30044 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, J{aNOO
BUILDING DIVISION APPIACATION/PERMIT PLUMB NG.JIECHANICAL _
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: � - SANITARY NO. APPLICATION SUBMITTAL DATE
�o V G -fZ- SrY
OW P 'S NAME: PHONE: CCTRACI'OR'S NAME' LIC NO:
4L I '' r _� 19 1 YYI,a.S O r 0,33 Cl(,� NIC CONTNOLM
1RCIfl'1'ECT/ENGINI?ER: LIC NO: ADDRESS. ksA „ 1 3 ❑
�'l o M O.f -dlr C I
CONTACT: PHONE: BUILDING PERMIT INFO
3 / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
V i ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm tato I am licensed under novi ins of Chapter 9(commencing JOB DESCRIPTION
♦r04 Z000 with Scetinn]0W)ofDivlslon3at(he Businemand Proc,somas Coda,mW my llecnna is RESIDENTIAL
,00 wt PERMIT ISSUANCE
in full force and of�oOT
QU j License Clue `I Lic.I 623399/ ❑SFDWL ❑KITCItP.N REMODEL
N<0. Da¢ � Contmna, APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
I. ARCHITECTS DECLARATION PANELS - ❑MULTIUNIT El STRUCTURAL
O2,�4a ec
I understood my plans shall he Used as public rords MODIFICATION
UI'TO 2110 AMPS�Cuaaa Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1010 ANTI'S IMPROVEMENT
kK 6 1 hereby affirm that I am exempt from the Contractors License Law far the OVER 1011(IAMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
O0.U following reason.(Section](131.5.DU'inesv and Professions Cots:Any city or countySIGNS P.LIiC'1'RICAL ❑OTHER
a,
h which requires a perm!,to cnntmn,niter,improve,demolish,or repair any structure
hoEE
prior to itsissuance,also require'the mpplicem forsuch permit to file a signed statement SPECIAL CLRCUTOMISC.
f�} that he is licensed pursuaouo the provisions initial Coatmcmts License Law(Chap¢r9
W�GO (commencing with Section 7")(of Division 3 ofthe Business and Professions Coded or TEMP.METER OR POLE INST. � COMMERCIAL:
that he is exempt therefrom and the basis forma unaged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION '
i� WN Section 7031.5 by any applicant far a permit momects the applicant to a civil penalty of POWER 6EVICBS ❑TENANT ❑FOOD SERVICE
In.five not are thve hundred dollars($500),
x6 1,as ownerofthe ro norm loees with woes as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ th Peet Y emP Y 8 .coxa
C
and
Profdo essions
work,and the structure is not intended Livns o Law md does not
apply to an Business ❑OTHER
and Professions Code:The oyes Contractors License Law does not apply to an owner la OUTLETS—SWITCHES—PIXTIIRES
hisformerlyown who builds or sided s martian,i and who does such work himself ar through
his If.employees,provided Nat such improvements ore no,intended or offered for NEW RESIDENTIAL ELECI'R SQ IT.
safe.mer-howevee the have
building of proving
is at heddwithin one build
or improve
the SQ.PT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he Aid not build or improve for put
El 1 of sole.).
❑ 1,as owner of the pec.701 am exclusively co ins%jong with:)The
mmtnct's y- T'O'TAL:
construct,be project(Sec.7634,Nosiness and Prnl'n'inm Code:)The Cantmcmr's Li- ,.
cense Lawdeas not apply to an owner ofpmpeny who builds orimproves thereon,ond QTY. PLUMBING PERMIT FEE
whumntmcts for such Projects with a contralumi)licensed pursuant to the Commetor's
License law. PERMIT ISSUANCE
E:1I ton axwnpt under Sec. ,B&PC for th,ocoon -
Owner
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECIE DEVICE /wO w�
Iherehnrun
yemde,,varety ofpequry one ofthe following declarations: Ar��eV
I have and will maintain a Certllicatc ofCoosenun self-insure for Worker's Compcn- DRAINS—FLOOR,ROOT,AREA,CONT. STGRIPS TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Lutwr Code,for the perhsrsnance of the
work for which this permit is issued. FIXTURES—PER TRAP
1 have may will maintain Warkn's Compensation Insurance,as required by Section
37M of the labor Code for the Performance oft he.,,,it for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLET
My Worker's mpcnxariolsur rand Palicynu OCC,GROUP pPN
e carrier �{�.
Cartler:S <�, 1'\alx Ia Policy Nn.: rkrs '791 GAS—P,A.SYS'fEM-OVL'R4(P.A) •
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
Alis section need not be completed if the pemdt is for one hundred dollars(SI(0) BUILDING DIVISION FEES
or Ices.) GREASETRAP PLANCHECK FEE
toy any that in Om say..are'c nflhe work liar inich,is to
ltisiswed.lsmtJ SLiWER—SANITARY—STORM EA. Isl'.
Zant employ any person in any munncr sn as m berome sabjecun the Workers Compcn- ENERGY IEC
.C, saline Lawa of Cali4smie.Date
z Q A lieaht WATER HEATER WNENT/IiLECIIt ,
PP GRADING FEE
NOTICE TO APPLICANT.do,Wo,k If,after musing this Certificate of LahertCodyou should WATER SYSTCM/1'RP.ATING
a [+ bemmo suhjmt y the Wmh par Cray,pcns his pentr suns of the eyed Code,you,oust SOILS PEE
Ll1 �ryy fonhwilh comply with such provisiare or this pe,mi,ssholl be deemttl revokr4. WATER SERVICE
0. lz
M CONSTRUCTION LENDING AGENCY NEWRESIDENL'IALPLMB. SQ.FT. PAID
U C l hereby affirm that hem is a construction lending agency far me performance of Data Receipt#
4. H the ,,,it for which this permit is issued(Sec.3097,Civ.C.)
Q U Lender's Name TOTAL:
Lenders Address TOTAL:
y 1 cattily that I have read this application and state that the abase information is BUILDING FEE
V) correct,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE _
U� hullding cnnstmction.,and hereby amhorlse representmivesof rhiscity menmrupanthc SEISMIC PEE
absve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,coat and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the granting of this Prmit. - PLUMBING FEE
APPLICANT UNDERSTANDS PAD WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 11,101 CFM)
URCE REGULATIONS. - MECHANICAL PEE
AIR HANDLING UNIT(OVER 1012A ,1100 CFM) CONSTRUCIONTAX
Signature ApplivanVCon or Date EXHAUST HOOD OMMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaurdous material IiHATING ON]]'(]0 100,00(y BTU)
as defined by one Cupertino Municipal Code.Chapter 9.12,and the Health and Solely
Cale,Section 25532py? HEATING ON]P(OVER 100,000 BTU)
T-1 Yes ❑No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicom or future huilding occupant use equipment or Devices which
Data It...'t It
all
emit hnimul sairaomamimana as defined bythe Bay Area Air Quality Management BOILER—COMP(3HPOR 100,00ORTU) -
Dearict? TOTAL:
L
❑No BOILER—COMP(OVER 10x000 BTU)ead the limardaas materials requirements under Chapter 6.95 ofthe Cull- AIR CONDITIONER ISSUANCE DATE
Safety Cade,Section 25505,25533 and 8534.1 understand that!fthe NEW RESIDENTIALMECH. SQ.IT.otcuttenIIy haveatchert,that itismynexponsibilirym notify theoecapant
ents which must he met finalto issuanceofaCertificateof(kal'ancy.
rzed ugcnt UmeOFI 'TOTAL: g t
SUED BY.
FICE