30139 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF.C'F IDENTIf'ICA'1'ION
BUILDING ADDRESS: ' SANITARY NO. APPLICATION
SUBMITTAL DA'1
OWNER'S NA
PHMI' CON'1'R ):
�� L
NAC CONTROL#
ARCHITE /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) SLUG 00� ELECT PLUM1iB MECII
❑ ❑ ❑
LICENSED COM'NACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arrrn.me 1 am fianxm ander provi,;nn,of enapmr v(enm,ment;ny JOB DESCRIPTION
ZWz with Seninn7(KK1pdDivision3of the Businessand Prnlcasioo,Code,nnd my license is TERN IT ISSUANCE RESIDENTIAL'
F W= in full forecast effect.
ceV l- License Class Lia.a
❑SPITAC El KITCHEN REMODEL
FQF. U
N66 Dam Contractor APPLIANCES-RF.SIDENHAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHD'i1CTS DECLARATION PANELS
f.o'n ❑MULTI-UNIT ❑STRUCTURAL.
024- lunderaWnJ or,plans shall he used as public records MODIFICATION
O Z o UPTO 200 AMPS A,__
F 4 F'W Licensed Professional ❑INTERIOR J TfININEY REPAIR
adyf; OWNER-BUILDER DECLARATION 201-11100,\MPS IMPROVEMENT `
ypX,C W ffi
6 1 hereby arm Ill.,1 am exept from the Contractor's License Law for the I OVER WOAMPS [I BATH REMODEUREPAIR ❑DEMOLITION
W 3 L U following reason.1Smdon]0315,Husinesc and Pr..fcssim s Code:Any city m c in, SIGNS ELECTRICAL OTHER
LL7 LL.y which requires a penin m construct,aRec improve.demolish,or repair any structure0� Pdorto its issuance,dmrcquires theapplieant forsnchpermiuo fileasigmed statement SPECIALCIRCUITIMISC.
that he is licensed pursaanuo theprovisinnofthe Commaor's
ommcme ,wLicense law lChapmr9
yyC� femith Section1 D
70( ivision 3ofthe Buxinessund Professions Codd or
YI p O TEMP.METER OR POLE INST. COMMERCIAL
d ro
that he,,exempt Iberufnun and the bass for thu ullegW exemption.Any vinlwinn of
Section 703 5 n ❑NEW BLDG/ADDITION ❑DEMOLITION
not mare than five hundred dollars sunjeanhe applicant ntncivil penally of POWER DEVICES []TENANT ❑FOODSERVICE
~Z} I.as owner of the IMPROVEMENT
❑ property,remyemntended withwvgesasthei(See. 044.Business gWIMhIING POOL ELECTRIC
d,^m will do ns,,ic.a Code: xwcmreisnolinUrmnorawdo, sale(See.]O a4.Business ❑OTHER
{acl3.. and crty whlonn Code:lac Conuaicreo License Law does ran apply , an owner of OUTLETS-SWITCHES-FIX' RES
properly who builds nr improves Ihercon,and who Jsws such work himself or through
his own employees,provided that such impmvemenu are not intended or offered for NEW RESIDENTIAL ELE SQ FT.
sale.IL howeves.the building or improvement is sold x thin one year ofeomplelion,the SQ.FT:FLOOR AREA, 5/gQ.FT.
owner builderwill have the burden nfprn'ing that he did not build or improve for put- 11
P of sale.).
❑
I.as owner of the progeny,am exclusively eurmmcting with licensed contractors m TO
consumer the project Ism.7046.Business and Prnfcssions Coded,The Contncmr's Li- Q JUL 01 1996
cense law does not apply to an owner ofpropcny who builds or improves themon,and W.. PLUMBING PERMIT FEE
whomntescts for such projects winsacunmetuds)licensed pursuant tothe Cont2cmfs CITY
s -
License Law. wI I
❑ lain excmpndcr see ,B&PC tat his reason ISSUANCE C�y�Ur U UT'Lli I IIVU
Owner — ALTER-DRAIN&VENT-WATER(EA)
DamVALUATION
S� WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby hy a1Rrunder penalty of perjury onmne of the fallowing dmmv:
lation
❑1 toennd will mvimme.CenificamofConwnuowif-in,me for Wurkeis Compere- DRAINS-FLOOR,ROOF,AREA,COND.
