30755 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30755
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRE S. - - - SANITARY NO. APPLICATION SUBMI'1.1'AL DATE
g,-a as
OWNER'S M PHONE: LTlC NO:
140
NIC COM'ROL M
ARCHITECT/ENGINEER: LIC NO'. ADDRESS: ❑
CONTACT: PHONE: A µ15. ,�'�_ I(+4.3 BUILDING PERMIT INFO
❑ Consultant Fecs Pa id y Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ .�
LICENSED CONTRACTORS DECLARATIONIS: QTY. ELECTRIC PERMIT FEE -
I Irony affirm mm I I licensed ander pmiai
. am of chapter 9(commencing JOB DESCRIPTION
0
T] z with Section 700Taf Divismt 3afthe Business and Profexsmrx Cade,and my license is
f� 0 PERMIT ISSUANCE
RESIDENTIAL;
m full force an t.
F�UZV License Class Lic.N x J" ❑SFDWL ❑KITCHEN REMODEL
W6� Oam�—Commcmr
PANELS
APPLIANCES-kFSID1iNTIA1- ❑ADDITION [I PLUMBING ItE-PIPI?
MULTI-UNIT CHITECTS DECLARATION CMU ❑STRUCTURAL
Z 0 s�7J. I understeotl my plana shall h used ux public«cnMs - MODIFICATION
OZ-0 UPTO 200 AMPS ❑INTI?RIOR El CHIMNEY REPAIR
or,l- Licensed Professional 201-1000AMPS IMPROVEMENT
d faro I m-BUILDER UE Ce ContrRAII 0N ❑BATH REMODEVRHPA1R [I DEMOLITION
I hereby amrm tAat 1 am exempt from the Cnntmanr's Lirense Law far the OVER 1000AMPS
W a S U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER _ ✓
LLO which reynors a permit to construct,alter,improve,Jemoli.sls,or repair any ah'ncmre
prions its im...re,lsoregnoesthe applicant ler such permit to file a signed smmment SPECIAL CIRCUIT/MISC.y 8 that he is licensed pursuant to the provisions of the Contractors license Use
480 (c°mmencing with Secdan WllNq of vision 3f Business unJ Profexeians Csde).r '1']PAR ME I'ER OR POLE INST. COMMERCIAL.
a y m ly that he is exempt therefrom and the basis for the alleged exemption.Any violminn of 'I]NEW BLDG/ADDITION El DEMOLITION
.ry Section101 IS by any applicant for a peransubjec¢the applicant ns acivil penalty of POWER DEVICES ❑7RNANT ❑FOODSERVICE
not..,.,ban five hundred dollars(S501p.Sq
E]1,I,as owner of the property,or my employees with wages as their sole compensation, SWIMM ING POOL ELECTRIC
will Jo the work,and the strvnure is nm imm�deJ proffered for sale(Sea](W4.Business ❑OTHER
and Professions Cale:The Cnntmetar's Licemc Law does not apply t.an owner of OUTLF.'I S-SWI TCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ f1'.
sale.If,however,the buildingorimproverfam Isiah!withiameycarof completion,theSQ.PT.PLOORAREA S/SQ.C.
owner builder will have the burden of proving that he did nor build or improve for put- Ifl w 1 D
poseofaale.). /i
❑ 1,as owner of Nm
e progeny,um exclusively contracting with licensed or oon 1. - TO i
c.nswa The Drojen(See.](114,Business and Professions Cade:)The Contmnors Li-
cense Low docs not apply to an owner of property who builds or improves Fencer,and QTY, PLUMBING PERMIT � AN -3 REPeD
who conwutx for such projects with a contractor s)licensed pursuant m the Contractor's b
License Iaw. PERMIT ISSUANCE
I con exempt under See. ,B&P C fm thin reason I UJ-E] 68
Owns,
ALTER-DRAIN&VENT-WATER(EA)
Owner DaVALUATION
Data
WORKER'S COM PENSAGON DECLARATION HACK FLOW PROTECT DEVICE
1 heresy affirm under penalty of perjury one of The following declarations:
Ihav,.Id will maimaina Ccrtific.¢ofConsemmself-insure for Worker'sCmge.- DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONS'1'RUCf1ON
salon, th
as Provided far by Section 3700 of the Labor Code,for e perl'onnce u
anC the -
work for which this permit is issued. FIXTURES-PER CRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700 Ume Lrbdr Ctme.for the parfornuaceof the work far which this pcomin,ixmad GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Work Co �ytioInIi-nsum'�ectimerand Policy r��c
Carrier. Policy No.: i GAS-EA.SYST(ihLOVF.R4(EA)
CERT'PICA'TH 01'EXEMPTION FROM WORKER
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not he completed iftbe Comic is Career hundred dollars lS l W) BUILDING DIVISION II?IS
or lexsJ - GREASE TRAP PLANCI IECK FRE
I ceitify Can in the l'afonnance.fdaw work for whichthis gamic is iswad.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject o the Workers'Compen- ENERGY FEE
O Z action laws of California.Dole WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
L,) NOTICE TO APPLICANT:IL after making this Cenilicam of Exemption,you should WATER SYSTHM/TREATING
a , become subject mile,Worker's Compensation pr..Wore min,Labor Coca,you nuts, SOILS FEE
W forthwith comply with such provisions or this permit shall Is,dame!revoked. WATER SERVICE
Q
UO CONSTRUCTION LENUINGAGENCY NEW RISIUENf1AL PLMB. SQ.t1'. PAID
1 hereby kforwhich his
that isaca (Sea on lending agency forthe performance of Data Raciptp
W the Leader
Bn which This permh is lssual lSec.91N97,Civ.CJ
U Lender's Name - TOTAL,:
III Londe Address TOTAL:
0. 1 1 certify that 1 have read this applicmimt nnd state that The above inlormaion is BUILDING FEF.
fA coren.I agrcemaunply with ell city and county oNinances end scam laws relating t. QTY MECHANICAL PI7RMIT FEE
U building construction.and hereby someone representatives ofthis city in enterup:m the SEISMIC FEE
aMwe-meTnioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of C.pmin.against ELECTRIC FEE
liabiliries,judgmenrs.costs and expenses which may in any way sccrve against mid City ALTERORADDTOMECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDIDSTAN S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO FEAR CFM)
SOU C:R:GU TIONS. MECHANICAL EFF.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION7'AX
Signal eofgppl' em/Comm{ Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION ItiE
IIAZARUG�IS MATERIAI S DISCLOSURE
Will the applicant or future building occupant store or handle bezardids material ItIi TING UNIT(TO I Ld.lind BTU) s
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING ON HT(OVER IOQW)ETU)
E]Yes I ❑No - VENTILATION CAN(SINGLE RESID) PAID
Date Receipt is
Will The applicant orfuture building byoccupant Bay A equipment ordmdcexwhich BOILER-COMP(3HP OR 100.001)BTU
emir hazardous air cnnmminanH os defined by the Bay Area Air Quality Management )
Distad? • TOTAL:
E3 Yes [I No _ - Il01LFR-COMP(OVER 100,0011 BTU) ,
I have read the hmallouvnaeriolx na,mosmenH under Chapter 695 of the Culi- AIRCONDITIONER _ ISSUANCE DATE
fomio Health&Safety Carl Sections 25505.25533 and 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ.Mr
building does not currently have a const,Nat it is my responsibility to notify The occupont �^+J
of the rcyulremcntx which mustbemm pour to'usuance ofa Cenlfsme of(tssvpaney. - I
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE