30225 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO. rk /�/�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. K O / / 5
BUILDING PROJECT'IDENTIFICATION �J L L
BUILDING ADDRESS, SANITARY NO. APPLICATION SUBMITTAL DAT
bL 3 SHAproviIkitLi_ i-r4 C.C.,P4FkTt Pat0 tis
OWNER'S NAME: PHONE: / / COM'RACTOR'S NAME: LIC.O:
� Cti N r,—% .?bb's'p!Q Mlfi ,1Cl L61•SIIS 0 t3 NIC COMHOI.p
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR
order Sokiwil ATIONfChr, QTY ELECTRIC PERMIT FEE
I hereby nlrrm ma I alts licensed ander pnrvinhan.of chapter 9¢omntmcimg JOB DESCRIPTION
OW with Section IINNI)ofOivixionJufthe Business and Pmfcssiom Code.and myliccntt is PERMIT ISSUANCE
F OW
O 'n full force and effect. RESIDENTIAL'
a U V Lic loss t3 Lid'M 6 $ / 3 ❑SPDWL ]KITCHEN REMODEL
APPLIANCES-RESIDENTIAL
y_W ate Cunvaaur ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MOI.TI-UNIT ❑S'T'RUCTURAL
O Z= Z I enderavnd my plans shall M nwJ ns public records PANELS
MODIFICATION
UP TO 200 AMPS El INTERIOR CJ CHIMNEY REPAIR
W Licensed Professional 201-1(NN,AMPS IMPROVEMENT
OWNEILBUILDER DECLARATION
,]Q 1 hereby affirm that 1 am exempt from the Contmnor's License law for the OVER IOOOAMPS ❑BATH IIEMODEI/REPAIR DEMOLITION
keel
3 uS U following isomm(Section 9031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHP.,7Jdo
W O y< which requires a permit m mw
cna,alter,improve,demolish,or repair any structure
.i pritrm its isaoanee.also requires the applicant fim,rch permit to fileasignnd stammem
y SPECIAL CIRCUIT/MISC.
p. that he is licensed pursuant tothaprovismosofthe Coalmends License Law(Chimera
WHO (commencing with Section 7000)of Division 3 of are Business and Professions Code)Or TEMP.METER OR DOLE INST. COMMERCIAL
,:.=.E that he is exempt therefrom and the basis for are alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITIONthSection 70315 by any applicant fiorn permit subjects the applicant mueivil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
not more than for,hundred dollars(S50(lk
EEC 331.as owner of the property,or my employees with wages as heir sale compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p.. will Bothe work,and lho,ancore i,.,,,intended or OBered Leslie(See7014,Business ❑OTHER
W
im and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-DXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are nor intended or offered for NEW RESIDENTIAL ELECTR SQ fT.
sale If. the building or improvement is sold within one year efcompletion the $Q.FT.FLOOR ARE1�A.- DSQ.ET.
nerbuilder will have the burden of proving that he did not build or improve for par- t., n 11 n
pose oriole.).
1,as owner of the property,am exclusively contracting wish licensed mnvanmrs to TOTAL:
couslmct the project(Sec-7000.Business and Professions Codc:)TT.Commetnrs
cense Law does no,apply to an ownerol property who builds or improves themon,Old QTY. PLUMBING P FEE IlO p9
who contracts for such projects with a commeor(s)licensed pursuant m the Convectors py V m
License Law. PI?kMIT']SSUANCE I I�V
❑ I am exempt under gee. ,B&PCftcdd'm..n. t1ITt Ur VtJfCfn
ALTER-DRAIN&VENT-WATER(GAJ
Owner Due' VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the follow ing declamation:
❑I have and will maintain a Certificate of Consent to sdLinmre lint Worker s Compen- DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 37W of the Labor Code,for the performance Of the STORIES TYPE CONSTRUCTIOC
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance.as n quirsd by Section
37M of the Labor Code,for the Performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.S OUTLETS OCC GROUP APN
My urkce,Compensation Immence came,end Policy number are:
Icr. Policy Nu: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(7his sect ion need not Ac completed if the t men is for one hundred dollar.Is 100) BUILDING DIV ISION FEES
or less.l GREASETRAP PLANCHECK FEE
Ianify chain the any erno,, ofthe work fee whichthishe Wes issued,Ishall
courflo,any Cason iny manner st nsmbre ome>ubje...he Wnrkcr.�Cant _ g13WF,11-SANITARY-STORM IiA.2I10IT.
Z scion Laws of California.aDate pma ENERGY FEE
� ApplicantWATER HEATER W/VENT/ELECTR
Z
V1 NOTICE M APPLICANT:If,aper making this Certificate of Exemption,you should GRADING FEE
? become subject m the Workers Com WATER gYSTEM/TREATING
j Compensation provisions of the Labor Code•you must SOILS FliE
fS.l foMwith comply with such provisions onhie pcm,il shall he dccmcJ revoked. WATER SIikVICF.
ao
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby uffirrn lhuuherc isaconslmminn lending agency limhe perfonnancc mf m Receipt#
U.O Dothe work for which this permit i......d(Sri,31X)7,Civ.C.)
Lender's Name
I]U qME
OTAL.:
F {L) Lender s Address TOTAL:
0.o 1 ccnify that I have read,his application unJ scam the the above informaion is FEE
V) correct.)agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
C.) building mmwcriov,and hereby authorise repmnemv,ivcs of this city memn upon the SEISMICEE
above numak ted pmpeny for inspection Putpuwn. PERMIT ISSUANCE
(We)agree 10 save,indemnify and keep harmless the City of C.Inica agairot FEE
liabilitics.judgments,costs and cxpenscs which may in any wary:moue against said City ALTER OR ADDTO MECH.
in consequence of the granting of this Permit. FEE
APPLIC NT UNDERSTANDS AND WILL C YWIT .NON-POINT AIR HANDLING UNIT(TO IQgN)CFM)
SOI, ;REGULATIONSS. ` O ALFEE
AIR HANOI-LNG UNIT(OVER IO,UW CFM) TION TAXMgmwu ofApphcanl/Uomracta ae EXHAUST HOOD(W/DUCT)
HAZARDOUSMATERIALS DISCLOSURE ITIGATION FEEWeil the applicant Or future building occupant store or handle hazardous material HEATING UNIT(TO 100,(10 BT U)o.s deFned by the Cupertino Municipal Code.Chapter 9.12,and Thu Health and SafetyCode.Secaion 25532(aE HEATING UNIT(OVER 100.000 RLD
❑Yes ❑No
VENTILATION FANS INGLE RESI D)
Will the applicant or future building occupant use equipment or devices which Dam Receipt N
elemit h.-Mem,air cantamrcurn,as d6mird by the]say Area Air Ocala,Management BOILER-COMP(3HP OR IDIOM BTU)
District, TOTAL:
❑Yes El No BOILER-COME(OVER 100,000 BTU)
I have read the teamsters materials quircmors,under Chapter 6.95 ofthe Cali- AIR CONDITIONER
fmmia Health&Safely Code.Seetiom 25505.25533 sand 2S5Mq l understand that if the ISSUANCE DATE
building does not comedy have a tenant,that'it is my responsihility mnnllfydte twcupaal NEW RESIDENTIAL MECH. SQ.FT.
of the requirements which must he met proton ismm ucc of a Certificate of Occupancy.
Owner or with mis W,gaol Date TOTAL: ISSUED BY:
OFFICE