30279 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O 0MI+AIAI r,
OWNER'SNAME: `,PHONE CONT'RACTOR'SN LIC NO:
CH123'S 1/tr'T4 YW-0j NIC CONTROL#
ARCIFFECf/ENGINCER: l LIC NO: p )RL.SS: ❑
Ffuli
CT: PHONE: BUILDING PERA1IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 'LEC PLUME MECH
C- ❑ ❑
LICENSED COM1TRACIORN DECLARATIONQTY ELECTRIC PERMIT FEE
CWZhereby cif.Thal I em Imm,ed under provisions of Chapter 9(commencing J B DESC PTION
WONtion]000)of Division 3 of the Businessand Professions Code.end my license is RESIDENTIALOO PERMIT ISSUANCECF- rce and effect. ❑SFDWL ❑KITCHEN REMODEL
QUUClass LispAPPLIANCES-R13SIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
I-ZW Contractor
dGG ARCHITECT'S DECLARATION [_1 MULTI-UNIT ❑STRUCTURAL
Z O't�Z Iunderstand mymlansshall heuxdaspuld,cremd, PANELS MODIFICATION
OZ-O UP Tr)200 AMPS ❑INTERIOR El CHIMNEY REPAIR
aw Licensed Professional 201-I001JAMPS IMPROVEMENT
� ON
KCQ Ihemby affirm hwNamB strep FGolo hDECe CHntrecTors License Law(or the OVER["AMPS ❑BATH REM ELot PAIR ODF:h1OLITION
�S 06 U following mason.(Section 7031S.Business and professions Csde:Any city or county SIGNS ELECTRICAL. ❑OTHER
which requires a permatt .T t alien improve,demolish,or remany.T cmre
Fq. O priarto itsane I:o require,the o'PlicamI h ciral to Ile it signed.dtment SPECIAL CIRCUI'I'/MISC. �
2;!(}
that h 1 I p : G Ih p f el C t t 1 I (CM1 pier 9 �^ 7
�aap0 (commenting wnh Sacfon]INNry.fDvi.ion Jaf The Bu.ine.ss and Professions Cale)or TEMP.METER OR POLE INST COMMERC���111...
a a that he is exempt therefrom and the basis for the alleged exemption.Any violation of E)NEW BLDG/ADDITION ❑DEMOLITION
a�"t Section 7031.5 by my applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZ
ore Than five hundred dollar,(SSW).Y "'n' IMPROVEMENT
=Q OLasow irk.the property
stroatrearmy employees with wages fend fosale(Se .m-sole compensation, SWIMMING PWLELECTRIC
�F.O will do the work.and the he Cant It not intended Licensor Law
dos not apply
yAoln,Business ❑OTHER
L 3 m and Profession Code:The COnmaaTofv License law dues not apply to an owner of OUTLETS-SWI'PCH FS-FIXTURES
property who Thai his or improves thane;,and who do,,such work himself or through
his own employees,provided That such improvements are not intended or(inbred for NEW RESIDEN PIAL ELECT SQ IT.
sale.If.however.the building or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA §/SQ.FT.
er-builder will have the burden of proving that he did not build or improve for pur-
pou of saket.
1.as owner of The praeny.am exclusively connecting with licensed comments,1.
TOTAL:
p
o..met The Project(Sec.RTW,Entities,and Professions Code:)The Conttacmh Li- p
cense law does not apply to an owner of primary who builds or improves mention,and QTY. PLUMBING PERMIT
whOcertooditnr such prnjmks wiThncontrnnngs)IlcenseJ pununnnnlhe Cnmrunor's `-c 6
License Law. PERMIT ISSUANCE
❑Ise Tonder ' ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) V UATIOI. v
0. Dam
R 'R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: -nr I o- 1.1 if Ldsl llt�
❑I have and will maintain a Certificate of Concatto self-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUCTION
sation,as provided fu by Section 3700 of The labor Code,lir the performance of the
work for which this pcnait Is ismed. FIXTURES-PER THAI'
❑ I have and will maintain Worker's Compensation Insurance,as mumreJ by Section -
INTOoftheLat, Cale,for the perfermcracof The work for which This Permit is issued. GAS-EA.SYSTEM.I INC.n OUTLETS OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy Na: GAS-EA.SYSTEM OVER n(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE(INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need nut be complatecllf The permit is furore hundred dollars(SIM) GREASETRAP
or le"') PLANCHECK FEE -
IcenifythatioTheperforanceaflhcworkforwhichlhispermaisissued,l shall SEWER-SANITARY-STORM EA.200 IT
nil employ any Ihrom in any manna,w,as to become smbject To the Workers'Compen- ENERGY FEE
Z cation Laws of California,Date WATER HEATER W/VENT/ELEC IR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:If,after making This Certificate of Exemption,you should WATER SYSTF-MO-REATING SOILS FEE
become subjectto The Worker's Compensation provisions of the Labor Code,you mnT
forthwith comply with such provisions or This pamTit shall be deemed revoked. WATER SERVICE
UJ
Q
7Z CONSTRUCTION LENDING AGENCY NITWRESIDEN'I'IAI.PLMB. SQ EL PAID Data RecciplN
C.) Ql hereby affirm That is a comaruction lending agency Re the performance of
me wn�:for wren mi,pc,md it�ttaed(sen.3a�l.em.c.)
0 Lender's Name TOTAL:
0 U Lende/s Address TOTAL:
} y 1 certify mat 1 have read this application and shim that The above information is BUILDING FEE
aF. N correct,l agree To comply with all city and county ordinances and state laws relating To QTY. MECHANICAL PERMIT FEE
C.) Z building connection,and hereby suhome representatives ofthis city ToteacTupon the SEISMIC FEE
above-mentioned property for inspection purposesPERMIT ISSUANCE
(We)agree m once,Indemnify and kecp hunnlcns the Ciry of Cupcnin0 a6ainss ELECTRIC PL'F
Iiabilitiesjudgments,costs and expenses which may in any way scctue against said City ALT'ER OR ADD TO MECIL
PLUMBING FEE
inconsequence of the Standing of this graph.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER TO."CFM) CONSTRUCIONTAX
Signature of A,Iumi/Commer, Data EXHAUST HOLD(W/IIUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAE S DISCLOSURE
Will Lha upphear serfumm m1dir,occupant,anorhandle hamrdousmaterial TENTING UNIT CTO 100000 BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and The Heath and Safety
Code,Station 25532(x)? HEATING UNIT(OVIiR HA."BTU)
Fl Yes E]No PAID
VENTILATION FAN(SINGLE RESHOT Data Receipt Of
Will the applicant or future building occupant use equipment or devices which
.emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR TOO."BTU) TOTAL.
District? BOILER-COMP(OVL'R M."BTU)
El Yes F-1 No
I have read The hazardous materials refinements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code.Sections 5505.25533 and 551L I understand That if the NEW RESIDENTIAL MECH. SQ.FT.
building dos nm correctly have a mnmt That it is in,responsibilitym notify The occupmt
of The rtgaimmants which mast b,met prior To issuance of a Cerificma of Oes apmcy.
Clwner Or aathori'ad agent Dam TOTAL: ISSUED BY:
OFFICE