30881 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BU LDINGADDRESS: - SANITARY NO. APPLICATION SUBMI'PI'AL DATE
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1TVINER'SAME: PHONE: CON' RACTOR'S NAME: LIC NO: O
's , 1 NIC CONTROL#
RCHITIiCT/1MANEEIL LICN N p U�l ❑
CONTACT. _ PHONE: BUILDING PERMIT INFO
C o _ ❑ Consultant Fees Paid by Applicant(Initial) BLDG LE PLUMB MECH
saff
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that 1 nm Licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
OmZ with See
e res Ax)0)nf Division3of the Rosiness and Professions Cade,.ndm license is P17RMIT ISSUANCE
O O y RESIDENTIAL:
in full 1'nrcc and eIT
IYUI= ❑SFDWI. ❑KITCHEN REMODEL
{QI..U V License CLI s Lie.N
.I.W Da¢ Cnmmnor APPLIANCES-RESIDENTIAL ❑ADDITION .UMBING RE-PIPE
ARCHI'FEC'SDECLARATION PANELS ❑MULTFUNIT ❑STRUCTURAL
Z p t7rs Z I understand my plans shall be used ns public.cods
MODIFICATION
OZ^ppp� UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
I P4 Licensed Professional 2B14000AMPS IMPROVEMENT
Y Oat I ma vUILDF.R DECLARATION OVER 1000 AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION '
y C Q I hereby a(Grm that
1 em exempt from the Contractors Code:s License Law for the _
ld a d V following reason(Section 90313.Business mrd Mnfase ndi h,oAny airy or county SIGNS ELECTRICAL ❑OTHER
41=Oa which requires a e.tils to ne'ane,t",alcor,improve,demolish,.,repair any tw"art
J list hesfiverviot,ol...e It,thare, rostaiicano,ol forsuch
onsanivaicese I.nedshaptert SPECIAL CIkCUITIMISC.
py. Ohm he is IlcanseA pursuant m the pruvislnns ul'We Cnnmtmor's llama Lnw(Chapter
p op (commencing with Section]000)of Division 3 of Ne Business and Professions Code)or THEIR MITER OR POLE BEST COMMERCIAL:
OR.p.=y that he is exempt therefrom and the basis for she alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ire t4 Section by any upplleum far n permit subjects the applicant m a aivll pumlry of MOWER DEVICES
..y ❑ ANT ❑FOODSERVICE
not more than five hundred dollars S500). EqT
I.
01,asownerofthe popery.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC PROV-ME
+_q will do the work,and the smuetum is not intended or offered for sale(Sec.9014,Business OTHI?R
6'3$ and prelcssions Cole:The ConhaenA License Tow does oat apply to an owner of OUTLETS-SWITCHES-FIXTURES ��.a�'
property who builds or improves thereon,end who chessmen work hireself.r though
his own employees,provided that such improvements are nm intended nr offend for NI7W RESIDENTIAL ELF.CTR SQ IT.
vale.IL however the building.,impmvement o imId within one yeaofcempletlon,Ne SQ. lF A $,SQ.FT.
owner-builder will have the burden of paving that he did no build or improve for pur-
❑M 1,res oun)e APR g 0 REC O
1,as t w r.1 the pmpcny.nm exclusively'ommding with licensed"rmmcvos m
ro entrul the project(Sce.]Ota,lousiness and Professions Code:)The Contactors Li-
seLow does not apply toanowner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT PES
who
who for such pngceis with a contmemnun
r(s)licensed puuano the Commarx CITY UF GUrEHiINO
License Low. PERMIT ISSUANCE
Cll am exempt under Sec. ,B&P C for this reason
Owner DateALTER-DRAIN Is VENT-WATER(EA) VALUATION
WORKER'S COMPENSAITGN DECLARATION BACK FLOW PROTECT.DEVICE
I hereby oflirm under penalty of perjury one of the following declinations:
❑ I have and will maintain a Certificates of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOK ARFA,CONED.
cation,as povided for by Section 37M of the labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued I FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Secdon
3700 oftlhµ'e�Laborr Code,for the performance ofthe work for which this permit is issued. GAS-EA,.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
y eWe,
1`[ ipento Incur ce carrier and Policy n t t —
r +1(Fy�P Policy No.: •j7
` GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF L- [004 FTION FROM WOiKEEi
C(OMPImA'r10N INSURANCE GREASPIINIIUSTRL WASTH INTERCEPTOR
section need not he completed if the I'rorat is for arc hundred dollars(S 100) BUILDING DIVISION PSIS
or IessJ GREASE'rRAP PLANCHECK FF.0
Loy any Nat in the perany manner so 0 t beconork r which this the W rkersuedlshn0 SEWER-SANITARY-STORM F.A.2M FE
net employ any Person in any mannan.as m beeotne subject the Workers'Compen- ENERGY FEE
O$ Ration Laws of California.Dam WATER HEATER W/VENT/ELFLTR
z Q Applicant GRADING FEE
Iti ti NOTICE TO APPLICAN'r:IL fire..king this Certificate of Exemption,you should WATER SYSTEM/BEAT R3
a � become subject o the Workers Compensation provisions of the Umr Cole,you must SOILS FEE -
{Ll forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
CONSTRUCTION LF.NDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
U Iherebydfinn lhauhereissed(Section leading agency for the p'rfonn.nee of Data Receipt
B-t P the work]or which this Permit is issued(Sec.3(9].Co,CJ
O U finders Name TOTAL:
Leaders Address TOTAL:
I certify the 1 have read this application and slue that the above information is BUILDING FEE
V) sone".I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
G building conswction,and hereby anhmize representatives ofthis city to enter msm the SEISMIC FEE
above-mernio wd property for musexiien purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiohilities,judgmealx,costs and expenses which may in any way.erne against said City ALTER OR ADDTO MECH,
in consequence of the granting of this permit. PLUMBING FEE.
APP ANT UNDERSTANDS AND/].COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
S (RCE tEGULATIONS. MECHANICALFEE
LI/.1 : 7 ALR HANDLING UNIT(OVER 10,M)CIM7
G `� CONSTRUCTION TAX
Signature of ApplicanVConmoctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous maenal HEATING UNIT(TO 100,000 BTU)
as defined by Ne Cupertino Municipal Code,Chuper 9.12,and the Health and Safety
Code,Section 25532(")? HEATING GIN r(OVER IIgkll x)BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RCSID) PAID Dae Recei t a
Will the applicant or hnurc.htfiecd by the Bl not co Air(R it devices which p
emit hazuNuus air contaminants as Defined by the Ray Area Air Quslily Management BOILER-COM11P(JRP OR 10i PTU)
DistrictP BOILER-COMP(OVER IIg1,IXq BE U) TOTAL:
❑Yes ON.
Ih id the havadom mut 'Is AIR CONDITIONER ISSUANCE DATE
requirements an under .1 and r 95 l t the if the
Tornio oc, Safety Calc,Se "x .51)5,th.lit,5., ood25534.1tonmynd the if the NEW RESIDENTIAL MECH. SQ.IT.
bui mg des nt.shi, em ¢m n.,mismyce.f.cror,onodf0c,oecupam
a he mems whit mu n poor m issuance of a CrniErme of flea rte.
Cache,orauthanzrl.,car l �am TOTAL: ISSUED BY:
_- —_ OFFICE 1