30860 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. ask 0 8 Aw 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JC VM Vh
BUILDING PROJECT DIIT NTIFICATION
ILL NCADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
15 rat v�A-Ace cr Ut 2rti no cA 9sp� -�
R$N ME: -4� PHOa 49 NE CONTRACT ORS NAME: LIC N0: NIC CONTROL#
AR HIT'ECf UNCI EER: LIC NO: ADDRESS: ❑
X]I__CONTACT: PHONE BUILDING PG PPER�M�MI�TCl//INFO
sas�I Ta A ',- ` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
I K LICENSIiD CONTRAC ORS DECLARATION S QTY ELECTRIC PERMIT PEE
1 hereby affirm that I tan licensed under provisions of Chapter 9(com
mencing JOB DESCRIPTION
y�y11�'Z with Sation7")of Division3ofthe Busines.and Professions Code,andm 1¢ense is RESIDENTIAL:
FOwro in full forecundeRect. y PERMIT ISSUANCE ❑ 5112EHOVE IT EN REMODEL
�ZULicense Class Lia# APPLIANCES-RESIDENTIAL. ADDITION PLUMNING RI.PIPE
G U Date Lis.# for
((��--.� 4 ARCHITECT'S DECLARATION PANELS ULTI-UNIT ❑STRUCTURAL
Z p h Z I understand my plans shall be stud as public records MODIFICATION
OZ4� UP'IY)200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 4 E' Licensed Pmfessionul 201-1000 AMPS' IMPROVEMENT
OWNER-exempt fr m the Commences
OVER 11100 AMPS
Q I herchy affirm that 1 am exempt from the Cnmmnorn L]ttnse Law for the ❑BATH REMODEVREPAIR ❑DEMOLITION
30.U following ream.(Section 7031.5,Business and Professions Cede:Any city or county SIGNS ELECTRIC A ❑OTHER
0.0 which requires a permit to construct.alter,improve,demolish,or repair any structure
prim,its isammee,alsnrequires theapplwant forsuch Permit it,filen signed statement SPECIAL CIR
ithat he is licensed pursuant to the previsions of the Contractors License Law(Chapter 9
QQ (commencing with Satinn]OW)af Divisionlof the Business and Profusions Code)or TEMP.METERP S'll COMMERCIAL:
0. n T that he is exempt therefrom and the basis for the alleged exampli. t [I NEW BLDG/ADDITION ElDEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICE
Tali nm mart Than
five hundreddolies S501)). ❑TCNANT ❑FOOD SERVICE
C ❑Lasnwnenif@e Property.or my employers with wages as their sole compensation, SWIM M I NO POOL ELECTRIC IMPROVEMENT
_ will do die work,and the structure is not intended or offered for sale(Sa.]Od4,BusinessM ❑OTHER
'W2$ and Imfession.s Cale:The Conerectnrs License law does not apply its an owner of OUTLETS—SWITCHES—FIXTURES
progeny who huilds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended tar offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,Wavelet,the building or improvement is sold within one year efcompletion,the SQ."..MOOR AREA $/SQ-IT.
owner-hadder will have the burden of proving that he did not build or improve for pur-
postof aale.).
❑1,as owner of the property.um exclusively contracting with licensed contractors m O'A: C.P qT
construct the project(Sec.](aK Business and Professions Code:)The Contractor's Li- h
cense law dices not apply to an owner or property who built or improves thervan,and QTY. PLUMB] GPERMIT FEE
who contracts for such projects with a contmcm0s)licensed pursuant to the Cmmmnnrs aw�
License Law. PERMIT ISSUANCE it pw
' ❑item exempt under See ,B&PCfee This mason
Owner Dat ALTER—DRAIN Be VIiM'— F:A) t UA
tyy�� VALUATIO
ORK :S COM EN.ATION DF IARATION BACK FLOW PROTECT.DEVICE (J,ef r ( r� r
I hereby affirm tinder penmty of perjury one of the following decbnutinino ✓✓��
❑]hove aril will mnimainaCenifhate of Conuns to sell-irtwrtfor Workers Compcn- DRAINS—FLOOR.ROOF AREA.COND. IT
STORIES TYPE CONSTRUCTION
smion,as provided for by Section 37M of the Labor Calc,for the Performance of the l
_ work for which this permit is issued. FIXTURES—PER TRAP
I have and will maintain Worker's Compensation Insurance.as required by Section
37M of the Labor Cade.for the Performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC GROUP ANN
My Worker's Compensation Insurance currier and Policy dumber are:
Cartier. Policy Na.: GAS—PA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRP.ASPIINDUS'1'RL WASTE INTTiRCCPfOR
(Thisneedction need not be completedifthe Permit is foropr hundred dollen(5100) BUILDING DIVISION FF.
or less.) GREASETRAP PfANCHECK PEE
I certify that in the perfarurnme of the work for which This Permit is issued.)shall
not employ any person in any manner so asta became subject Ne Warkers'Coni SEWER—SANITARY—ST'ONM EA.2tp IT.
3 pen- ENERGY HE
s amn Laws dCalifnn in.Dole
7� Applicata WATER HEATER W/VENT/ELECfR GRADING MIT
NOTICE TO APPLICANT.If,arm,making this Cenillcata of Exemption,you should WATER SYSTEM/REAFING
[ become subject To the Workers Compensation provisions of the Luhor Code,you most SOILS FEE
G forthwith comply with such provisions or this barrel shall In domed revoked. WATER SERVICE
Q
Uz Cat the is
const LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT PAID
C) 1 hereby affirm that them is s construction lending agency for performerce of Doe cipt#
F thurie,for which this permit is issued(See.3119],Civ.CJ
Lenders Name TOTAL:
WLenders AddressI
1 certify that I have mad this application and state that the above talon union is TABUILDIN FE
LOT correct.l name to comply with all city and county ordinances and state lows relating to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby mahovc representatives ofthis city to enter upon am SEISM] F
ahave-mentioned property for inspection purposes PERMITISSUANCE
(We)agree to save,indemnify and keep Worries.the City of Cupertino against ELECTRIC FEE
liabilitiesjudgments,costs and expenses which may in any way accrue against saidCity ALTER OR ADD TO MITE PLUMBING PEP
In consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(10 CFM)
SOURCE REGULATIONS. MECHANICA PEE
41 /17 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRU ON TAX
. gnatum of Appli unContrector JDate 13XHAUST HOOD OYMUCf) HOUSING TION FEE
AZARDOUS MATER] DISCLOSURE
Will the applicant or form building occupant store or handle harsdous material HEATING UNIT(TO I MOM BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and The HeuOb and Safety
Cade,Section 25532(a)p HEATING UNIT(OVER 100,000 BTU)
❑Yea C]No Vf?NTI[,Al]ON EA N(S INGLE RES do PAID
Will the applicant or future building occupant use equipment or devices which Date Re iin#
nit hermal air contaminants as defined by the Bay Arta Air Quality ManagementBOILER—COME DHP OR 100,000 BTL)
Distrie,q TOTAL:
El yes El No BOILER—COMP(OVER IMAM BTU)
I have read the hamdous materims mquirements under Chapter 6.95 of the Culi- Alit CONDITIONER ISSUANCE DATE
fomia Health&Safety Cole,Scemona 25505.25533 and 255M I understand nest tribe NEW RESIDENTIAL MECH. SQ.IT.
building does ant cuoendy have a tenant,the,it o my resrymsibility to notify The secupant
of the requirements which must be net prior m issuance of n Certificate dOccupancy.
Owner mmdmrieed a gent Date A ISSUED BY:
OFFICE