30480 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT'INO BUILDING-ELECTRICAL - - PERMIT NO. 30480
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL J
BUILDING PROJECT•IDENTIFICATION
BUILDING ADDRESS: T - SANITARYNO. APPLICATION SUHMITTAL DATE
O V I>G H
• PIIONE: CWTTAOOR'Sc N/C CON'TROL#OWNEj C
ARCHIT/ENGINEER: LIC NO: AU12 /S
/ G. ❑
CONTACT. /' PHONE: - BUILDING PERMIT INFO
J e5i / M,P"I ki S 71/-1490 ❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECT PLUMB MECH
[,�(� L/� (/(/ ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aaZ with Section 700(bufDlvlslon 3ofthe Business unit Profesalune Codennday Iatric is Tj s /D RESIDENTIAL'
DO PERMIT ISSUANCE .7
n full force and effect.
<ZU License Class Lic.# DSFUWL
❑KI'TCHIEN REMODEL
Date Contractor APPLIANCES-RESIDENTIAL DADDITIGN D PLUMPING KE-PIPE
Foy ARCHITECTS DECLARATION PANELS [IMUTA1-UNIT' ElSTRUCTURAL
Z O y Z I understand my plana shall be used as public remain /J MODIFICATION
O Z.^0 UPTO]00AMPS 22 El INTERIOR ❑CHIMNEY REPAIR
F44, Licensed Professional 2DI-1g10AMPS IMPROVEMENT
�+ OWNER-BUILDER Earn
Ce Contractors
ON
W, 1 hereby vffitm that I um exempt Tram the Commemrs License Law for the OVER IOMIgMPS ❑BATH REMODEIBEPAIR E3 DEMOLITION
ip5,060 following masan.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
su a n,y which requires a permit to construct,altar,improve,demolish,or repair any inticu re ^
,F. priamits issuance.also requires the applicant mrsuchpermil m file a signed statement SPECIAL CIRCUIT/MISC.
QE thatheis licensed pursuant the provisions ofthe Contractors License Law(Chapter 9
G0 (commencingwlth SeaaLm 7000)of Division 3 of No Busine„ and Pool ..imo Code)or TEMP.METIER OR PULE INS,, COMMERCIAL:
d e that he is exempt Nercfrom and the hanis India alleged exemption.Any violation of
Saban 7031.5 b an Cl NEW BLDG/ADDITION D DEMOLITION -
y yapplicatnfor.pt subjects Ne applicant tnacivil penahy of POWER DEVICES
t more than five hundred dollars($500)
DTENANT ❑FOODSERVICE
C=Qair Las owner ofthe en.orm loves with wages as their sole coat IMPROVEMENT
wil22 ❑ Atop Y Yemp y g ,Businss SWIMMING POOL I?LEC'fklC
F and dafiewons Case:and mrvcmmis roti Licensrofficurl e Law
Lawes of appreJOLL Business0 DDTHER
3 and rdy who
Cale:The oyes then' License Law Vms not apply m an owner of OUTLETS-SWITCHES-FIXTURES
his o ny who build,or vides that
such i and who dies such work himself or th dfor
his own employees,provide)that such improverrmma are not intended or offered for NEW RESIDENTIAL IiLECTR SQ PT.
sale If.however.the building or improvement is sold within one yearof completinm Ne SQ.FT.FLOOR AREA $/SQ.FT,
owner-builder will have the burden of proving that he did not build or improve for put- a
pose of rule.).
