30085 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELEL-MUCAL PERMIT NO. 30085
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IINKNTIF'ICATION
Bull.DI AD .RE/S/.q: SANITARY NO. APPLICATION SUBMITTAL DATI
G /
OWNI? N ME: PITO ' CGNTRACTOR'S NAME: LIC NO:
NiC CON'f120L
RCII'1? TIEN 'CR: LIC NO: ADDRESS: ❑ 4)/ D
CONTACI: PHONE: BUILDING PF,R IT I FO
,Jp`/'/ , ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I he by a(ffin That 1.m licensed under provisions of Chapter 9(commencing JOB DESCRI ION
,�„�Z with Section]000)of Division ofthe Businaa and Pm ssi Cr, J ylicenseis RESIDENTIAL:
Op in full force and eRa PERMIT ISSUANCE,
U U� Liccnse las .•• Lic N C SFDWL C KITCHEN REMODEL
u1 Dam Cnnvocror PANELS -RESIDENTIAL CADDITION ElPLUMBING BETTE
CHI'rHCT:S DEC (]MULTI-UNIT (]STRUCTURAL
Z p v�Z I understand my plans shall he used m public ret xR MODIFICATION
OZ—, UPTO 200 AMPS (]INTERIOR ❑CHIMNEY REPAIR
F Tar F- Licensed Professional 201-100f1AMPS IMPROVEMENT
Tay � OWNER-BUILDER DECLARATION
`get 6 1 hereby affirm the,1 am exempt from The Contmcwr's License Law for The OVER 1000AhfPS C BATH REMODEUREPAIR C DEMOLITION
k C)6 U following mason.(Section 7031.5.Businns and Prefessiorm CNe:Any airy or county SIGNS ELECTRICAL C OTHER
ul LLO which requires a pernm m T
ommarr ,ohee improve,demolish,or repair any swemrc
prior to its issuance,also requires The applicant for such Permit to file u signed statement SPECIAL CIRCUIT/MISC.
N that he 11 icercsed pursuant to theiroAkiunsnf the Catharines Liccnse Low(Chapter 9
OC (cmimnencing with Section70om of Division 3ofthe Businns.IJ Prdcssiots Codc)nr TEMP.METER OR POLE INST. COMMERCIAL,
I 0�' Thai he is exempt Therefrom and the basis tor The alleged exemption.Any vinlatiou of^ C NEW BLDG/ADDITION (]DEMOLITION
Section]OJI Sby any applicant fnrapermit subjects The applicant ovcivil penalty of POWER IJEVICES ❑
tri TENANT (]FOODSERVICE
z} not more than five hundred dollars($500) IMPROVEMENT
CCl.as owner of Ne property,or my employees with wages m Their sole compensation, SWIMMING POOL ELECTRIC
C will do the work,and thestructine i...I intended oroffeted for ale(See 70.11-1
❑OTHER
w
63 and Professions Code:The Canno is License law does amt apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who buihk ar improves themon,and who does such work himself or Through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELMTUf SQ FT.
sale.If,however,The building or improvement is sold within one year ofcomplehion,the Q.FT.FLOOR AREA SISQ.FT.
owner builder will have the human of paving that he did not build or improve for pur-
"m or mile.).
1,its owner of the property,am exclusively contracting with Ilunsed conunriorx to SOPA
construct The project(Seo.7144,Business and Professions Code:)The Cnnuuemr's Li.
cense Law does not apply to on awnerofpmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT
who ConTmri9 for such projects with a mmmcmr(s)licensed pursuant 0 The Contractors
License Bdw. PERMIT ISSUANCE
C]1 um exempt under Sec. ,B&P C for this reaznn
Owner Dam ALTER-DRAIN&VENT-WATER(FA) VALUA�.
