30137 (2) I' APPLICANTTO;FILL IN INFORMATION WITHIN_RED LINES-USE BALL POINT PEN ONLY ' t
CITY OF CUPERTINO - BUILDING-ELECTRICALS. _ PERMIT NO.' 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL "
" t BUILDINGPROJECT IDENTIFICATION
137
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAT
,t.w4k 4k-^A Pl tom- WIAAG
OWNER'S NAME: I I PHONE: CO RACfOR'S NAM LIC NO: -
` ralro : kA 19l 'TA&C rL ,N/C CONTROL#
ARC ITE 'NGINEER: - - - - hIC NO:' ADDRESS: J (� ty
CONTACT: , PHONE: 13UILDING PERMIT INFO
""`^ 1 �I a..L1,2(l'_G�� ❑ ConsWtant Foes Paid by Applicant(Initial) BLDO ELECT PLUMB MECH
Tyr
(LICENSED CORTRACTOWS DEECCLL/ARATIOlN J QTY ELECTRIC PERMIT
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
RIZ with Swtion]000)ofDivision3ofthe Business and Professions Code,and mylicwseis
�o in fall is.Tied effect. PERMIT ISSUANCE RESIDENTIAL:
U U License Class Lic.# OWL ❑KITCHEN REMODEL
FZ�W Date Contractor APPLIANCES-RESIDENTIAL ADDITIGN ❑PLUMBING RE-PIPE
Z N 7 y ., ARCHITECT'S DECLARATION PANELS r ❑MULTI-UNIT ❑STRUCTURAL ,
�Z ' Iunderywri yplens shall be used aspublic recards MODIFICATION
OZ�- - UP TO 200 AMPS
F ❑INTERIOR ❑CHIMNEY REPAIR
-F�qqU Lensed Professional 201-IOWAMPS IMPROVEMENT '
OWNER-BUILDER DECLARATION Cmawh -
CC Y(fill G I hereby atfvm that 1 am exempt from the Contractors License Law for the OVER IOOO AMPS [_1BATH REMODEL/REPAIR El DEMOLITION'
O6 U following reason(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL
❑OTHER"
4 eaEyQ which requires a Permit m comoruct,alter,improve,demolish,or repair any suuctune
Nr4 priorto its issuance,also requires the applicant for such permit to file a signed statement
(commencing
CIRCNTIMISC.
y that he is licensed pureuatnto the provisions of the Contractor's License Law(Chapter 9 -
G�O (conening with Section 70010)of Division 3 of the Business and Professions Code)or TEMP.METER OR POI. ST COMMERCIAL:
that he is exempt therefrom and the basis for.the alleged exemption.Any violation of '[I NEW BLDG/ADDD'ION ❑DEMOLITION
Section 7031.5 byuny applicant for a permit subjects the applicant o o civil penalty of POWER DEVICES .
_ out tame than Eve handled dollars($5W). []TENANT [I FOOD SERVICE
p6 -1 I,as owner of The piopeny,or,my employees with wages astheirsole compensation. SWIMMING POOL ELE IMPROVEMENT
will do the work,and the oructure is not intended oroffcred for sale(Sec.]Of4,Business El OTHER
pend Professions CWe:The Cutaneous License Law dues act apply to as owner of _ OUTLETS-SWITCHES-PIXTU
G pmpeny who builds or improves thereon,and who does such work himself or through ,t
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTft SEC
sale If.however,The building.,improvement r,ond Tinhinone yearofcompledon,the SQ.FT.FLOOR AREA $/SQ.ET.
owner-budder will have the burden of proving that he did not build or improve for put.
ptsof soled., r
1 ��.
