30526 (2) 'APPLICANTTOTILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN'ONLY _
CITY OF CUPERTINO .. BUILDING_HLECTRICAL - PERMITNO. e]
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-t BUILDING DIVISION _ - APPLICATION/PERMIT PLUMBING-MECHANICAL O 5 Z� '
BUILDING PROJECT IDENTIFICATION
UILDING ADDRESS r - - SUBMITTAL DATE
C [ -SANITARY NO APPLICATION
a =1�rERTI �� cA
NER'S NAM PHONE ' CONTRACTOR'S NAME: LIC NO:
• �� 1. ' A REG *r- Me N N/❑C . - $ 'wiCONT(R///O�►►LM�
ITECTwNGRJEER ��
LIC �
.r i.. U • � YVVI /vJ`
CO TACT. - PHONE: i BUILDING PERMIT INFO
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alt tit Aces PHi by pp, n t - BLD c ELECT P UMB MECH-
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1 LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby firm N t 1 licensedud provisions of Chapter 9(commencing JOB DESCRIPTION ,
OOZ with Seni n 700(0 ofDivson3 fth_Busi dLr fessioa C and my licease' RESI._ DEr_N_7TIAL, "
O O in full f rce o il PERMIT ISSUANCE
0.�wy f• ❑S D TI ❑KITCHEN REMODEL
QUU License Lic�g APPLIANCES-RESIDENTIAL DDITION n ❑PLUMBING RE-PIPE
h a a nate eenimeter
HrrECTS DECLAR TION i MULTI-UNIT L3 STRUCTURAL
z 0 774. I understand my plans shall be used ie public records „ - PANELS _ _ ,_ _ MODIFICATION
Oz-O " .. UPTU200AMPS ❑INTERIOR [I CHIMNEY REPAIR
ig4 0Licensed Professional a - 301-10!10 AMPS IMPROVEMENTS
OWNER BUILDER DECLARATION OVER IOOO AMPS '�BATH REMODEUREPAIR [I DEMOLITION
yy Q 1 hereby
affirm that I am exempt f theC t ui L cense Law for the `
bd 30.VV following reason (Section 7031.5,Business and Professions Code Any city or county, SIGNS ELECTRICAL ❑OTHER
IIxv10.p y which requires a permit to consumer,alter,improve,demolish r repair any swcture ., A • Is•
poor a.its ilsomica,mSt. q the ppl ant for such pereat to file a signed statement SPECIALCIRCUITIMISC.
yN
Oat lei,licensed puant to ther i pn oftheC nutio r I License
c n La 9(Ch pt -
�K QD
(commencing with Stet 7000) fD' 3 ftheB .eand ProfessionsCod) r ' TEMP.METER OR POLE INST.
0.ax p e' that h 's pi therefromd theb f Oralleged exemption.Any-' I t f {,p [:]DEMOLITION
.
Sect 7031.5 by y app! t f portion subjects the app! nt to a civil penalty of POWER DEVICES ❑
,yy, not more than five hundred donors($500). - f//I ENRpV ENT ❑FOOD SERVICE -
' Q ❑Les owner of theprogeny my employ ith- g as le pe ationn, SWIMMING POOL ELECTRIC � 'LyI+tHTIAP -
O will do the work and the trod i t t
n end d r ffefedpasse(S- 7044 Business - ❑OTHER o
0. and Professions Cade The Connector's L'cen a Ls doenot apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are notimmndud on offered for NEW RESIDENTIAL ELECTR. 4. SQ FT.