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 herebyaffirm under Penalty tperjuryone offs,insure for dcrker's o
❑ Ihave and de for tain a by SectioCertificate 700or the ent toLabor
Orem,fu
for Worker's Cnmpem DRAINS-PL0(1R,ROOF,AREA,COND. STORIES . TYPE CONSTRUC'HON
.workf as provided for by Ss ssu J7hN1 of the L.uGn Gde,for the perfonnunce of The
work for which This palmar is Issued, PIXTURIiS-PIiR TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700.Ohl Of CodRet un e,f h perfr of The work for which this dis Tasu GAS-RA.SYSTEM-IINC.40UTLI?TS DEC.GROUP APN
My We nV ca rand Pa
Can . Policy - GAS-EA.SYSTEM-OVER 4BEAT
CC PICA :OF it MPf10N FROM WORKS S'
COMPENSATION INSURANCE GRIiASP/INDUSTRL WASTE INTERCEPTOR
(Thissmdan need ooh be completed Brom permit is(Drone hundred dollars(Si0)) BUILDING DIVISION PEES
GRFASHTRAI'
,it I.,.) PLANCHECK FTE
Boy any that in the performance mfthe beam which this The
rken'c41tha0 SEWER-SANITARY-STORM EA.2001T.
not employ any Person in any manner sir us to racoma subject In the Workers'Compcn- ENERGY PEE
0Z s:nion Luwsof Celifomia.Dam WA'TBRHEATERWNENT/f?LEC'I'R { d
.j 0 Applicant GRADING FEE
G NOTICE TO APPLICANT If,offer making This Ceni('vma cf Exemption,you should WATER SYSTEMTREATING
abecome suhjeet To the Workers Cumpcnsmion provisionsof the Labor Cale,you..at SOILS FEE
[3I forthwith comply witbsuch powkionsonhis Permit shall he deemed revoked. WATER SERVICE
Q
CONS7RUCcIONLFNDINGAGENCY NEW RESIDENTIAL PLhiB. SQ.PL PAID
U. I for whit thi thanhemissued(S .3097.ndingagency for performance of Dam Receiphp
CLF the work for which This permit is issued(Sec.JW7,Civ.C.)
Q Landale Name TOTAL:
L) lender's Address TOTAL:
y1 certify that 1 have real this application and sham that the above information is BUILDING FEE n r
eA correct.l agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
(,) buiWingc...unction,and hemhy ouhhorim«pmsenahives ofhhiscry ut enter upon the SEISMIC FEE
UN
.h.ve-menhiomed property for imisin.n purposes.
(We)agreem..au,indemnify and keep harmless The Cihyof Cupertino against PERMIT ISSUANCE EL[CfRIC FEE
livbifiieajudgmems corsand expenses which may many way nv.a...inu said City Af,TERORADDTOMECIL
in consequence of the granting of this permit. PLUMBING FEEJI- I,r.
APPLISOURC NT UULATIONDERS ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING Ust IO."CIM) MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
Signature of AiniicamVCmmmrior Data EXHA UST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI'HRIALS DISCLOSURE "
Will the applicant or future building oaatpant store orhaadlc hueurdnut material HEM INC,UNIT(10 1011,0X0 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Calc,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn
VENTILATION PAN(SINGLE RESID) PAID
Date ReceiPt0
will me amilentaminantures a building excupby
at By Am
eno or uality Management
BOILER-COMP QHP OR 100,000 BTU)
emit hnmmous air contaminants as defined 6y the Bay Area Air Qualify Management TOTAL: y/
UrshnO7 ❑No BOILER-COMP(OVER 100,0X1 BTU)
❑Yes
1 have-mail Nb
One wamous materials requirements under Chapter!95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
fomia Head k Safety ' 5 ,255 D wd 25534.IumFahethat if theId NRW kCSIDRNTIAL MECFI. SQ.IrI'.build's csp ipB�yo Tlly mnuu mof W it antort a ofuCef y.wire .1. Y TOTAL: ISSUED RY:
OFFICE