D I,as owner of the property.am exclusively contracting with licensed contractors to TOTAL: 6
construct the project(Sec.](IY1,Business and Professions Code:)The Contractor's Li- SEP
ll
gse Law does no,apply u,un owner A property who builds(it improves thereon,unit QTY. LUMHINOEr G PERMIT FIiE 31996
who convects for such projects with a commnth
ctons)licensed pursuant e Contractor's
License Law, PERMIT I.. NCE
El vat exempt under Sec. B A P C for this rcnson
. II r' s.t acct t_tuusV
ALTER-DRAT -WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK ICE
I hereby affirm under penalty of lerfory one of the following declarations:
D l have and will maintain a Certificate of Consent to self-insure for Worker's Compem DRAINS ROOF,
sation,as provided for by Section 3700 of the Labor Cade,for Ne prourreance of the -Is STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PE P
D I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code.for the performance of Ne work for which Nis Ismail is issued. GAS-F.SYSTEM-IINf O OCC.CROUP LETS
APN
My Worker's Compensation Insurance currier and Policy number are:
Carrier: Policy Na, GAS-EA.SYSTEM-OVER 4(IiA) '
CERTIFICATE OF EXEMPTION FROM WORKERS' ”
COMPENSATION INSURANCE GRP.ASEANDUSTRLWASTE INTERCEPTOR
(Thisec
stion recd na M cumplemd ifthe permit is for one hundred dollars($100) NUILDING DIVISION FEBS
or lase.) OHIiASP.'I'RAP PLANCHNAK TEE
1 amity that in the any no m er nphe work forwhich this the W is issued,I shall
•
art employ any perenn in an manner so asbbec�me sub object Workers' WER-SANITARY-STORM EA.200 PT. ,
Y J, Co.,.-pen- ENERGY FEE
�. ,aOon Lnws of California.Due
C O A licant WATER HEA'I'LR W/VENT/ELGCfR
PP GRADING FEE
h NOTICE TOAPPLICANT:e.agermaking this Certificate f of Exemption.Cod you should WATER SYSTEM/IREATINC
fH became subject m the Worker's Coon,or is pmviai hal of the meed vukc you must SOILS FEE
forthwith comply with such provisions or permit shall be deemed rcvaked.
WA'I'F.R SERVICE
0
CONSTRUCTION LENDING AGENCYNEW RESIDENTIAL PLMB. SQ,IT. PAID
V Ibcrthy alliin that there isacnnrlruction lending agency fonhe perfnrmm�re of Data Receipt#
E^' the work for which this permit is issued(Sec.3097,Civ.C.)
p Lenders Name TOTAL:
LUSL Lender's Address TOTAL:
y 1 certify that 1 have read this application and stale that the above information is BUILDING FEE
h mated.l agree to comply with all cityand county nwin anccsundstalelawsulatingm QTY. MECHANICAL PERMIT FEE
U building conshudivavnd herehyautherite represcnmtives nflosizity otemenmun the SEISMIC FEE
above-memimim pnopeny for inspection purposes.
(Wo)agree to save,indemnify and keep harmless the City of Capron.against PERMITISSUANCO ELECTRIC FEE
Iiabilitics,judgmems,costs and expenses which may in any way same against said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]F(TO 10,000(PM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Apithem/Conaemor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicant or future building accupmn store oT handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)] HEATING UNIT(OVER 100,000 BTU)
❑Yes DNo VENTILA3'ION FAN(SINGLE RESID) PAID
Will the applicant or furore buildinguse equipment or devices which
Dam Reccipt#
canit hazardous air contaminants as defined byy the the 11 Buy Arev Air Quality Management HOLLER-COMP(7HPGR 100,000 ETU)
TOTAL:
Disvim]
E]Yes PIN. BOILER-COMP(OVER I00,N)ORTU)
(have reaA the hazardous materials AIR CONDITIONER- -
requircment under Chapter h.95 of Ne CWi- ISSUANCE DATE
fumie Health&Sa@ty Cale,$¢tions 25505,25533 and 25534.1 understand Nm if Ne NEW RESIDENTIAL MECH. SQ.IT.
building doesting cmrtmly have a tenant,that it is at,responsibility m mnify Ne compam
of the requirements which muss be met prior to issuance of a Campeau,of Occupancy s
Owner m authodaed agent Dae TOTAL: ISSUED BY:
OFFICE