30643 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO _ BUILDING ELECTRICAL - _ PERMITNO. O
BUILDING DIVISION •APPLICATION/PERMIT PLUMBING-MECHANICAL
' BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARYNO. APPLICATION SUBMITTAL.DATE
S yv w D
OWNS NA{v1E: �, PHONE: CONTRACTOR'S NAME: - LIC NO:
L N -
NIC CONTROL N
RCHITECUPENGINEER: 1, .NO: ADDRESS'. ❑
't u /11
CONTACT: PHONE:, BUILDING PERMIT INPUT
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
- LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby infirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Won with Section 9000)ofGolann3ofthe BminessandPefidoionsCode,andmylicenseis RESIDENTIAL
FWF in full force and effect. PERMIT ISSUANCE_" 1SFDWL ❑KITCHEN REMODEL
UW License Class Lic.N
VFiZW Date Contractor - APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
❑y ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
OZ b 24 Imidpowndmyplans.ahreachesall be deadaspublicreachesPANELS, MODIFICATION
UP'10200 AMPS
Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
CeWd .201-1(100 AMPS IMPROVEMENT
OWNER-BUILDER I am cU11.UF.to DECLAItAT10N 'OVER 1000 AMPS ❑BATH REMODEL/REPALR O DEMOLITIO
y 1 hereby affirm That I nm exempt from the Commmors License Law for the "
l)(3 d U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑O ER
tsl O which requires a permit to com uct,alter,improve,demolish nr repair any sun ore -
rr��ii palmic its issuance,ulsorequires the applicant Twitch permit o fintio,ned.vwtemem SPECIAL CIRCUIT/MISC. .
y that he is licensed prommnl to the provisions ofthe Contractor's License Law(Chapter?
G0 (commencing with Section 7")ofDoislon 30fthe Business and Professions Code)or TEMP.MET ER OR POLE INST. COMMERCIAL
a y o y that he is exunpt therefrom and the basis Theme Apiece exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DPMOLITIO
iC M 0. Section"1031.5 by any applicant file a permit subjects the applicant to u civil penally of POWER DEVICES
W Z y TENANT Q FOOD SERVICE
5l) not more than five hundred dollars($500). IMPROVEMENT
❑ Losh work,the properly, remyemntended wilbwagea r aei(Sw. 044,8 sines SWIMMING POOL ELECTRIC
y will aothe work,Code:
The tont isnot i Livens Law reffiersd
rot apply to
Business ❑OTHER
3 m and erty he
b Cade:The toe Throw License Law docs nal apply m on owner of OUTLETS-SWITCHES-F1XTU KSQ
'
property who builds or improves thereon,and who deer such work deed o f or t dfor
his own employees,provided to such mens ive old w are nnl inlander or offerer for NEW RF:SIDENTIAI.ELECTR
sale.If,however,r willthe h vethe buruilding improvement ithat he ilhin one uildyear
orfup..a for the "' ,SQ,FT.FLO T AREA' $ISQ.FT.
wnenbuilrer will have the burden of proving that he did not build or improve for par- - P' A ' T
pose of sale J. r I'1 IJ
❑Las owner of the property,am exclusively contracting with licensed_contractors t TOTAL: OCTnose uct Law d es nota ply to an
Bnslness and supply
Professions builds
ds or improves The then tr'e dr' OC ' 2199
a censeommeneor such plr loan ithaanas net rounar who sed eort it)thCompa,ana QTY. PLUMBING PERMIT F
who comment for such projects witacouaacmq.a)Ilmnsed puramm ronin Conoamors /s -
License Law g PERMIT ISSUANCE ��'11y
I am exempt under Sec. .B&P C for this reason CITY 11 OF UWIiIIM)
Owner Doe
ALTER-DRAIN&VENT-WATER CA) ,VALUATION
- -
WORKER'S COMPHNSA'I']ON DECLARATION BACK PLOW PROTECT.DEVICE / DOO
I hereby affirm node,penalty of p,jury one d the following declarations:
I have and will maintain a Cenificad of Consent to sell'-insure forWmker'a Camper- DRAINS-FLOOR ROOF,AREA,COND.•
.action,as provided for by Section 3900 of the Labor Code,fill the petiennance,of the • STORIES TYPE CONSTRUCTION
work for which this permit is issued FIX'T'URES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Labor Gsde,for the performance of the work for whiehthis pemtl[is issued.' GAS-HA.SYSTEM-I INC.4 OUTLETS OCCGROUP APE
My Worker's Compensation Insurance carrier and Policy number ace: _
Cartier: Policy No.: _GAS-EA.SYSTEM-OVER 4 BEG
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not be completed i Rhe permit is for one hundred dollars(5100) _ BUILDING DIVISIONFEFS
or lees) GRBASETRAP' PLANCHECK FEE
. (certify thatintbe performance nf[he work fnrwhich this permit Lsissuea.I shall SEWER_SANITARY-STORM EA.2W FT
not employ any person in any,manner so as to become subject to the Workecd Compen- ENERGY FEE
OZ soden Laws of California.Dote WATER HEATER W/VENT/ELECTR
Applicant GRADING PEE
NOTICE TO APPLICANT:If,after making this Caudicae of Exemption,you should - WATER SYSTHMRREATING
F^ become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
Wti forthwith comply with such provisions he this be deemed revoked. WATER SERVICE'
Q
yyy CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
Q I hereby atTrmthat them l.aaconxwetion lending agency for lheperfotmahce o6 _ Dole Rweipt#
L>r the work for which[his permit is issued(Sea 3099,Civ.C) _
O U Lender's Name - - -TOTAL:
W Lenders Addle,, TOTAL: _
I certify that 1 have read this application and state that the above information is BUILDING FEE
fatl cottta.I agree io comply with all oily and county ordinances ana store lows reliningt QTY MECHANICAL PERMIT FEE
U 71 building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-nmmioned propeny for inspeainn purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AWI .COMPLY WITH ALL ON-POINT SOURCE REGULATI"N
AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATION
`D AIR HANDLING UNIT(OVER 10,00(1 CPM) CONSTRUCTION TAX
gnom ofACommemr Det EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEP,
HAZARDOUS MATERIALS DISCLOSURE.
tenpplicanl orfuwre buildia,ilawpamsmre or handle hazardous national HEATING UNIT(TO Ret"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I/V
Code,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn. VENTILATION FAN(SINGLE RESID) PAID
Dale Receipt It
Wi11oro a 1.pplicantorantra building occupant useequipmentordevices which BOILER-COMP(3HP OR 100,000 BTU)
mit hazallous air contaminants as defined by hy the Bay Ray ArcoAir Quality Management BOILER
District?
❑Yes, ON. - BOILER-COM P(OVER 100,000 BTU) -
Ihave read the Incardous materials require mems under Chapter 6.95 of the Cilli AIR CONDITIONER - ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building drys nal currently have a ma.t.that it is my re,haribility to notify the occupant
of the requirennuns which must be mel prior to issuance of a Cefficam of Occupancy. ..
Owner or mnhodzed agent - - Date TOTAL: ISSUED BY.,
OFFICE '