30505 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBUILDING-ELECTRICAL PERMIT NO. O 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' A E: PIIONE: CON A OR'S NA LIC O:
L _ NIC CONTROL#
ARCHI '
' C' GINEEIL L N I: .DDR SS: ❑
CONTACT. gPHOONEEBUILDING PERMIT INFO
Vy- �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
-LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 131 hereby my.that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWZ ITh Section701)(yof Division 3 ofthe Buslnessand PmfessionsCode,and my licensees
�DO w PERMIT ISSUANCP. RESIDENTIAL: -
m full force and�FUz License Cl Lie.# ❑SFDWL ❑KITCHENREMODEL
NQ0. Date Conwmm APPLIANCGS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I ARCHITECTS DECLARATION ❑MULThUNIT �$TRECfDRAL
PANELS
Z p Z I understand my plans shall be used as public records MODIFICATION
OZ-, UPTO 200 AMPS ❑INTERI& ❑CHIMNEY REPAIR
rota] Licensed Padrisioeal 201-1000AMPS - IMPROVEMENT
9WOWNER BUILDER DECLARATION
CO OVER 1000 AMPS [2 BATH REMODEL/REPAIR ❑DEMOLITION
1 hereby affirm that 1 am exempt from the Contractor's License Law far the
S�dd 6 V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL —g-�
LL131L ❑OTHER I" which requires a permit m consmet,alta,hnprove,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
Ycc;vW!��} That he is licenmd pursuant to the provisions ofthe Contractor's License Law(Chapter,r)
ad (commencing with Section 70011)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST, COMMERCIAL: '
C{y m e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
Yee W Section 7031.5 by any applicant for permit subjects the applicant to u civil penalty of POWER DEVICES
ti []TENANT ❑FOODSERVICE'
p., } not mare Nan five hundree dollarsy em). IMPROVEMENT
G ❑Losownerul The property,or my employee%with wages as Their sole compensation, SWIMMING POOL ' IC \�
W III Bothe work,cull The nmcture IS trot inrended coffered far sale(Scc.7044,Burin.•. COTTER
dand Rofessio.is Code:The C'munto is License Law does not apply to as owner M OUTLETS-SWITCH - RES
property who builds or improves thereon,and what does such work himself or Through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIALECTR Lz 8QpT.
mIe.IL howevtt.The building or impmvcmem is sold within one year of eomplttion the SQ.FT.F�QORAAR�A® SISQ.ET.
ownerbuilder will have the burden of proving That he did not build or improve for par, .a,
pose oLmla). -
1,as owner of the progeny,am exclusively contracting with licensed contractors to
constmet the project(See.7044,Business and Professions Codec The Comracmrs Li- as 1 ga-
cems,Law does not apply tow aware of property who builds or improves thereon,and QTY, PLUMBING PERMI FEE /s/„, •( .Aaa�/•{p/�1
who contracts for such projects with a contmemr(.$)licensed parsunm to the Cormcmr'a
License Law' I
PERMIT ISSUANCE
❑I am exempt under Sec. ,R&P C for this reason rMl�1V
Owner Dare ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby.Oirm under peachy of perjury one of the following declarations:
❑I have and will maintain aCetificaeofConscntm self-insure for Worker's CompeteDRAINS-FLOOR,ROOP,AREA,COND.
ration,as provided for by Section 3700 of The Labor Code,for the pserfmmunce of the STORIES TYPE CONSTRUCTION
work for whichthis permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
By of the Labor Chile,for The performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLET OCC.GROUP ANN
My Work sCc , .tion instP Cy t mycnyryypb�r ;�� /
Cartier: / /a// Policy No:PiK:S Of, GAS-EA.SYSTEM-OVER 4(EA)
CERTI.CAT O (EMPl'ION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This x,clam need hot be completed if mho permit is ounce hundred dollars IS100)
or las) GREASE TRAP PIANCHECK FEE ,
I certify that in the performance addle work for which this permit is issued,l shall SEWIiR-SANITARY-STORM EA.2m PI'.
not employ any person in any manner so a to become subject to the Workers Co.,.- ENERGY FEE
Z
salon Laws of Chilterns.Date
Q O Applicant WATER HEATER WNENT/ELECTR GRADING FEE
VJ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
a become subject to the Workers Compensation provisions of the Labor Cade,you must SOILS FEE
[37 forthwith comply with such previsions or this permit shall be deemed invoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
VQ I for
thithatthehais.con(Sit.on[ending agency module performance of Data aeiPs#
� F the work for which this permit is issued(Sit.3W7,Civ.C.)
Q Lenders Name TOTAL:
Lenders Address TOTAL:
C 1 ect ify said I have hard this application and state that he above information is BUILDINTVE
LA correct.I agree to comply with all city and county ordinances and state haws relating to QTY. MECHANICAL PERMIT FEE
L)z bend uildaliconstructon, hertbyinumaimccirescntativesafthis city warderupon The SEISMIC 'E
.hove-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hatmless the City of Cuacao..egainxs ELIiCTRIC PE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING 'F.
in consequence of The grading of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANI AL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER BLOOD CFM) CONST CTIONTAX
Signature of Applicans/Coneactor Data EXHAUST HOOD(W/DUCT) HOUSING MITI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthcapplicant m future building occupant smromliwlle hazardous mderml HEATING UNIT(TO 100,000 BTU)
as declined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)') HEATING UNIT(OVER 100011)TO
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the air dram rocas a,turn”building racby the Bs use equipment or Mara which BOILER-COMP OHPOR 100,000 BTU)
l emit hazardous air cnmumimm�s as defined by the Bay Area Air Quality Management TOTAL: _
1 a Dizsritt? BOILER-COMP(OVER100.001 BTU)
❑Yes ON.
AIR CONDITIONER
1 have read the hazardous materials rtquirtments under Chapter 6.95 of the Cali- ISSUANCE DATE
forma Health&Safety Cade,Scdiom 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,That it is my responsibility ro notify the occupant
of the menswhich must he met prier to issuance of a Cedific.te o'Occupacy.
( ngi
Owne{obi emhorized'ngem Dat TOTAL: ISSUED BY: JjPee
OFFICE