30801 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY• - '
CITY OF CUPF'.RTINO' BUILDING-ELECTRICAL.L. - - PERMIT NO. 30801 O 8 O 1 i
BUILDING DIVISION AI'PLICATION/PERNIIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DAD
�v� ,KiN � LoTy-
O :R'S AME: 1 p TRA OR' NAM LICN
MM, oDI nc, �l'61�0 . , s oyp T {� q5 NIC CONTROL#
RCHITE7NGINEER: LIC NO: ADDRLSS: Vl1
i O' DDi # #slat
co p - PHONE: BLIIl,U1NC PERMIT INFO
1 /� O ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB:' MF,CH
LNj I.10 _ _Oq , btR"
_'ice .
LICENSED C RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Lam' Lit
1 herehy a iota that I am licensed under Pnwnums of Chapter 9(commencing JOB DESCRIPTION
OZZ with Section 7000).f Divisio 3ofthe Biamessand PtbfessumiC c.and mylianse is
5 S PERMIT ISSUANCE RESIDENTIAL
IW,�0 full force anJ eRect. J FDWL C3 KITCHEN REMODEL
aFUZ�j License Ins LIC.#
.NQS DamConm¢mr APPLIANCES=RESIDENTIAL [JADDITION ❑PLUMBINGR&PIPE
,FON RCHITF.CT'S�UHCLAIXA'IO PANIll.S, ❑MUL'1'1-UNIT l' ❑STRUCTURAL.
Z O 1 understand nay plans shall be used as public records - - MODIFICATION
OZr��'� IIP TO gal AMPS El INTERIOR '. (]CHIMNEY REPAIR
Licensed Professional OWNER-BUILDER 201-IWOAMPS IMPROVEMENT
6s�Q � - , '1 hereby affirm thatatIa.am epempt from DECtheLARATION Cmm�emrs License haw for the OVER["AMPS ❑BATH BEMODEUREPAIR [I DEMOLITION
Ka.ate,U following reason.(Section 7031.5,Business and Professions Code:Any city or courny SIGNS ELECTRICAL. ❑OTHER,,
which try6ircs a permit io camsuua,cher,improve,demolish,or m,cm,any awnute -
^� y Prion.its issuance,alsoregnim.,theupplicunt l'ar.,och Permit Id file n signed statement SPECIALCIRCUI'I'IMISC.- p
shot he is licensed pursuant mtbe provisionsofthe Commetors Llcenne l.uw(Chapter9 R—t+-�p
p�CG (commencing with Scetwo7000)of Division 3.1 the ltusinessand Professions CMe)or TIiNIRMLTERORPOLEINST. - COMMERCIAL:
a u that he is exempt therefrom and the basis for the alleged exemption Any violation of - ❑NEW BLDG/ADq[J'ION _ DEMOLITION
_u• Seen.7031.5 byanyapplinted faropeor.subjemstheapplicou In.civil penalryof MOWER DEVICES d0eIISR irial`•ADEMOLI IO
r� n more than Eve hundred dollars S5aB. ❑TENANT `"TY ICE
_ �ZO,Q Lasowneroftbepeopeny,or my employcea with wages utheir sold mmpensatinn, SWIMMING POOL ELECTRIC IMPROVCMENT VY
Sat will do the work,and the swcmre is not intended oroffcrcd for sale(See.7144,Business ❑OTHER r" �—
a and Professions Code:The C.ntmctor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
tH Illuu
property who builds nr impnrvea thsuch improvements and who does smcb wnrk dad or or through - -
sal own employees,building that such w are not intended of
or offered for NEW RESIDENTIAL IiLFiCI'R,.
sale.IL however.the building orimpmvemem is wig within one year of completion.the SQ.FT.FLOOR AREA 81SQ.FT.
osaser-builder will have the burden of proving that he did not build or improve for put- - 1015-2
W.of sale.). - -
1,as owner of the pmperty am exclusively corseting with licenced contractors to TOTAL:
construct the project(Sm.7644;Business and Professions Code:)The Contracmrs Li-
cense Law does not apply to an owner of property who builds car improves Thereon,am] QTY. PLUMBING PERMIT FEE
who cnmraets fur inch pmj.ms with o conuumnr(n)IicenseJ putfiuenl m the Cnmm�cmr's -
Liccnu Law.. t, PERMIT ISSUANCE I
❑I am exempt under Sec.' ,B&l'C for this rtes
on
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Datew�
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT DEVICE Y
1 hereby affirm under Penalty of perjury one of the following declarations
]I Ionic and will nminmin a Certificate of Consent to celflnsme fin-Workers Compen-
DRAINS-FLOOR.RUfOP,AREA,GOND. - STORIES - TYPE CONSTRUCTION
nation,as provided for by Seetlon 37M of the Labor Code,for the performance of the ,..