scion,as provided for by Section 37W ad the Labor Code,for the performance of the STORIES TYPE CONSTRUCTW:
work for which this permit is issued. - FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Code,for the prfonnance of the work fur which this permit is i.uuod. GAS-EA.SYSTEM-I INC.4 OUTLETS qPM
My Worker's Compenxminn Insurance cannerand Policy number um:
Came. OCC.GROUP
olicy No: GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GNEASE/INDUSTRL WASTE INTERCEPTOR
(This season need not W completed rinse permit is for one hundred dollars IS 101) BUILDING DIVISION FEES
arta,) GREASETRAP
1 ecnify that in the pereentrance of the work or which Isis permit is issued,1,4L.11 PLANCHECK FEE
noemploy any person in any,manner so as to become subject to the Worleco Compen- SEWER-SANITARY-STORM EA.200 FT.
Z
cationlawsof Califomia,Date ENERGY HE
z2 Applicant WATER HEATER W/VENI'/ELEC R
Cl NOTICE TO APPLICANT:If.after making this Cunlfmcnlcof Exemption,you should GRADING HE
WATER SYS'IVM/fRGATINC
ai
become object to he Workers Compenwtiun provision,of the facer Code.you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
9L. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIN.ntSQ.FT PAID
U
Imeds effirmthmlhac
ereisnruailn rfo
lending agency lm the permarce of Data Receipt
LF P the work for which this permit is issued(Sec 301 Civ.C.)
0 U Lender's Name
f Leader's Address :
pk TOTAL TOTAL
R
l}„� r 1 ecnify that 1 have read Ibis application and slam that the#have information is BUILDING PGE
r+
L) z(n eonecl.1 agree tocomply with all city and county ordinances and stale lows relating to QTY. MECHANICAL PERMIT FEE
building contmetinn,and hereby mahurire representatives of this cityle enteruponlhc SEISMIC FEE
rat above-mentioned properly for inspection proposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep lu m icss the City of Cupertino against ELECTRIC FEE
Imbilides.judgment,roasand espenc,which may in any wayaceraeag.irm said City ALTER OR ADD TO MECH.
muen
o
e nseqceof the gmntingofmis perush, PLUMBING FIT
APANT UNDCRSTq S AND WILL COMPLY WITH ALL N�IN' NDLING UNIT(TO 10.000 CFM)
S RC REGUL IONS MECHANICAL FEE
a 1 'BLIND UNIT(OVER 10.000 CFM)
CONSTRUCTIONTAX
Signator ApplieaHA,ARDO Date %H ST fI00D(W/DUCT)
f{AZAk muck b MA'IPRIALg DISCLOSU i HOUSING MITIGATION FEE
ill the epplicam nrlumre building sucupant,wnre ur handlehaxardou,macrial HEATING UNIT(TO 000010 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 255321x1' HEATING UNIT(OVER IIXkBOB BTU)
❑Yes 0 N
VENTILATION CAN(SINGLE RF,SID) PAID
Will the applicant or future building occupant use equipment or devices which Dine keceipt#
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP LHP OR IW000 BTID
District,
❑Yes ON. BOILER-COMP(OVER IW.Of,O BTU) TOTAL:
1 have read the haeurdous materials requirements under Chapter 6.95 of the Cab- AIR CONDITIONER
burns Health&Safety Crile.Sections 25505,25533 and 25534.1 atderaand that if the ISSUANCE.DATE
buildingdocs nolcunemlYhaveatcwalalic it is myaspeasibilirynnaifynse«apam NEW RESIDENTIALMECH. SQ.PT.
of the requirements which must be met prior to issuance of a Cendicam of Occupancy.
Owneror atilmni al agent Data TOTAL'
ISSUED BY:
OFFICE