30409 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPRRTINO - BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION". APPLICATION/PERMIT PLUMBING.MECHANICAL 30409-
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - ^ - SANITARY NO. APPLICATION SUBMITTAL DATE
LA IPA
OWNER'S NAME: HO E: CONTRACTOR'S NAME: LIC NO:
N/C„ - CONTROL#
RCHITECT/ENGINEER: - LIC NO: ADDRESS: -
1
CONTACT: PHONEfL ,
BUILDING PERMIT INFO
Q Consultant Fede Paid by Applicant(Initial) BLDG ELECT• PLUMB MECH
s ' EJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed ander provisions of Chapter 9(ex mommoingIOH DESCRIPTION
CZO with Section7WO)of Division 3 oldie Business and Professions Codelandmylicenseie pERMITISSDANCE ,RESIDENTIAL:
in full fore end effect. _
C W r - ❑SFDWL ❑KITCHEN REMODEL
License Class Co #
yQ WW'Dam - L'onvammr APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE.
ARCHITECT'S DECLARATION PANELS ���]]]_
F'W F4 - 1 understand my plans shall he used as blit records El STRUCTURAL
ZO Zy Pu MODIFICATION
"24OZ'`2Lensed Pmfeasionel - UPT02WAMPS IDINTERIOR ❑CHIMNEY REPAIR
OL 201.1000AMPS IMPROVEMENT
L OWNER-BUILDER DECLARATION
yy 1 hereby affirm that 1 am exempt from the Contractors License Low,for the OVER 1000 AMPS' ❑BATH REMODEUREPAIR ❑DEMOLITION
id 3 0.E• following reason.(Section 7031.&Business and Pmfewicna Code:Any city or county ❑OTHER
YY]] SIGNS ELECTRICAL
W CN¢ which req a Permit to t d alter,imp demolish. r repair_ y structure ,
NJ
prior to its issuance, to requires the applicant for such permit fl.a signed statement SPECIAL CIRCUIT/MISC.
y
In,,be is licensed pmmor,to the provisions ofth C t t r'x LicenseLaw(Chance,9
muninuencing with Se ti 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. GDMMERGIAL"
EEE c
that he is exempt therefrom and the basis for the alleged cxcmplion.exemption. Any violation of
Section 2031.5h applicant Can El NEW BLDG/ADDITION El DEMOLITION
m y y pp permit rnb3ects the appb lm "Ipanalty of POWER DEVICES El TENANT ❑FOOD SERVICE
i• norm owthaner
hundred petty, r my emP1500)ployees
- IMPROVEMENT
Q ❑La woe ofthe propcay,or myemntender wrthwages asale lac compensation, SWIMMING POOL ELECTRIC
O will doth k andtheThe mreis hot actme, kens orofw mal does not
apply 1044,Burmese ❑OTHER
1
and P lessons Code.The ve.%th mmr,and
Law ices not apply to if owner of OUTLETS-SWITCHES''-F ES}
properly who builds or provided
th thereon,and who does such work himself or through •a t• r
his own employees,provided that such improvements are nod intended or olfered for NEW RESIDENTIAL ELECTSQ FT. d
sele.lf,howev<e the building or improvement is sold within one year of completion,the //� .ySQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden o6maling that he did not build or improve for par- I/ ,( (] ��
pose of sale.). • 1 9 (]
❑I,as owner of the property,am exclusively contracting with licensed rommebox to TOTAL V��}" � 9g
construct the Protect(Sec.7044,Business and Professions Coda:)The Contractor's Li- ..
se Law does not apply to an owner of property who builds at improves thereon,and QTY, PLUMBING PER FEE l.(ipCPY
who contracts for such projects with a eontoramrs)Ilcensed pursuant m the Contractors //vU .
License Law. _ PERMIT ISSUANCE - '
E]1 am exempt under Sec. ,B&P C for this reason `
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE _
/hereby affirm under penalty of perjury one of the following declarations:,
❑ l have and will maintain a Certificate of Consetnto self-insure for Worker's Compete DRAINS-FLOOIC?OOH AREA,GOND.
sation,as provided for by Section 3200 of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. " FIXTURES-PER TRAP '
❑1 have and will maintain Worker's Compensation Insurance,as required by Section -
3700oftheLaborCit for Ple perfor once oin, work for which this parmit isrssu GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Werke' nsatioi/(hsuranc Cartier and Policy wbe m
Carries C' Policy No.- GAS-EA.SYSTEM-OVER4(EA) r •:Y
CERTIFICATE OF EXEMPTION FR WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR-
(Tha dian need notbe completed ifthe permit is forone,hundred dollars(SIM)
BUILDING DIVISION FEES
or less.) I GREASETRAP - PLANCHECKFEE
I certify that in the performance ofthe work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 PT.
not employ any Person in any mmm
manner so us to become subject the Workers'Carrier. - ENERGY FEE
O �., sation Laws of California.Doe
O Applicant - 1 WATER HEATER WNENT/ELECTR GRADING FEE y
o-'7• y NOTICE TO APPLICANT:If;after making this Codificvm of Exemption,you should WATER SYS I EM/TREATING
become subject to the Worker's Compensation provision of the Labor Code, variant SOILS FEE -
{aTa forthwith amply with smch provisions or this permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V n I hereby affirm that hem is a construction lending agency for the performance of Date ` Recy t# .
Wi r97,the work for which this permit is issued(Sec.30Civ.C.)
Q U Lender's Name O L:
Lenders Address T
LL 1 certify that 1 have read this application and state that the above information is BUILDING FEE. AIV
h cored.I agree to comply withal[city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE -
U building conslmctinn.and hereby amhorizn representatives of this city to enter upon the SEISMIC FEE
.hove-mentioned property for inspection purposes: - - }
PERMIT ISSUANCE
(We)agree to save,indemnify sad keep harmless the City of Cupertino against ' ELECTRIC
linbilittes,judgmen ,costs and ex uses which may in any way acerae against said City gLTER OR ADD TO MECH. pLUMBIN F _
conseq ten egmnting is permit
APPLI I DERSTA AND WILL COMPLY WITH ALL'NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOLI .ATION ' MECHANICAL FE '
AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION AX
ignamreof ApplicanUC mraetor d Date EXHAUST HOOD(W/DULY) HOUSING MITI ATION FEB
HAZARDOU RIALS DISCLOSURE
Will the applicant orfutuwbui ng accupani store or handle hazrimous material HEATING UNIT(TO]OU. 0p BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and Ne Health and Safety
Code,Seen.25532(x)1_ HEATING UNIT(OVER 100,"BTU) '
❑Yes ❑No - VENTILATION FAN(SINGLE RESID) PAID `
Date' Rmelp /
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
it hazardous air conmminants as defined by the Bay Area Air Quality Management TO L:
District', `
❑Yes F-1 bow ROILER-COMP(OVER 100,000 BTU)'
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- • AIR CONDITIONER - , ISSUANCE DATE
fomia Health&Safety Crab,Sections 25505,25533 and 25534.1 understand Plot lithe NEW RESIDENTIAL MECH. SQ.pr..'
building does not currently have a tenamt.that it is my responsibility to notify the mcupant
of the requirements which must be met in,to issuance of a Certificate of Occupancy.
Ownerur authorized agent, - Date t TOTAL: ISSUED BY,
OFFICE