30239 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
.. CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMIT NO. Q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ' O 2 V
BUILDING PROJECT METIGI FICA'1'ION
BUILDING ADDRESS: - , SANITARY NO. APPLICATION SUBMITTAL DATE
75 '13F46WAOW PR. .
OWN NAME: PHONC: CON'TRACTO NAME: LIC NOgob: r :
NIC CONTROL#
IV RCHITECOENGINFER: LIC NO ADD .SS 11n ❑
CONTACT:. . PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION , QTY. ELECTRIC PERMIT FEE
1 busby vffnn that 1 vin IlceroW undo provisions of Chapter 9(commencing JOB DESCRIPTION
Woo with Section]000)ofDoismn3ofthe Bueinessand Professions Code,nddm license is. RB ID N
Woo in fu 11 farce ottle ' PF.RMIq'ISSUANCE
�UV LicenseCas I,ir.# OSFDWL ❑KITCHEN REMODEL
APPLIANCES-RESIDENTIAL RESIDENTIA L
F�W ate Commdor - ❑ADDITION El PLUMBING R&PIPE.
y 0.
ARCHITECTS DECLARATI N PANELS ❑MULTI-0NIT ❑STRUCTURAL
1 ypW4 Imdersthnd my plans shall be used as public records •. ' MODIFICATION.
OZ4 UPTO200AMPS
F 4 O Licensed Professional Ll INTERIOR El CHIMNEY REPAIR
U 201-I00(1AMPS IMPROVEMENT "
¢a SG Om I are racrptBORDER DECLARATION OVER 1000 AMPS '
gyp-^a W 6 1 hereby.onto on I am exempt from the Convacmo License Law fur the ❑BATH RF,MOfjEW7 PgJ DEMOLITION c
, 100.0 following reason.(Swoon]031.5,Business and Pndeasians Code:Any city or ceunty SIGNS ELECTRICAL []OTHER
� SUEN¢" which requires perenitl t f alter'improve,demolish, {a any structure ///
He,to t '. a Iso q .0 pplic I fth,mmp it1 fl a-tgnd,moment SPECIAL CIRCUITIMISC. `
q� (comb licensed p mane Thep ns of the Contractors Li easel (Chapter 9
W�Qo b with Steri 9000) fD' sin 3 fthe Business and Professions Code)or TEMP.METER OR POLE INST.. COMMERCIAL•
a M e'
but he is exempt therefrom and the basis for'beallegedexemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION to
Section 703it, 1.5 by any applicant for u Permit subjects the applicant penalty of pOWUk DEVICES
y, not more than five bond dollars(&500). " ❑TENANT ❑POOD SERVICE"
Qp ❑I,as owner of the proIscny,nr my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will dome work,and the soucore is not mateded h offered for sale(Sec.90c4,Business ❑OTHER
'and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does Inch work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RUMDEN'GAL ELECTR IMTAI.:
sale,If,however the building or improvement is sold won
i thin,he ynof compladmi'lhe ,SQ'4.BOOR AREA $ISQ.PT.
owner-builderde
will have the harden of proving that he did not build or improve for Isar-
pose of stile.). -
1' ❑1,as owner of the property,am exclusively contracting with licensed contractors m �1�� 2 3' 1996
construct theprojeet(Sec 7144,Business and Professions CodcJ The Contractor,LI111L (
-
cense Law does not apply to an owner of property who builds or improves ihercon,and QTY {t�PLUMBING PERMIT -
whocommetsforsuchprojeetswithaconthamilm licensed Pursuant o the Contractor's /�i v yIIIYV
License Law. n PERMIT ISSUANCE yyr Assyria -
1 am exempt under Seo. B&P C Tonins reason
Owner Doe ALTER-DRAIN&VENT-WATER(EA) VALUATION
'WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm underpenalty,of porlrryone fthe following declwmiom: cc
E] -
❑llm, rd willmvinminnCeniflcate o[Coreentmself-insum far Worker's Cnmpen- DRAINS-PLOOR,ROOF,AREA,GOND, / V -
,mtloa,m provided for by Section 3]fNl of the Labor Cada,for rho Perfnmiance of the STORIES' TYPE"CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will mainland Worker's Compensation Insurance,as required by Section -
370aofthe Labor Code,for the performance M'the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC CROUP APN
My Workrs eompenantiantasrr a vdnir,.rd Policy u
Cortise Policy N.,: a GAS-EX.9Y9TEM-OVER 4(EA) -
CEkTIPICATE EXEMPTION FROM WORKERS' GRGASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE - _ BUILDING DIVISION FEES
(Tris section need not be completer ifthepermit ie far oda hundreJ dollars(8100)
or lessGREASETRAP) - - PLANCHECK PEE
I certify that in the performance of the work for which this permit is issued,Ilha11 SEWER-SANITARY-STORMEA.200FT.
not employ any person in any manna'f e m bq o e�Iuhlact to the Worker,'G unisom ENERGY PEE
,0 smiop Laws of runs.D
O r WATER HEATER WNENT/ELECTR
z Applicant / GRADING FEE
y NOTICE.TO LICANT:IL after making this Certificate of Exemption,you shoulJ WATER SYSI'HMITREATING
a5 became subject o the Worker's Compensation provisions of the Labor Code,you must SOILS FEE -
W lonhwith comply with she h mtnvisimns or this permit shall he deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID '
U O I hereby affirm that there is a construction lending agency for Be Forbiddance of d Date ,. Receipt#'•
LL H the work for which this permit is issued(,See 3099,Co,C) -
O U Lender's Name - TOTAL
,�t W Lender's Address TOTAL:
I certify that I have road this vppl irmion and some thin the shove informnrion le BUILDING PEE
iy V1 correct l agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
U building concoction,and hereby authorize representatives of this city to enter upon the SEISMIC FLF
shove-mentioned progeny,for inspection purposes. PERMIq'ISSUANCE,
(Wej agree to smharm
ave,indemnify and keep less the City of Cupertino against ELECTRIC FIRE
liabilities,judgments,casts and expenses which may in any way acerae againstxaid City ALTER OR ADD ID MECH
in consequence of the granting of this permh. PLUMBING FEE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE. -?OLAT PIS MECHANICAL FEE ,
7�2111/J/_ AIR HANDLING UNIT(OVER IO,IHI(1 CFM) CONSTRUCTION TAX
Sig IApplovntlCoulne, 9T��_/{� EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE ""'-
Will the applicant or future hullding occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU) _
as defired by the Cameroon Mdradl nl Cale,Chapter 9.12,end the Health dad Safety '
Code,Section 25532(a)] - HEATING UNIT(OVER I0p0W BTU) -
❑Yes (]No VENTILATION FAN(SINGLE RE9ID) PAID
or Dale Receipt#
Wrdons,applicantiniums futurebuilding occupant
TarykaquipmQualay or deviceswhich
BOILER-COMP(3HPOR 100,000BTU)
emit hamrdors air cpmmminants vs defined by the RnY Akea Air Quality Management
District? .T L.BOILER-COME(OVER 100,000 BTU)
❑Yes C]No -
Lf
I have read the hazaamew materiels requirements'tinder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
domain Health&Safety Cale,Sections 25505.25533 and 25534.1 derstmtd that if the NEW RESIDENTIAL MUCH. SQ.FT.
building does not currently haven tenant,that it is my responsibility to notify the oreapam `
of the requirements which must be met prior to issu:mce of a Ceriifcwm of Ihcupodcy.,.
Oishchmnflemb Ind agent Date TOTAL: ISSUED ByI
OFFICE