sale.If,however.the building or improvement is sold within one yearofcomple[ibn,the SQ.FP.FLOOR AREA �vo$ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- .�, O �'•`�`
pose of sale.). .. 5. ., 1 so
❑I as owner of the property,amexclusively contracting with licensed tat m 7
construct the project(So 7044 Business ad Profe Cad )Th C v t Li-
cense Law does not apply to an ownet_f pr perry who Int Id.,or improves themon,and QTY. PLUMBING PERMIT FEE •.�..{;�
who contracts for such projects with acontmirOlcensed pursuant to the Contractors '
License Lew. i PERMIT ISS CE - •>• '
❑I am exempt under Sec. ,B&P C for this reason _
ALTER-ORA VBNT-WATER'(P.A) VALUATION -
Owner - "Dale
I herebyaffemundaprnaOPENSATIONlyofperjury neDofthe following declarations:ECLARATIONBACKFLOW O VI 1�.�'
V
-I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROO , A,COND. STORIES - TYPE CONSTRUCTION
station,as provided for by Section 37M of the Labor Code,for the perfomlance'nf
work for which thio permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance;as required by Seediln ,
37M ofthe Labm Cale,for the Performance ofthe work for which this Permit is issued. GAS-EA.SYSTFM-1INC.40UT E - OCC.GR O APN
My Workerr's�C.�m��sunyn gu nce carrier rad Policy nu rare' - -
Cartier.�a IIR �alr� Policy No.: GAS-EA.SYSTEM-OVER 4(EA) 11 "
CERTIFICATE OF EXEMPTION FROM WORKERSQQ�1 GREASE/INDUSTRL WASTE INTERCEPTOR_ ,
COMPENSATION INSURANCE, NG DIVISION FEES
phis section need not he completed ifthe permit is foronehundrcddollam($Iflo GREASE TRAP '
or ass.) i - s - s PLANCHE r %,Lo -
I nfytht in the performance ofthe work forwhich this permit is issued l shall ° �� O.
not employ SEWER-SANITARY-STORM EA.200 FT. '
p y y person on m any miner so as m become subject to the Workers'Camper - � ENERGY rp
"
O 'z, sation La a fCarfomia Dam WATER HEATER WNENVELECTR _GRADING FE '
yy O Applicant - - -
q,y NOTICE TO APPLICANT:If,after making this Cecate of Exemption,you should + WATER SYSTEM?REATING SOILS FEE -
E become subject to Ne Worker's Compensation previsions of the Labor Code,you mus[ _
forthwith comply with suchp, r this permit shall be deemedrevoked. WATER SERVICE x -
� CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLMSQ.FL PAID Z B,I hereby affirm that is a concoction lending agency forthe performnce of ate tk
U the work for which this permit Is issued(Seo.3097,Civ.C.)
V*` I-" Lead
els Name - - TOTAL:
yO U Lenders Address -
L, yW f certify that.1 have read this application and state that the above information is BUILDI G /•
�i V2 correct.1 agree m comply with all city and county ordinances and state laws relating to QTy, MECHANICAL PERMIT FEE D
U Z building construction,and hereby authorize representatives ofthis city'to coloration the SEI FE
F-i above-mentioned property for inspection purposes PERMIT ISSUANCE
T (We)agree'.
gree m sa a indemnify and keep broaderas the City f C penino against ELE R E
liebdnree.judgmenis c t d penses which may in any w m against said City ALTER'OR ADD TO MECH.
in consequence of the granting of this peimit. - PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMP WI i ALL NON-POINT AIR HANDLING UNIT(TO Ig WO CFM) MECHANICA FEE r�
'OURCE RE - IONS.- p "
AIISHANDLING UNIT(OVER Iff"CPAD CONSTRUCT NTAX
i naNre of ApplicanVContmctor Date EXHAUST HOOD(W/DUCT) NOOSING MI ATION PEE
,. ,HAZARDOUS MATE ALS DISCLOSURE' -
Willth'eappliamor future building occupan[store orhandle mausolea,minarets HEATING UNIT(TO 100,000 BTU;
-
as defined by the Cupertino Municipal Cade,Chapter 9:12,and the Health and Safety _
Coda,Section 2553.2(0)7 r HEATING UNIT(OVER 100,000 BTU)_
❑No:9 ' VENTILATION FAN(SINGLE RESID) PAID -
Will the applicant future building a p t use eyu proem or devices which Date Receipt
. i hazardous ntmma
air conts as defined by the Bay Area At,Quality Manugemen[ " BOILER-COMP(3HP OR IOO,OW BTU)
Distne[7 -
❑Yes 0 N 'IiOILER-COMP(OVER 100,00)BTU)
"0 AIR CONDITIONER
I have read the mcandous men 'I"'
"'ohm c,Chapter 6.95 of the Cali- - ISSUANCE DATE
fomia Health&Safdy Cade,Sections 25505,255 and 5534.I understood that ifOm - NEW RESIDENTIAL MECH. SQ.PC
ulldingdoes na rrently have a toned that it is yre onslbllity to notify the occupant
of the requi" tswtlfch must M no'sp a of a Cenifyate oi'upwcy -
thonzed agent (� r,Dam .i'�� t T � ISSUED BY:
. '.- _ ,; .'. •> , OFFICE •I '