30636 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL �, ,PERMITNO. 301636 O^.••k/N
BUILDING DIVISION .' APPLICATION/PERMIT PLUMBING-MECHANICAL Jl lV� JK FVC
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAD
O.5 ZOnNNf1 .
O BR'S AME: PHONE: CO RAC R'S NAME: . LIC NO: -
RCHITEC /ENGINEER: LIC NO: 2-56. ADDRESS r 'SSS N/C CONTROLM .,
R �� ❑ ' -
cQNTper PHONE� �D BUILDING PERMIT INFO
sul
• tant Fees Paid by Applicant(Initial) BLDG . ELECT PLUMB MELD
a ❑ Con ❑ • '-❑ ❑
LICENSED CONTRACTOR'S DECLARATION - QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of hapten (commencing JOB DESCRIPTION
,O,r�'Z with Section 70001 of Division 3nf the Busmessand Profexsio sCode, dmylic se is, RESIDENTIAL:
00 in fullforce and effect PERMIT ISSUANCE
�UV License- Link G _ ❑SFDWL [I KITCHEN REMODEL
�aW Dete Co.racmr APPLIANCES—RESIDENTIAL El ADDITION ,�LUMBING RE-PIPE
1„p>y> ARCHITECTS DECLAR • PANELS ❑MULTI-UNIT L1 STRUCTURAL
Z O H G I understand my plans shall be used as public records' •• MODIFICATION
oz-,NUPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I2tit Licensed Professional -- - - 201-IOMAMPS IMPROVEMENT'.
""•OyC� that I a -BUILDER DECLARATION CmuniON' OVER If100AMPS ❑BATH REMODELBEPAIR DEMOLITION
y 1 hereby aHtrm that 1 am exempt tlnm the Contrmemr'e License Law[or the
p(3E F fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county t❑OTHER
E.fti SIGNS ELECTRICAL
which requires a permit to construct,alter,improve,demolish,or repair any structure _
„f�0y� priormits lsevenm,also requirestheapplicvnt for such penniuo files slgmed natetnent SPECIAL CIRCUIT/MISC.
�y that he is))tensed pursuant
to provisions ofthe Cemmetore License Law(Chapter 9
LGC (commencing with Section 7000)of Division 3 ofthe Business and Professions Coca)or TEMP.METER OR POLE INST. COMMERCIAL:
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iWC Lr.
Section 7091 5 by any apphwm fora perm t b)ct,fficapplicam m a ci 1 penvlty m POWER DEVICES
pN„ nutm than E e hundred dollars(SSW) - _ []TENANT- ❑FOOD SERVICE
C �I, fth p pity, y employees with g their sole compensation, 'SWIMMING POOL ELECTRIC IMPROVEMENT
f� I will the k and the structure is n6l intended orofferedf sale(Sm.7044.Business ❑OTHER
a and Professions C de.TT C t r r. L e . L- d not apply 1.an owne d OUTLETS—SWITCHES—FIXTURES' IR ,� f Ih(
.. Property who builds or improves thereon,and who doe,such work himself or through
his own employees,provided that such improvements are not intended or offered for 'NEW RESIDENTIAL ELECTR SQ Ff. -
sale.If,however,the building or improvement is sold within one yearofcompletion,the - R j SQl Fl,pjll�}EEA $/SQ.FT
owner-builder will have the burden of proving that he did not build to imp rove for par- - 6q �1JJ96
pose of sale.)_. -
❑ TOTAL:. ,1
I,as owner of the property,am exclusively contracting with licensed contractors m Vt yurt H�11^'u
comou ii the project(Sm.7044,Business and Rofespames Cole:)The Contractors Li _ t
ase Law does not apply m an owner of property who builds or improves thereon,and 'QTY. P UMBING PERMIT E
who contracts for such projects with a conoacmr(s)licensed pursuant o the Contractors
License Law. PERMIT ISSUA
❑I am exempt under Sec.' B A,P C for this reason
,ALTER— VENT—WOTER(F.A) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION - BACKFOW PR 'DEVICE y
°I hereby affirm made,Nouhy of perjury one of the following declarations
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Comped- DRAIN O ROOF, A, D. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
workfmwhichthispeoratisiseued. " FIXTURES—PE
❑ I have and will maintain Worker's Compensation Insurance,as required by Section - `
37M of the Labor Code,for the performance ofthe work for which this permit is issued. - 'GAS—EA.SYSTEM-1 C.§7LTS OCC.CROUP APN
My Work mens ten Insurar ecvrier and Policy e: -
Cartier: Policy No.: ki=lj3 GAS—F.A.SYSTEM-OVER
CERTIFICATE F EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
'(This section need not be completed Life permit is forone hundred dollars S100) GREASETRAP or less.) PLANCHECK FEE
Icertify that in the performance of the work for which this permit is issued,l shall
SEWER—SANITARY—STORM EA.200 FT. -
not employ any Person in any roamer so as to become subject m the Workers'Compen- - 'ENERGY FEE
cation Laws of Califomia.Date
O O Applicant WATER HEATER WNENT/ELECTR GRADING FEE
In NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMII'REATING
AA
INNn"� "t become subject to the Worker's Comperealion provision of the Labor Code,you most SOILS FE
W forthwith comply with such provisions or this permit shall be deemedrevoked. WATER SERVICE
z -' _ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.UE PAID '
U 0 I hereby affirm that there is a construction lending agency for the performance of Date R int# •'
Lis(F:,-,' the work for which this permit is issued(Sec.3097,Civ.C.) -
DU Lender,Name - MTOTA.LTOTAL:
W Lender's Address00
1 certify that have road this application and state that the above information is conal.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT EVbuilding construction,end hereby imitative representatives ofthis city to enter upon theabove-mentioned propeny for inspection purposes. PERMIT ISSUANCE
W agree to save,indemnify and kecp handless the City of Cupertino against FEEliabilities,] dgments, actsand expenses which may in any way accrue againstsaid Ciry ALTERORADDTO MECH.in miners ' of tit grmnting ofthis peproo G FEE -
APPLICA UN 'RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ILOW CFM) CAL FSOU E EGI IONS.
_ AIR HANDLING UNIT(OVER IO,OW CFM) CTIONTAXteEXHAUST HOOD(W/DUCT) MITIGATION
. HAZARD US MATERIALS DISCLOSURE. '
Will the vpplicanmr future building occupant store or handle hazmdmusmememil HEATING UNIT(TO 100.000 BTU)
'as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532pol '' HEATING UNIT(OVER 100.000 BTU) -
OYeso - PAID
VENTILATION FAN(SINGLE RESID) Date Receipt
` Will the applicant icfuture building by the Bt use equipment or devices which BOILER—COMP CUP OR 10010W BTU) s
east hazardous air comhminants as defined by the Bay Area Air Quality Management TOTAL: .
k District? BOILER—COME(OVER 100,000BTU)
1 ha a read NIA"aricious materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
'.-in
Hca &Safetde,Sections 25505,25533 and 25534.I underearm that if the NEW RESIDENTIAL MECH. SQ.FT. '
buddi. dr snot carteyhaveaten t that sus myrespmnsibdityto notify the mcoparnt
mare
a remea comust be m t pno,to iammwe of a Centfcate mf u ancy. +
Owner miswcFigml TOTAL: ISSUEDY:
B _
III.
OFFICE ,; ,