work for which this permit is issued.. 4' FIXTURES-PERTRAP -
1 have and will maintain Worker's Compensation Insurance,us require#by Section
3700ofthe labor Cale,fnr the Perfomtanee of the work for which this permit isissued GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP AI'N
My Worker's Compcnmtion Insurance artier and Policy number me: GAS-EA.SYSTEM-OVER Cartier: Policy No.:
CIiR'1'IPICXM OF EXEMPTION FROM WORKERS' -
COMPENSAT]ON INSURANCE GRP.ASFANDUSTRL WASTE INTERCEPTOR y JAGDIVISION PEES
- (This seminnnecdnnt be completed if the permit is fmone hundraddolits.($u0) OREASE'TkAP'
nrinssJ `' - PIAN -
Icertifythotintheperformance @cwndfnr hich this permit is isadeA,Ishall
.mem to an SEWER-SANI'T'ARY-STORM 6A.2(X114.
p y y Person in uny,manner o s rT c n w the Workers Cnmpen- ENE G P
0 z anti..to alifn 'q. ate WATER HEATER WNPNTIELF.0 R
Z 6) A"do"nt - GRADIN nor
rA NOTICE APPLE .If,afte a mg this Ce fisme of Exemption,you should WATER SYSTEMOREA TING SOILS FE,
a �
become subject ro the Workers Cd s an,,.provisions of the"hor Code,you man _
LGl forthwithrcomply with such provisions or this permit shall be deemed revoked WATERSERVICF.
� O CONSTRUCTION LENDING AGENCY NEWRESIDENT'IAL PLMB. SQ.BT, PAID '
I hereby affirm that there is a construction lending agency for the Performance of Date Receipt#
Or the work for which this permit is bamed(Sec.7097,Civ.C.) -
ULenders Nome TOTAL:
I<ndcrs Address TOTAL:
-� y -I certify that I have read thisnpplicmion and state that the nMBl11LDING FEEwe information is l
IA srorrect.I agree 10 Comply with all city and county ordinances and state lawn relating to QTY. MECHANICAL PERMIT FEE
V building consavetion,and hereby mamoriLe representatives of this city to enter upon the SEISMIC FEE.
id nswormatinned pmpeny fnr inspection Pmposns. PERMIT ISSUANCE O
(WO biose m save,indemnify and keep hamdeas the City of Cupertino against ELECTRIC FF.P,
Iia lutes., parents,costs and expenses which may in any wayaccmeagainst said City ALTER OR ADD TO MECIL -
JIAN�G are of Ne .at a,of this permit. PLUMBING FEE
PII 1 'RSTANOS A'D WILL COAIPYWITH ALL NON-POINT AIR HANDLING UNIT(TO In."CFM) MECHANICAL FEE
11 ONS.
2 AIR HANDLING UND(OVER IB,000 CFM) CONSTRUCTION TAX 'r •
In.are of pP et d c Date EXHAUSTHOODOVj)UCT) L ,
IIAZ Il(r M ERIAL.$DISCLOSURE HOUSING MITIGATION I'
Will the applienm aro
are i4 ng occupant same or handle hazardous material IIBATINO UNIT(TO IIX1,0a)BTU)
as Jtimed by the Cupertino Alunict Code,Chapter 9.12,and the Health and Safety HEATING UNIT'(OVEN 1(#,1100 B
Code,Sado.25532(ayl TU)
❑Y<s ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or furore building occupant use equipment or devices which Data Receipt#
At hazardom air canmmlnann as defined by the Bay Area Air Quality Management BOILER-COMP UHP OR I 0 BTU) t -
Lvain7 Yea No u BOILP.R-COM P(OVIifk 101,00 BTU) 0rn1,:
I have mad the hazardous materials rryuimemems under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
fomin Truth&Safety Code,Sccdons 25505,25533 and 25534.1 understand that if the PT.
NEW RESIDENTIAL MECH. SQ.
building resistant currently have.mount,that it is my responsibility m notify the pan
e occut of the the requirements which must N,met poor to issuance of a Cenificate of Occupancy.
' Owner or amhmizadagcnt, Date TOTAL; ISSUEDBY:
OFFICE