30595 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30595
BUILDING PROJECT IDEN'nFICAI']ON
BUILDIN pORE$S: ����/�� T'l� SANITARY NO. 7LICATIOJNSUBMITTALDAHrWNER'S NAM n PHON:: CONTRA OR'S NAMIE: LIC NO:
d NIC CONTROL#
11111 /E IN ER: -LIC^i ADDR+ :: E
corvTACI': PHONE: BUILDING PERMfT INFO
11F"r 2,yq�31S% ❑ Consultant Feas Paid by Applicant(Initial) BLDG iLECT PLUMB MECH
LICENSEDCONTRACH3R'SD— ARATION l 'PY. ELIiCTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commenting JOB DESCRIPTION
O0Z with Section l(010)of Uivision3 of the Business and Profession Cede,andmylavinvis
y�O O PERMIT ISSUANCE RESIDENTIAL.:
F full force and effect.
�� 1° ❑SF'DWL ❑KITCHEN REMODEL
UU License Class Lick APPLIANCES-RESIDENTIAL ' DDITION El PLUMBING RE-PIPE
Uate Contractor �[y7�sa'
ARCHITECTS DECLARATION RJ MULTI-UNIT ❑STRUCTURAL.
OZ4— lundcrsmnd my plans shall he used as public mcoN.• PANELS MODIFICATION
OZ�O UP 10 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
h.N.� Livmm professional 201-I000AMPS IMPROVEMENT
sY� OWNER-tlU11. DECLARATION
yqys�tX W 1 herehy affirm Ihthat1 um ucmptpt Mention
from the Conuacmrs License Law for the OVER["AMPS El BATH REMODCIJREPAIR ❑DEMOLITION
W 3 d F I'nllowing reason.[Semon]031.3,Business and Pml'essinns Code:Any city or county SIGNS ELECTNICAL ❑OTHER
lal O whish rWuires a permit m caasmah,site,improve,demolish,or repair any surnome
prior in issuance,also requiresthe applicant for such Permit to file signolsatemcm SPECIAL CIRCUMMISC.
>y that he is licensed pursuant mthepmvrsiom the Cnntmdnrs License Law(Chaprer9
00 (commencing with S,nhmi]o10Bof Division 3oFlhe Buoumssand Pm@ssinn.,Code)ar THNIF METER OR POLE INST.'
a S eG that he is exempt tit riffin m and the basis far the alleged exemplioa Anv vinlntion of ❑NL•W D�I'�N ODHMOLITION
x n, Section L5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES ''��((��IVJSVL'_
a1^on ❑TI?NANT IJ OD SERVICE
Qnot 1,as thanwoe fvehundreddolours(Sem).
Lo the work,
the en,mis employees forma(See
cum OaT,ftH�p V MENT
❑ prop y y p y g compensation, SWIMMING POOL ELECTRIC V'I` �r
tX.F.O will dothework,and thehe C.iteisnotiLiihosoLaw itdforml...1,u.an, wriar of ❑OTHER LI/rT.fl1T17p
1a anderty who
Code:The Commereo License Lawdoessotapplytol r owner of OVI'LETS-SWITCHES-IRXTURfS
properly who builds or vided that
thereon,and who does such tinte himself or Through
his own however
the
provided thus such improvement.ure not intended or offered for NEW RESIDENTIAL ELIICTR SQ FT.
sale.ILhowevenll have
building ofpemeng that he
non build or fmmpletfon,dorput. OWN r FIWRAREA ESQ.FT.
owner-FWO.will hove the burden of proving that he did not build or improv for Aur V
rytse of sole.).
