30888 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O 8 8 8
BUILDING DIVISION' APPLICATION/PERMIT PLUMBING-MECHANICAL. 3 VR IY!(VX
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
119.
ER:S NAME: � .?Hu NqJ1 CONTRACTORS NAME: LIC NO: NIC CONTROLM
ARCHITECT `k GINEER: LIC NO: ADDRESS: --❑
CONTACT. PHONE: tlU1LDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI,QG ELECT PLUMB MECH
-�fJYC� ❑' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that l on licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
p0Z with Section 7000)of Division Sof Ne Businessand Pum,iinm Code,and my Imemcis ' RESIDENTIAL:
E 1_ and-
� in full force effect. ISSUANCE t. ❑SFDWL .I]KITCHEN REMODEL.
License Class Lit.X gPpLIANCLS-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
N6a Data Qonocour
VJ=y ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT [:1 STRUCTURAL
ZO
[understood my plans shall be used.,public neon, MODIFICATION
W Licensed Professional[al UP TO 200 AMPS - ❑INTERIOR CHIMNEY REPAIR
301-I000ANPS I IMPROVEMENT
��d thatOWNER-BUILDERI mfr m Ce Contractor's
ON OVER 10110 AMPS ❑BATH REMODEUREPAIR ]DEMOLITION
y C I hereby eRmt that 1 em exempt from the Contractor's Liccnu Lew for the
�(3LU following ressm.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL []OTHER
tri LL.e which requires o permit re cones the settee,improve,demolish, file
repair any statement
c
�u'OJ ht he is licensed
palmrequhee the ficarthe CohpewiuofileaeLaw(statement SPECIAL CIRCUIT/MISC.
Q the[he is Ilccnsed pursuant m the provisions of the Contractor's License Law(Chapter 9
�p0 Icammencingwit efandth basisonJ alleged
exe and Pm Any vi Code)or TEMP.METER OR POLE INST El NEW BLDGIA�
d c nL the[he is 31.5 b ang.therefrom sim the basis for the alleged exemption.m Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Sat tion]1h1.ive anympplidonafor arsP$5crmit subjects the applicant ntacivil penalty of POWER DEVICES
:Zy nut mase than five huadred dollars(fSW). ❑TENANT ❑FOODSERVICE
X 60 ❑I,as ownerofthe prvperty,or my employees with wages an their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the st;imme is not intended oroflered for mile(Sec.7044.Business ❑OTHER
0.a and Professions Cade:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
prepeny 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 TR SQ FT.
male.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FLFLOORAREA $/SQ.FI'.
owner-builder will have the burden of proving that he did not build or improve for pun -
pou of sale,). i
1,as owner of the pmpeny,um exclusively contracting with licensed commicton to TOTAL:
conswct the project(See.]OW.Business and Professions Cade)The Contractors Li-
cense
i-c e law does not apply to an owner ofpropcny who builds or improves thereon,and QTY, PLUMBING P RMI FEE
who contracts for such projects with o contractor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE //�� '�fI(u�
❑i em exempt under Sec. ,B&P C for this reason �/f LV
Owner - Uma ALTER-DRAIN&VENT-WAER TION
I OR s OMPL'NSAT ON DECLARATION BACK FLOW PROTECT.UGVICF,
I hereby affirm under penalty of perjury one of the following declarations: _ L.O
I hive and will maintain a Certificate ofConsenuo salf-insure for Worker's Compen- DRAINS-FLOOR,RODE,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37N of the labor Code,for the pamornmawc ofthe work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTI.ITf OCC.GROUP MIN
Worker's Compensation Insurance carrier unit Policy number am: -
Carrier: - Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRLWASTE INTERCEPTOR
(This section nceJ nm be completed ifthe permit is forone hundreddollms($I WI BUILDING DIVISION FBE.S
GR
or less.)
GREASETRAP
PLANCHECK FEE
I certify that in the performance of Ne work for which this permit is issued,l shall SEWER-SANITARY-STORM[q.3W PT.
not employ any person in any manna so sun Insecure subject td the Workers'Compen- ENERGY FEE
0z sution Laws of California.Date .. WATER HEATER WNENT/ELECfR
,7. 0 Applicant GRADING FEE,
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING ,
Isecome subject mine Worker's Compensation provisions of"Ne Lobar Code,you must - SOILS FEE
{3J foMwith comply with such pmvisionsor this pammunition he deemed revoked. WATER SERVICE
Q
CONS'I'RUCTION LENDING AGENCY NEW RESIULrNT1AL PLMB. .SQ.FI'. PAID
U„0 l hereby affirm that there is a construction lending agency for the performanu of Dam Recei e
' Lkr .r the work for which this permit ie issued(Sec.3119],Civ.C.l
0F' Leader.Name - TOTAL:
U Lenders Address s TOTAL:
CL certify that 1 have reW this application and nose that the shove information is BUILDING PEE `
ti!) carne[.I agree to comply with all city and county ordinances and state laws relating in QTY. MECHANICAL PERMIT FEE O
U Z building construction, m
ction,and hereby authorise representatives of this city enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,.indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE
ELECTRIC FEE
liabilides,jud,inami,comlind expenses which may in iuy wayaccrue against said City ALTER OR ADD TO MECH. 11 PLUMBING FEE
in consequence ofthe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
/� MECHANICAL FEE
S r REGULAT ON {L��
AIR HANDLING UNIT(OVER 10,000 CFM)
p Dote CONSUC10N TAX
many r .
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materiel HEATING UNIT(TO I WAIgI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health anal Safety
Can Seetion 25532(0)1 HEATING UNIT(OVER 1(10,000 BTU) .
❑Yes ❑No PAID VENTILATION FAN(SINGLE RESID) Date Raeip
Will the applicant offuma building by the Buse eyviir Quofdeviceswhich BOILER-COMP OR 1011.000 BTU)
mit hezaalous air comeminanu as deftned by the Pay Area Air Quality Mamvgcmcnt - TOTAL:
District BOILER COMP(OVER I00,M)BTU)
❑Yes ❑Nm - ,
1 have read me limstomux mmerim,requirements under,Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foams,Health At Safety Code.Sections Z5505,25533 and 15534.1 undersand the[if thn NEW RESIDENTIAL MECH. SQ.FT.
building does at currently have a tenant,the[it is my respmsib'dlty,to notify me overmim,
of the mquireamts which must he met prior to issuance of a Cenilicate of Occupancy.
Owner or authorized agent I Date TOTAL: ISSUED BY:
OFFICE