30847 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OFCUPERTINO BUILDING-ELECTRICAL "' PERMIT NO. ^ pp
BUILDING DIVISION, APPLICATION/PE"IT PLUMBING-MECHANICAL (O Q,�
BLILIIING PROJECT IDENTIFICATION 3J V 1
ILDING ADDRESS: - .. a - r SANITARY NO. APPLICATION SUBMITTAL DATE
e2IL o.`I� TA 9�f Gov 6PT� .�/D GA9�D
WN 'SNAME: - PHONE CONTR OR'$NAW�/S LTC NO:
N �' ` NIC CONTROLN
\ R I Cf INEE LICNO: ADDRESS: ❑
CONTACT. - PHONE: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) •gpLDyG� E a' PLUMB ECx
a N ` �..
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby al➢rm that 1 am licensed Bu ander provisions of Chapter 9(commencing JOB DESCRIPTION.
p"pZ with Section
and11)ect. sion3 of the Business and Professions Cale,and toy license is PERMIT ISSUANCE RESIDENTIAL:
F tyO in full License
Class
end effect.
❑SFDWL ❑KITCHEN REMODEL.
License Class _ Conti _ APPLIANCES-RESIDENTIAL
N6�
Data—Cantracttir ❑ADDI770N [I PLUMBING REPIPE
a' '
ARCHITECTS DECLARATION
I^Dvr PANELS ❑MULTI-UNIT [I STRUCTURAL
Z O n Z 1 undenunJ in,plans shall tersest its public records - MODIFICATION '
OZ—O UPT02tpAMPS ❑INTERIOR ❑ IIIMNEY REPAIR
Licensed Ptnfcssnonal
OWNER-BUILDER DECLARATION 201-IMAMPS IMPROVEMENT-
Y
es C4 T hereby affirm that 1 am exempt from the Contra ores License Law for the OVER 1000 AMPS [I BATH REMODEUREPAIR RMOLITION
3IL following o vmn.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
Vd O which"vires construct.a pcnt to construct.altertmm
,improve,demolish,or repair any scre
prior it)its issuance,also requires the applicantfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
a that he is licensed pursuant to the provisions of the Conlmctoes License Law(Chapter 9
O (commencing with Section 7")of Division 3 of the Business and Pinfesainns Code)or TEMP MET ER OR POLE IN COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION'
flXl Y•
y} Section 7031.1 by any applicant fora permit subjects the applicant)a civil penalty of POWER DEV ICEg ElTENAN ❑FOODSERVICE '
not mart than five handfed dollars($SW). IMPROVEMENT
G ❑1,as owner ofor,property,or my employees,with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the swcture is not intended oroffered for sale(Sec.7044,Business ❑OTHER
W 3§ and Professions Cnde:The Commences License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURESIs. -
propeny who builds or impresses thereon,and who does such work himself or through -
his own employees,pmvidrd but such imprevernems cure not intended or entered fm NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building orimpmeadmal is .to within one yearofcompletion,the SQ.FT FLOOR AREA $/SQ.FT.
onamr-builder will have the burden of proving that he did not build or improve for pur-
pose cuts owner - TOTAL: 8
❑ sun owner of the propenyl am exclusively confessing with:)"a Cconfessors a „ [1
consumer'he Project(Su.]044,Business end Professors Calca'D¢Cnnuu<tor s Li' M
onsc low deer not apply to an owner of property who builds or improves Become,and QTY, PLUMBING PERMIT FEE �T[n
who contracts for such projects with accn0vetons)licensetpurvuant tothe Contractoes AR 18 I{Lu
License low. PERMIT ISSUANCE IV'
C]I am exempt der Sec I ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) 'yII�•Uf VVrLITfIIYV r
Date V Mit I� 'f
Rnderp O DECLARATION 1lpCK PLOW PROTECT.DEVICE
I hereby affirm under,penelty of perjury one of the following declarations:
E3I have and will maintain a Certificate of Camentto self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION s
cation,as provided for by Section 37M of Ne labor.Code,for the performance of the
work for which this permit is issued. - FIXTURES-PER TRAP
❑1 have and will maintain Workers Compcnoadoa Insurance,as required by Section
37M of Ne Lehr Code,for the performance of Ne work for which this permit is issued. GAS-RA.SYSTEM-I INCA OUTLETS OCC GROUP APN
My Workers Compensation Insurance turner and Policy number arc: .
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPHON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not becompleted ifthe permit is for-utiehundreddoliars($100) D G IVIS NPERS
or less.) GRF,ASETRAP PLANCHEC E �a
Ff.
EN
I ratify that in the performance ofthe work for which this permit is issued,Ishall SEWER-
notemployanypersoninanymannersoastobecomesubjecttotheWorkers'Comped- SANITARY-STORM EA.200 ER
.had Laws of Cut fomiu.`Date
Z
H G Applicant ,. • WATER HEATER WIVENT/ELECTR GRAD"E
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a 'become suhject to @e Workers Compensation provision of the Labor Code,you must SOILS FEE
Lkl forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINdinga,AGENCY NEW RESIDENTIAL PLMB. SQ.PR. PAID
UO l fare which thi that there issued Pum.3097,
agency fonhe penfomnan«of Date ReeeiplN
ti the work for which this penton is issued(Sec.309],Civ.CJ_
O I"'
Lancers Name - TOTAL:
Lender's Addms TOTAL: N
l F.y Icenify that 1 have mad this application and state that the slave information is - - BUILDING FEE
IA corriet.I.,.atocomplywide all chy and county ordiaencva endswte laws relating to QTY, MECHANICAL PERMIT FEE
U ,zU. building iotionction.and hereby enhance representatives of this city at enter upon the SEISMIC FEE
above-metnionel property for inspection purposes. PERMIT ISSUANCE - -
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Imbilith,.j.Mar a.cost sod expenses which m.yready way acerae ergmoved City PETERORAUD TO MECH.
r in consequence of the granting of this permit. PLUMBINGFEE
APPLIC6,liq UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
a SOU GUNS: - ••j v _ - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature bf Applic omesctoraa EXHAUST HOOD(W/DUCp
HAZARDOUS MATERIALS DI CLOSURE HOUSING MITIGATION FEE
Will the applicant or future building vac tent store or handle hazardous material HEATING UNIT OT)100,"RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety •
Code.Section 255320)? - HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Data Receipt N
Will the applicant or fume building use equipment or devices which BOILER COMP DHP OR 100000 BTU)
mitcontaminantsazardous air contaminants as by as definby the the Bay Ameranagement - ,
ey AAir Quality Management TOTAL:
District? BOILER-COMP(OVER 10100K BTU)
❑Yea ❑No ,
I have mad the hamrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE
.miss t{eehh&Safety Code,Sections 25505,255]3 and 255]4.1 undersmnd that if the- NEW RESIDENTIAL MECH. SQ.FT. -
'I ' d,%mi emrentlyhave a reason, at it is my resrymsibility to nolify the occupant _ - '• , .
} lan ents which must be nor to isauanceof Certo are n( cu ,
Ownerers. misedv at TOTAL: ISSUED BY:
OFFICE