❑ 1, B owner of the property,, exclusively contracting wi
licensed contrunars to s
constructhe project(Sec.]814,Business and Professions Cade:)'Ihe Comnnnrs Li-
cemeLawdoesnotapplytoanownerofpropetywhobuildsorimprovesthereon,and Q'TV PLUMBING PERMIT FEE
who contracts-for such projects with a conaunoro)licensed puromm to the Con rachor's
License law. PERMIT ISSUANCE
E]1 am exempt der SeC. ,B&P C for this reason
Date ALTER-DRAIN&VENT- 'm A)
VALUATION
WORKE 'S COMPENSATION DEC RATION BACK FLOW PROTECT.DEVl _•
Ihemhy affirm under penahy o(perjury one n(she following dedamtions: `
❑ I have and will maintain aCenifcate ofConsent o self-insure for Worker's Cramped. DRAINS-FLOOR,ROOF AREA,CONIT
variant.as Provided for by Section 3701 of un Labor Grier for the Isr(mmuncv of the STORIES7 TYPE CONS'TRUCT'ION
wort far which this Permit is meso W. PI%TURES-PER TRAP
❑I have and will maintain Workers Compenalion Insumnce,as required by Section
37M of the Labor Cale,for the performance of the work for which this permit is issued. GAS-BA.SYSTEM-I INC.40UT. OCC GROUP ANN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRCASEgNDUSTRL WASTE ENTERCEPTOR
phis section dead not be complemd iflhe permit ie boron hundred dollumSlm
( ) BUIL 1 BION PEES
or lased GRGSF.TRAP PLANCHECK FEE 6
1cenify that in the Performance o as
work for which this Permit isissued.)shall
SEWER-SANITARY-S'fORM EA.200 Ff.
not Lawn
any person in any manner so us m hecome subject the WarkerK C, Pan_ ENERGY FEE
Z Armon Lawn of California.Use
WATER HEATER WIVIiM'/GLECTR
2 O Applicant GRADING FE
NOTICE TO APPLICANT:If,Coen making this Cki,on, fof FLabor ,ion,you should WATER SYSTEM/TREATING
a [` become subjectIy the Worker's kimap amtinn provisions of the Labor Code,you most _ SOILS FEE
� I^, forthwith comply with such provisions or this pcmtil shall he dumeJ ievoked, Wp'fBR SENVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID
V liar wit Brisk enherc snad(See.ioer?.Cin.agency for the per[nmtvnceof Unto Re iplk
F tit Ladders
N r which this permit is issued(See.3(19J,Civ.CJ
0 Lenders Name V TOTAL:
L) Lenders Address T T ,
Fa I cenify that 1 hove read thirty and Minn and sine Nm the&lava iws mlntinn is BUILDING FEE
I?) cumenlagree to comply with all any and mumy oNinenees and atom laws retuning to QTY MECHANICAL PERMIT FEE
L) z buildingconsauctionahertby amtionzerepresemmives o(Nis city to enmr upon Ne SEISMIC FEE �A1a
above-mentioned Pmpertny for inspection purrysses.
(We)ngrce msnve,indmnnil'y and keep harmless the City of Cupenhm ngelnsl PHRMIT ISSUANCE ELECTRIC FCB
liabilities,judgmems,corn and expenses which may in any way attune against mid City
in consequence of the granting of this t. ALTER ON ADD TO MECH.
pn PLUMBING FEE 11 2W
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10AII)CFM)
SOURCE REGULATIONS. MECIIANICAI.FEC
AIR HANDLING UNIT(OVER I0,00)CFM) CONSI'RUCTIONTAX
Signature of ApplicanVContractor [)air EXHAUST HOOD(W/DUCT) HOUSING MITIGATION THE
MA'ITRIALS DISCLOSURE'
Willtheapplican.mfffrou buildugoveupant it..arbandle haaardous road.] HEATING UNIT(TO 101,000 BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Seclian 25532(tp'f HEATING UNIT(OVER 100,000 BTO)
❑Yes ON. VENTILATION FAN(SINGLE RESI)) PAID
Date Receipt#
Will d the applicant or future building occupant use equipment lor ily Mara which
emithazardousnus Dir cnnmminams uv defined by the Boy Area Air Quality Management ROLLER-COMP CHIP OR Im,Om RTU)
Districts - TOTAL:
El Yes ❑No BOILER-COMP(OVER 100.0010 BTU)
I have road the hmallous ntmanah requirements it,,Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE.
forma Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the - NEW RESIDENTIAL MECH. SQ.FT.
building does rancurently have a tenant,that it is my responsibility to notify the occupant _
of the requirements which most he met prior to issuance ma Cenificam of Occupancy.
Owneroraulhamedogent. Dam /STA ISSUED BY:
OFFICE LVA