30794 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY—
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. 3 0 /y 9 q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 4
BUILDING PROJECT IDENTiFICNI'ION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' AMF.: PHONE: CONTRACEOR'g NAqM/e LIC NO:
Mk
. _ / NIC CON'1'ROLq
RCHITECf/ENGINEER: LIC NO: ADDRESS:
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ITpGf
I hereby affirm that I sum licensed under provisions of Chapmr 9(commencing JOB DESCRIPTION
DO with Section]II00)ofDivision3 o(Ihe Business and Pnrfessi...Code.an my license is PERMIT ISSUANCE RESIDENTIAL:
W
in fall[[force an at. 9t'/f ❑SFDWL ❑KITCHEN REMODEL
�Vj LicenseC ass Lic.M •LO APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
on Dem Com
Z8prn ' ARCHITECI-S UECL DECLA PANELS - ❑MULTI-UNIT ❑STRUCTURAL
Z 1 understand my plans shell be used us public records PANELS
OZ- UPTO 200AMPS
Ag„ Licensed Professional 201-1000AMPS ❑IMPOVVEMENT RIOR 0 CHIMNEY REPAIR
�fd OWNER-BUILDER DECLARATION Commences
yy CC I hereby affirm Ihnt 1 em exempt from the Cnnsrecmta License Law for the OVER IOOD AMPS ATH REMODEURF.PAIR 0 DEMOLITION
pd 3 G V following mason.(Section](131.5,Business and Professions Code:Any city or county YYFSIGNS ELECTRICAL
❑OTHER which respires a permit to comauct,alrca improve,demolish,or mpoir any slrsrewre
prior m its issuance,1I,om4rim,,the applicant forsui'h peri I,,file.signed strainer, SPECIAL Cl RCUIT/MISC.
that he is licensed pursuant to NC Provisions of the Conaamors License Law(Cloy
C£O (commencing with Section]00B.f Division 34 the Bisiness.nd Professions Code)., TEMP.METER OR POLE INL'
ST. COMMERCIAL
IY a that he is exempt therefrom and the bolls for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora ❑NEWBLDG/ADDITION ❑DEMOLITION
y permit subjects the applicant to.civil Penalty of POWER DEVICES
E,yy not more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
C ❑ 1.as owmcof the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the wodr m d Illustrator,is oat intended or offered lar late(Sec.]044,Business ❑OTHER
Wand Professions Code:The Contractor's Licence law does not ripply or an owner of OUTLETS-SWITCHES-FIX TURES
prolixity who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
safe.If.however,the building or improvement is sold within one year of completion,the SQ.FT,FLOOR AREA SISQ.Ff.
owner-builder will have the burden of proving that he did not build or improve for pur- p y f1�
Potentiate). � A. 9 S/
Fl 1,as owner of the property,am exclusively contracting with licensed contractor to
comment the porta,(Sec.]0,4,Business and Profession,Cade:)no Contractor's Li.renep pp 7 MID Law does net apply m an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE WRI
whocroracls for loch pooms with a m
contrecgs)licensed pursuam to d e Contromes
License Law.
I am exempt under Sec. ,B&PCfor Nisreawm PERMIT ISSUANCE CITv
ALTER-DRAIN&VENT-WATER(EA) 1 UC Vor Cal 11NU
Owner Date yALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 8
EII hereby off on under penalty of perjury one of she following declarations
have and will maintain a Ccnifica¢af Consent to self income far Workers Compeer. DRAINS-FLOOR,RODE,AREA,COND. STORIES TYPE CONSTRUCTION
E
4_section,as p...ided for by Section 3700 of the Labor Code,for the performance of the - r
work for which this permit is issued. FIXTURES-PER TRAP
❑I hsve and will maintain Workers Compensation Insurance,n,required by Section
3700 of the labor Cale,for the perfarriance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP AYN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-it.SYSTEM-OVER 4 EDO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE 1NTERCEFfOR
(This section teed all be completed ifthepcnrdt is for one hundred dollen OGNB BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCNECK FEE
I certify that in the performance of the worts forwhich this Penni,is issued,I shall SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any marine so ey �gl�rvject m,he Workers'Compeer- ENERGY FEE
,0 A11 taws of Califrelo-a.gArey 1/ /-�,
>OO ApplicU Com '/, WATER HEATER WNENIDELECTR GRADING FEE
q(/j NOTICE
ICAPP A ing Nos Cerifcmc of Exempu.n,you should WATER SYSTEM/IREAGNG
F become subjw to t e Workers Compensation provisions of are labm Cade,you mus, SOILS FEE
fonhwid,comply with such provisions or this permit shall he deemed revoked.
WATER SERVICE
z CONSTRUCTION LENDING AGENCY NBWRESIDEN'NALPLMB. SQ.FT. PAID
U� l hereby affirm Ont them is a construction lending agency for probernance of Dore ,at is
f" Ne work for which this Terri,is issued(See 3097.Civ.C.) -
C U Lender's Nome
TOTAL:
Lenders Addmss
y I certify that 1 have read this application and state that the.Love information is BUILDING FEE 14 OT
`e
(Z) cornice I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building construction,and hereby amhorim representatives of this city to enter upon the SEISMIC FEE11
above-mcmioned property for inspection limper., PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless;the City of C.Pro mo against ELECTRIC FEE
liobilities,judgmenu.cosh xmdefinds which may in any way ettmeegxinsi said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting.f this rmil.
APPLICANT UNDER TANDS Ais WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO IO,100 CFM)
SOURCE RE IA MECHANICAL FEE
4gA /7 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCDONTAX
Signature of ApplicantlCoontractor '/^Dom EXHAUST HOOD(WMUCI) HOUSING MITIGATION NEE
HAZARDOUS MATERIALS DISCLOSURE'
Will theapplicenlm far..building ac.pum stun or handle harardom mptcrid HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,100 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will Neu licant or future building t use Date Receipt p
applicant gby then Area
equipment devices BOILER-COME(3111'OR 100,000 BTU)
mit hazardous air conmminanb m defined by the Bay Area Air Quality Mnwgcmem
Uistrin] BOILER-COMP(OVER 100.(IW BTU) TOTAL:
L
Y ❑No
ad the harWous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
briHealthr arms Cale,Sece. or 25505,I,my std 25534.1 undenmnd that if nt NEW RESIDENTIAL MECH. SQ.Ff.t.wic y have a,met p Nat it is ua ce ofa Cert.y m notify Ne.lancy.ns wldcM1 muss be ma pdmmiauance ore Cerificnte ofOccupancy.imd agent Dam TOTAL: ISSUED BY:
OFFICE