co f,as owner of The progeny,am exclusively contracting with licensed c.mmemrs i- • , TOTAL:
r 'construct the project(Secapply
to an wner of roperty who onsbut ds or i The es Theron, nd
Li-
cense Lew aces not apply to an owner of property who builds m improves thereon,and QTY. PLUMBING PERMIT FEE ✓V
who contrasts for such projects with a wntramdgs)licensed pursmnt to The Contractor -
I] lam io, PERMIT ISSUANCE _
❑lam exam unde�Se ,B&PCfur This reason '
ALTER-DRAINStVE WAT2 (EA)
Owner Date_ VALUATION
WO (ER'S PE ATION DECLARATION BACK FLOW P TEC VICE 2Z1
I hereby affirm under p ally of perjury one of rhe following declarations: V■
•❑I have and will maintain a Certificate of Consent o.self-insure for Worker's Coolant- DRAINS-MOOR, FA D. STORIES TYPE CONSTRUCTION
salter,as provided for by Section 37W.f the Labor Code,far The performance of The
work for which this permit is issued. FIXTURES-PER TRAP,
❑.I have and will maintain Worker's Compensation Insurance,as--quire-by Section
3700 of The"hot Code,for The performance of the work for which this permit is issued. GAS-EA.SYSTEM-IINC.40U TS
My Worker's Compensation Insurance carie,and Policy number are: OCC.GROUP APN
Cartier: Policy FROM
GAS-EA.SYSTEM-OVER4
CERTIFICATEOMPE SATIONINSUROM WORKERS' '
'COMPENSATION INSURANCE GREASFAINDUSTRL WAST R
(This section neat not becomplcted it'The permit is furore hundred dollars it Ilk) _ BUILD( V ION FEES
or less) GREASE TRAP U O
PLANCHECK FEE
(certify peonthean,mmance, ofta to ork berme,subject
ich jetto permit isissu Compr- SEWER-SANITARY-STORM 2
.or employ any person i Da manner w us to become subjecrto The Workers'C.mpen- ENERGY FEE
2 s pplir LAws of Californiaa,Date
'- OO A lienal � 1 - WATER HEATER W/VENT/ELECTR
PP GRADING FEE
V) NOTICE TO APPLICANT:If,atom making this Certificate of of Exemption,you should WATER SYSTEM(TREATING
a ; become subject y The Workers Compensation provisions b the Labor Code,you most SOILS FEE
� 'forthwith comply with such provisions or this permit slid[be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
U O I herebyaffirm that There is a construction lending agency for The performance of Date Receipt
LTs F the work[or which This permit is issued(Sec.3097,Civ.C.) `
O,U ,Lender'.,Name r TOTAL:
Lenders Address - TOTAL:
0. 0 1 certify that I have real This application and state that the above information is BUILDING FEE �a
rA c reit.I agree c comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,7�. building c.nstrvli.m,and hereby amhodze representatives of this city to enter upon The SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hnemless the City of Cupertino against ELECTRIC FEE
liabilities,judgment,costs and expenses which may in any way areme agaiastsaid City ALTER OR ADD TO MECH
in consequence of Ne granting of this pernal. . PLUMBING PEE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT(TO 10,000 CFM) - ,s
SOURCE REGULATIONS. MECHANICAL FEE
" AIR HANDLING UNIT(OVER IQOOO CFM)
�I CONSTRUCTION TAX
Signature of ApplicanVComracor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) r
as defined by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 - HEATING UNIT(OVER pon,000 B'rU)
F1 Yes ❑No' PAID' x
VENTILATION FAN(SINGLE RESID) Rweipt#
Will the applicant or future building occupant use equipment or devices which DBOILER-COMP(3HP OR 100,000 BTU)
D
hazardous mit ards air canurnments us defined by the Bay Area Air Quality Management
istncO 1 , . 11
BOILER COME(OVER 100,000 B'rU)
- ❑Yes ❑No -
AIR CONDITIONER Ut- LUi"t": 0 )
I have reed the hazardous materials requirement under Chapter 6.95 of the Cali- ISDATE
fornia Health At Safety Cude.Sections 25505 25533 and 25534 I understand that if the NEW RESIDENTIAL MECH. SQ.Pr.
,building does m
:n t Tammany have a tenant,Thal it' y .ponsibiltyt notify theoccupant
'of the Deformities huh mast be mel prea,to issuance of Certificate f Oweirpsent, - X/
Owner or audit,rized agent pale - TOTAL: ISSUED By,
OFFICE