30507 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - BUILDING m ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL ° 30507
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. s•
, SAN]TARY • APPLICATION SUBMITTAL
AL DATI
I Ct IT
& ORfy LIC NO: WILD.NAME: I
Lv - NIC coNTROIx t M
e_
ARCHITECT/ OUNCES LICNO'. , ADDRESS:
4�110141_14,0r Ak,JCTI?f le-%;e
CoNTA PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
'G.SS ❑ ❑. ❑,.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE -
Iher y affirm that I am licensed under provisions of Chapter 9(cmnmermag JOB DESCRIPTION
OaZ with Sectio ]000)mf Divisian3nfthe Business and Prcfeseions Cwle.ant mylicense is
P o 0 PERMIT ISSUANCE RESIDENTIAL:
n full faros and affect.
� u r ❑SFDWL s ❑KITCHEN REMODEL
- (W License Class LiaN APPLIANCES-RESIDENTIAL ' ❑ADDITION ' ❑PLUMBING RE-PIPE
an
0. Data Contractor --
[F+ ARCHITECT'S DECLARATION PANELS ElMULTI-UNIT ❑STRUCTURAL
Z O ae)z 1 nadersomd mused as plans shall he uas public records MODIFICATION
OZ`3 - UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
��N.� Licensed Professional 201-IMAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS O BATH REMODEIJREPAIR El DEMOLITION
yy 1 hereby difrm that 1 am exempt from the Contractor's License Low far the
p(a G F fallowing reason.(Section]031.5,Business and Professionx Code:Any city.,,..at, SIGNS ELECTRICAL - � []OTHER
WW I
E O which requires a permit to construct,alter,improve,demolish,or repair any structure _ a
prior to its issuance.also requires the applicant for such permit o file a signed statement I SPECIAL CIRCUIT/MISC.
6 that he is licensed pursuant tothe pmisions of the Comm,ne,License Lan,(Chapter 9
O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE MST. COMMERCIAL:
d Oo that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'^ Section 7031.5 byanyapplicant fora mumnmblects the applicant civil penalty of, POWER DEVICES
m ❑TENANT ❑FOOD SERVICE.
ant more than fvehandred doil.t$50h. IMPROVEMENT _ '
Q ❑Lasownerefthepropeny.ormy employeeswith wages as theirsole colnpensalian, SWIMMING POOL ELECTRIC
will dothe work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
e$ and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
('$' .. propeny.who bonds or imprnves thereon,and who does such work himself or through
his own iaad.y1a1.ProvidW that such improvements ora not intended or offered far NEW RESIDENTIAL ELECTR SQ /y FT.
sale.If,however,thehuilding mimpoe,sciem is xoldwithirimv ycntofcomme
pho ,the SQ. fT:OQRPItfiA 8/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par- it 1� 1996
poseofsele.) .
E]1,as owner of the property,am exclusively connecting with licensed eontmem s m TOTAL: r
construct the protect(Sec.]044,Business and Profession Code)Tho Contractor's Ll- WV, t_r rf`r
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such pmjeew with a comreacer(s)licensed pursuant m the Conuvcrods
License Law, PERMIT ISSUANCE "
❑1 am exempt under Sec. ,B&P C for this reason
Owner Date
ALTER-DRAIN&VENT-WATER(EA), - VALUATION
-
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herchy affirm under penalty of,,.,one of the following declarations: .. ^ .
(h ave and will maintain a Certificate of Consent m self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND., STORIES TYPE CONSTRUCTION
ns provided for hy.Seadi n 3700 of the Labor Code,for the performance of the
work Por which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,h requited by Section -
3]n0ofthe ker de Orth p..a amoceof theolic for which this permit ix issued. GAS-EA.SYSTEM-I MC.4OUTLETS OCC GROUP APN"
My Worker' mace carrier end Policy GAS-EA.SYSTEM-OVER 4(EA)
Carries Policy ✓f , '
CERTIFICATE OF EXEMPTION FROM WORKERS' -
' COMPENSATION INSURANCE CREASEIINOUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section Deed not be Completed if lhepermhis Tomas hundred dollars($10d GREASETRAP
or less] PLANCHECK NEE
(certify thatinthe woffinanynpnnceof the work for which this the
is issued
'&ur er- SEWER-SANITARY-STORM EA.200 FT. -
ell
not employ any person in any manner an n to hearths subject to the Worker Compen- ENERGY FEE
Qz serine Laws of California.Date WATER HEATER WNENT/ELECTR
O Applicant - - GRADING PEE "
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption;you should WATER gYSTEM/1'REATING SOILS FEE
F `I�' become subject to the Worker's Compensation provisions of the Labor Cade,you most _
MQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY r NEW RESIDENTIAL PLAIN. SQ.FF. PAID
�" Ihereby affirm that there is a construction lending agency for the performance of Dam Receipt#
LUkt the work for which this permit is issued(Sec 301 Civ.C)
Q Lender's Name - r TOTAL:
>i Lenders Address TOTAL: '
I certify that I have read this application and state that he above information is BUILDING FEE
fn correct.I agree to comply with all city and county ordinances and state laws relining to QTV, MECHANICAL PERMIT FEE -
I;,,)7 building construction,and hereby umhorim representatives of this city to enter upon the SEISMICFEE
G above-cam aned property for inspection p."a,,. PERMIT ISSUANCE .
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses whit any way acrme against said City AI,TERORADDTOMECH. - n
nsequenni,r, theg'rantn ispa PLUMBING PBB.
APYLICAN DE DSA WILT WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.WOCFM) MECHANICAL FEE
SOURCE T. S. �`� -
��'/. AIR HANDLING UNIT(OVER I0,0100 CFM) CONSTRl1CTIONTAX
Tdo. Appli ommmorJDutefo EXHAUST I100D(W/DUCT)
AZARDOUS TERIALS DISCLOSURE HOUSING MITIGATION FEE
l pplicvatorfmureboldinguccupnmstoreorandle hazardous material HEATING UNIT(TO 100,000 BTU)
iliaCaperton Municipal Code,Chapter 9.12,and the Health and Safety
io 255320)7 HEATING UNIT(OVER I0g000 BTU),
❑Yes FI No I
VENTILATION FAN(SINGLE RESID) PAID r •
Dam Receipt
Will the amdamet ir contumacious
u building by the Bay Amm AirQutordManaemes ent BOILER-COMP(HIP OR I OQWO BTU) -
emit hazardous air chntaminan¢as defined by the Bay Arce AinQuality Management .roTAI-: .
'District? I
F)Yea ❑Nn BOILER-COME(OVER 100,01)(i
� -
I have read the hersom ms reatermix requirements under Chapter 6.95 of the Cali. AIR CONDITIONER _ ISSUANCE DATE
fomin Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the 'NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a accord,that it is my responsibility to notify the occupant
of the requirements which must be at prior to issuance of a Coi dleme of Occupancy.
Owner or authorized agent Date I TOTAL: ISSUED BY:
OFFICE