALS DISCLOSURE •-
.t Will the applicant or future building occupant store or handle houndous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code;Section 25532(0)? HEATING UNIT(OVER 100,00)BTU) .�.
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt
Will the applicant or future building occupant uta eut or as which
emit hazardous air contaminants as defined by the Bay Arcaa AiAir r Quality Management BOILER-COMP LHP OR 100,000 BTU)nagement - TOTAL:
District? "
,O Yesil ON. BOILER-COMP(OVER IW,IX)O BTU)
I he,.read the hazadoa normal,reqrem
uients under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomin Health&Safety Cock.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. '
building does not currently have a tenant,that it is my responsibility to notify the tecupron
of the requirements which must he at Prior to issuance of a Certificate of Occupnnay.
Owner or authmired agent Dem TOTAL:I I ISSUED BY:
OFFICE.