30459 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMIT NO. �O {`J1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENI'IFIGYTION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
OWNER'S NA E: PII �6Z79GONE: CONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
HIT'T:CT/ENGINEER: LIC NO: ADDRESS: ❑ -
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MITCH
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby oferm that 1 am licensed under provisions of chapter v(commencing _ JOB DESCRIPTION
wo, with Semion]tYJfl)of Divisinn3 of the Business and Rofessions Code,and my license is RESIDENTIAL-
= in full fume and effect. PERMIT ISSUANCE, ,
aUV License Class Lim. `❑SFT)WL ITCHEN REMODEL
rFii6W Datc Convector APPLIANCES—RESIDENTIAL TfADDII [IP UMBING RE-PIPE
F.Dm ARCHITECT$DIiC1.ARA1'ION BANTUS - MULTI-UNIT ❑STRUCTURAL
ZpyZ I understand my plans shell he used as public records MODIFICATION
OZ
UP 10 200 AMPS
F ~W Licensed Pmfessinnal ❑INTERIOR ❑CHIMNEY REPAIR
�Yfj OWNER BUILDER DECLARATION 201-OMOAMPS IMPROVEMENT
SM
¢wy1 Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER I000AMPS .0 BATH RF.MODEUREPAIR El DEMOLITION
3 L U following rwson.(Section 703L5,Holiness and Professions Cade:Ary city or only SIGNS ELECTRICAL ❑OTHER
LL y which requires a pemnt to contmn,altar,innpmve,demolish,or repair any structure
F. pnorto its issuance,whomquire.stheapplicautforsuch vernin to lite a signed statement SPECIAL CIRCUIT/MISC.
�yy that he is licensed pursuant to the provision'ofthe Common[Llcensc Law(Chapters)
O (commeoeing with SecOon]OW)of Division Sof NC Business and Podesnions Cnde)nr TEMP.METER OR POLE INS . COMMERCIAL:
d d e C that he Is exempt unaefmm sad the basis for the alleged exemption.Any violation of
�H
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑TENANT ADD=TION ❑DEMOLITION
crc than five hundred Jullars($510), ❑TENAM + ❑FOODSERVICE
asowner nfthcpmpcny,ser my employee wiW wages as their sole compenatiun, SWIMMING N701.ELECTRIC IMPROVEMENT
F ill dmhewod,andthe,trvetumisnotimendedorofferedfrrsale(Sec.]044.Business ❑OTHER
6 3 eo ml Professions Crider:The Contractors License Law Jmes not apply m mt owner of OUTLETS—SWI.1 CHES—FIXTURESU1.1
.. property who builds or inu mvex Neuron,and who does such work h imselfor through E- ' I
1YnnO
his own employees,provide)Nm.wch improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FP f s
sale.If,however the building or improvement lsxold within one year ofecmplmim,theFLF�RAREA $/SQ.FT.
nwnerhuilder will have the burden of proving that he did not build or improve for put- U
aveofsme.).
❑I,n construct the p of ct(Sao eny,am esclus and crowning C d.kens Conntmnum i- A 1.
the project(Sic.]W4,Rosiness and Professions CuJc:)The Cnnbucusrs Li-
cene Lw does not apply to an ownerofprmeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmemos)licensed pursuant to Ne footmen's
License Law.
�❑I am exempt under Sec. ,B&P C for this reason PERMITISSUANCE
LTJI!)1L.d �x�A4 D. .P.a71TV6 ALTER-GRAIN&VENT-WATER(IiA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
/ Thereby. sour nderperth,of per ury one of the[allowing dcelamtions: V
Ihave and will maintains CcniOcnne ofConsent to self-insum for Worker's Conspen- DRAINS-FLOOR,ROOF.AREA,COND.
,mumu,m pmvideJ fur by Section 37W of the labor Cale,for the performance of the STORIES TYPE CONSTRUCTIO:
work far which Nis pom,is issued. FIXTURES-PER TRAP A Q
❑ 1 have and will maintain Worker's Compeasation Insurance,as restudied by Section
37W of the labor Code,for the performance of the work for which this permit is issued. GAS-ISA.SYSTEM-I INC.4 OUTLET OCC GROUP qPN
My Worker's Compensation Insurance came and Policy number arc:
Carrier: Policy Nn: GAS-EA.SYSTEM OVER 4(EA)
CEK'1'IFICATE OF EXEMPTION FROM WORKERS•
COM PENSA IION INSURANCE GREASFIINDUSTR_L WASTE INTERCEPTOR
(This,roina inerrant bcwmplepermit is peris faro.hundred dollars(SIM) BOB, I, VISION FEES
or less.) GREASE TRAP PLANCHECK
Eloy any that int he my performance the work
mufor vaborlthis permit.kcr,'Cmn'mssued.I l SEWER-SANITARY-STORM EA.200 FE
not employ any person in any manner sn as or bccrnte smbjcn to tM1c Wnrkerd Contpcm ENER tiG
OZ station Laws of California.Date WATER HEATER WNF.NTBeLECIR
Z 2 Applicant GRA IN 'E
M NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMaREATING
a ; Mcomc subject to the Worker's Compensation provisions of the Labor Cale,you most SOILS I7EL
forthwith comply with Inch provisions or this permit shall be devoted revoked. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Fr. PAID
C.)O I hereby aflirn Nat them is a convection lending agency Baltic perfnwms,rdf Da¢ Receipt#.
W F the work for which Nis permit is issued(Sec.309].Civ.CJ
Lenders Name
"I Danker,Address .,'A 'TOTAL:
f, C. I certify that 1 have ad this limlicmlon and nm r and the shave information is BUILT ING FEE
V1 comt l agree to comply with all city and county ordinances and state laws relmingm QT'Y. MECHANICAL PERMIT FEE
U Z buildingconswction,anit hmchyamhonze representatives of this city to cater upon he SHISbf1 E
above mealu med property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless Nc City of Cupertino against ELECTRIC FE
Iiabilities,judgmenty.crisis and expenses which may in any way accrue against said City ALTER OR ADU TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTATR HANDLING UNIT LTO 10.100 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature ofApplicausCommcmr Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MIT'IGATIO FEE
Will the applicant or coon huilding occupant stere or handle hams material HEATING UNIT(TO I00,00)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cala Section 25532(a)? HEATING UNIT(OVER IOO,aO BTU)
❑Yes ❑No
s VENTILATION PAN(SINGLE RFSID) PAID
Will the applicant or future building acupam use equipment or devices which Dole eceipt R
'14i 1.0ou.s air contaminants as defined by the Bay Area An Quality Management BOILER—COMP(3HP OR]BLOW BTU)
DrImel? TOTAL:
D Yes FjNo HOILER—COMP(OVER I W,L00 BTU)
I have real the haurdrus materials calummanu under Chapter 6.95 of the Cali- AIR CONDITIONER
fomia HWIlh&Safety Code,Sections 25505,25533 and 25534.1 understand that if Nc ISSUANCE DATE
building does marturenly have a home.Nat it is mymsNn%jbility mmauty,lece,c'nt NEW RESIDENTIAL MECH. SQ.FT.
of Nc mquircmemn which nun homet prior m issuance of a CeniOcam of Occupancy.
Owner of uuthoro l agent Date TOTAL: ISSUED BY:
OFFICE