30268 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE'SALL POINT PEN ONLY
• CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 30268
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: x2.V� SANITARYNO. AP LICATION SUBMITTAL DATE
O ER:S NAME: Pf10NF,: CONTRACTOR'S NAME: LIC NO:
r? NIC CONTROL#
CHITECT/ENGINEER: LICO: .ADDRESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ -�z ❑
LICENSE!)CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licenced under provixita-of Chapter 9(commencing JOB DESCRIPTION
09Z with Suction 9000)of Division 3 raphe Business and Professions Code.and my license is RESIDENTIAL:
WOO PERMIT'ISSUANCE. '
FFa ty� in full force and effect ❑SFDWL �[I CHEN REMODEL
6U Llcemc Class LIC.# pppLIANCES-RGSIDIiNTIAL ❑ADDITION UMBINGRE-PIPE
yZW Datn Contractor
L
ARCHITECTS UECLARAi'[ON ❑MULTI-UNIT ❑STRUCTURAL
Z O`-Z 1 understand my plans shall be used as public records PANELS MODIFICATION
O Z 4 q UP ED 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
YJ.F.1+] licensed Pro[cssianul 201-1000AMPS IMPROVEMENT
E OWNER-BUILDER DECLARATION OVER IfNN1AMPS ElBATH RFMODEUREPAIR [I DEMOLITION
6 I hereby Wina that I an exempt from the Crafted—License Law for the
O6 U following reason(Suction 9031.5,Business and Prnfessiom Code:Any city or county SIGNS ELECTRICAL ❑OTHER/
a C y which requires a permit to compact,alaq improve,demolish,or repair any structure \1
����' p,innoits issuance.aka reyuireslhe applicum hn xueh permit mlileasigned statement SPECIALCIRCUPI'/MISC.
m� that he is licensed pursuant to the pmvisiansof the Contractor's License Law(Chapter 9
W�dO (commencing with S,etion7axp of Division3of the Business and Prnfessmoos Cmdu7ar TEMP.METER OR POLE INST.
d b o aa that he is exempt therefrom and the basis for the alleged c.,fn,Any vsmalia.of NEW BLDG/ADDITION ❑DEMOLITION
❑N Section 70315 by any applicant for o permit subjects the applicant to a civil penally of POWER DEVICES sNANT [I FOOD SERVICE
ray a., are'ban five hundred and...($500) IMPROVEMENT
nI,as owner of the progenth
y.or my employees with wages asen,ade compensation, SWIMMING POOL ELECTRIC
0 will do the work,and the simulate is not intended or offered for sale(See 704f.Busineas ❑OTHP,R
3 w and Profes.sinns Gds The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-PoXTURES
property who builds or:mproves thereon,and who does such work himself or through l• n
his own employees,provided that such improvements are not intended cr offered for NEW RESIDENTIAL ELE-CTR SQ ET. i• P ^
sale.If,however.the building or improvement is sold within one year ofcompinion-the SQ.IT.FLOOR AREA 5/SQ.ET.
nbullder win have the burden or proving that he did not build or improve for put-
,roc
ut- Jut
p Feeof sale,. J 1
❑ h as owner of the property,am exclusively contracting with licensed contractors to TOTAL' �/y�(�
cocoon the project(Sec.7044,Business and Prafcssiam Cade)The Comactofs Li- •�))- "�1
cen%c Law aces not apply to an owner of property who build or improves thereon, QTY. PLUMBING PERMIT FEE r
whncnmaca far such projects with acupuncturist licensed pursuant to the Conwcto, GOr�f(/NyU
License Law. PERMIT ISSUANCE
❑I am exempt under See. ,B&P C for this reason
Owner Dale ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER nder collyofCOMPENSATION, on
BACK FLOW PROTECT DEVICE
1 hereby under penaltyofperjuryoneofthefollowing dCo
❑....as ro will maintain stion 37ac of Consentto r Codenforemi-Worker's Compen- DRAINS-FLOOR,ROORARF,A,GOND. STORIES TYPE CONSTRUCTION
onion,as provided fur by Senior 3700 if the Labor Code,for the perfnrmuncc of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Cmnpcnsation Insurance,as required by Section
3700ofthel.dna Codefnnhepeit ancent,ha warkforwhichlh penial scold. GAS-EA.SYSTEM-IINC.4OUTLETS - OCC,GROUP APN
orker'sC t 'trier and Poli angr' IMIf�Fd
o '4�
rtier. Policy Nn.: GAS-EA.SYSTEM-OVER 4(EA)
'ERTIFICATEOFE EMPTIONFRO ORKLRS'
COMPENSATION RI'SURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need nm benmmplwed ifthe Penni(is Cornus hundred doners(5100) GREASETRAP
of less.) PLANCHECK FEE
I certify that in nopertairmaee efthe work!or which his permit is issued,l shall SEWER-SANITARY-STORM EA.200 PT.
not employ any parson factors any rammer w as to beeoc subject 1.the Worker,'Compen- ENERGY FEE
,7, smion laws of Califomia Date WATER HEATER WNENT(ELECTR
Z Q Applicant GRADING FEE
NOTICE 10 APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMOKEsATING
(, become subject to the Worker's Campcnsatfon provisions ofine Labor Code you.,of SOILS FEE
Wforthwith comply with such provisions orbic permit shall h,deemed revoked. / WATER SERVICE
DzCONSTRUCTION LF.NDINGAGENCY NEW RESIDENTIAL PLMB. SG.FI'. PAID Date Receipt#
T hereby affirm that there it n construction leading agency for the performance of
UD the work for which this permit is i...ed(Sec.3097,Civ.C.)
OULenders Nam, 'TOTAL
r Lunda',Address BUILDING FEE
1 cenify that 1 have recd this application and sate that the about information is
r'�.t Val correct.T agree to comply with an cityand county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby andante representatives of this city to enter upon the SEISMIC FEE
aawe-mentioned property for im,ealipn purposes. PERMIT ISSUANCE
(We)ngree to sat,,indemnify and keep hamelen the City of Cupertino ngmp,t ELECTRIC FEE
liabilities,judgements,costs and expenses which may in any way ammo against said City ALTER OR ADD TO MECH,
orae acnes,oftha granting o this permit. PLUMBING FEE
in c
SC f STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I 0.0M CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SISA Com,autur Date EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
s HAZARDOUS MATERIALS DISCLOSURE
WillytheCupertno Municipal ode,Chaptr9.12,handle Health and Safety HEATING UNIT(TO I00,000 BTU)
as definedStu by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Cale Section 25532(x)7 HEATING UNIT(OVER I1N1,03 BTU)
❑Yes ❑Nn PAID
VENTILATION PAN(SINGLE RESID) Date Receipt 8
Will the applicant or future building occupant use equipment or devices which
( emit hazardous air contaminants as defined by the Bay Area Air Qonlity Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
Duanal BOILER-COMP(OVER 1(10,1X)0 BTU)
❑Yes ❑No
1 have read the hazardous outworals m rt under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
yuir
forme Hearth p Safety ly have
Seniors 25hat i i,soy and 25534,1 undersand that if the NEW RESIDENTIAL,MECH. SQ.FT.
building does nmcuwhich have atenanttaut it Lanryaccof asCertifcateofov ecanter,
of the requirements which most be tail prior to isswn,u n(a Certificate of Occupancy.
Owner or authorized agent Date TOTAL. ISSUED BY:
OFFICE