30688 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. r1 O C H H
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG•MECHANICAL 3 v
BUILDING PROJECT IDENTIFICA'T'ION
BUILDINGADDRESS: - SANITARYNO. APPLICATION SUBMITTAL DATI
"17/ Z 70 MIL 1 Li tak �Z►�9"Ltf
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
��ARCHITECOENGINEHR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Pald by Applicant(Initial) BL$ ELECT PL� - MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hemby,oinn Net 1 am licensed urWcr provisions of Chapter 9(commencing JOB DESCRIPTION
yO00 with$ccriod701 of Division 3 ofthe Business and Professions Code.and my h ease is
FOO in full farce and effect. y c PERMIT ISSUANCE RESIDENMAL
�UW DWL El KITCHEN REMODEL
y�j License Class Com APPLIANCES-RESIDENTIAL
Dme - Cnnvucmr ❑A DITION ❑PLUMBING R&PIPE ,
p.O oI ARCHDEC'S DECLARATION ❑MULTI-UNI s ❑STRUCTURAL
Z O z I understand my plans shall be used as Public records PANELS
MODIFICATION
OZ - UPT0200AMPS ❑INTERIOR (D CHIMNEY REPAIR
Luerssen Pndesstonal 301-IfNX)AMPS IMPROVEMENT
pbd
OWNER-BUILDER exempt
UER DECLARATION OVER 10110AMPS ❑BATH REMODELREPAIR 0DEMOLITION
y 0 I herd .(firm on 1 1. exempt from the Cocoons Cu License Low co Ne
x OyU followhich ingreason.Permit
to o3L5, t.dtcssimpr Professions Cm le:Any city or county THER
413 tL SIGNS ELECTRICAL
U. which requites a permit to conswct,alcor,improve,demolish.or repair any structure
16-1 to cense pursuant to the thovisiosofthe Contrutor.am icensle e aed aw(eta¢mem SPECIAL CIRCUIT/MISC.
Na he is licensed pursuant to provisions ofthe Contractor's License Law(Chapter as
O00 (commencing with Section7orm)of Divisma 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. �
d c that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Scene.7031.5 by any applicant for a permit subjects the applicant toe civil penalty of POWER DEVICES []TENANT
TENANT/ADDITION O
El
FOOD SERVICE
I
mom had five hundred dollars(55001.
C"'OG ❑1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
ag m will do the work,and the structure is not intended proffered llvxale(Sca.4044,Business ❑OTHER
Land Professions Cade:I'he Convector's License Law Noes not apply to an owner of OUTLETS-SWITCHES-FIXTURES
r property who builds or improves Hereon,and who does such work himself or through
his own employees,provided than such improvements are nm intended or olRred far NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one yearofcompation,Nr-
e • O� SQ.FT.FLOOR AREA $/SQ.FT.
aw a of a
t ildcr will have the burden of proving that he did not build or improve far pa
v'kof'
oalee.
❑1,as owner of the property,am exclmively contacting with licensed contractors In
construct the project(Sec.70M,Business and Professions Cad,)The Comm chm s LI- , y
censeLaw does not apply toanowner ofproperty whobuilds orimprovesmarked.arW QTY. PLUMBING PERMIT FEE RO
who contracts for such projects with a Mammo ist licensed pursuanto the Contmctofs
License Law. PERMIT ISSUANCE
E:1I am exempt under Sec. ,B&P C for this reason
Owner Dvm ALTER-DRAIN&VE •R(EA) ^^VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIL R.] `r
• 1 hereby afford under penalty of pe Jury atm of the following declarmions: v - 1.` V
❑ Ihnve nnJ will muinwinv Cenificme of Cnnsem mselGinsure far Warkds Camlrcn- DRAINS-rLOOR,ROOF,AREA,COND, STORIES s TYPE CONSTRUCTION
Nation,as provided for by Section 37W of the Labor Code,Tim the perfommme of the
work far which Nis permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,ns required by Section
3100 of the labor Code,for Ne performance of the work for which this permit is issued, GAS-EA.SYSIFN-I INCA OUTLETS
My GROUP 1 -UPN
My Worker's Compensation Insurance carrier and Policy nmnber are:
Carrier: Pal icy,No.: OAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FL•6S
or lessJ(This section need not be compined ifibre pemN is for one hundred dollars D 100) GREASETRAP
)s .PLANCHECK FEE r
Loy MyNmin the performaany
ymannr oathe s to orkbecome
me which this perthe W isissued,'Com an-all L
not employ My person In nnyomnner so netnhecome sub'ecnothe Workers'Com en- SEWER-SANITARY-STORM EA.200 IT.
1 p ENERGY FEE w i�
cation Lowe of Califomiu.Date
Z O APP licant WATER HGTER W/VENT/ELECTR
GRADING FEE
y
NOTICE subject TO APo the ANIT.If.Worker's ompenster ati Nis Certificate of Labor io d you,you mulst WATER SYSTEMTBEATING
a become op y the Worker's Compensation provisions of the labor Code,you man SOILS FEE
forthwith comply with such provisions or this permit shall he decoded revoked. WATER SERVICE
aQ
11 y
U
CONSTRUCTION LENDING AGENCY z Ihercby affiwthenherc isacunswctionlendin NEW RESIDENTIAL PCMB. - SQ.PE PAID
U O case«rrarthe perrarm.nce or Dole ceipt#
its U she Leworkfor which Nispewit is issued(Sec.3097.Civ.G) a
LerWelL:
Lender',Name TOTAL
W Lender's Address O
0. I certify that 1 have read his application and nate thavtbe above inlimmmion ie BUILDING PER aoaalll
V) come[.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V 7- building construction,and hereby serum"mpreseaddives of Nis city to enter upon the SEISMIC FEE waaaa'
above-mem ixied property for inspection purposes.
PERMIT ISSUANCE
(We)agree to save,indemnify and keep hay in an the City of Cupertino,s against ELECTRIC FEE !�
in
equnce of thecousin,expenses thisNora.
may inanyway accrue against soilCity ALTER OR ADD TO MECH. I'1
Aconsequence of UNDERSTANDS
this peoWI ' PLUMBING FEE 4 `
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT GM to."CFM) 11
� MECHANICAL FEC L
AIR HANDLING UNIT(OVER IQ000 CFM)
CONSTRUCTIONTAX
Sigmturem(Appliumu'Comracho s Dd)O EXHAUST HOOD(W/DUCf) 1.
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIl the applicant or future building«culand store or handle hucardous material HEATING UNIT TO IOLD00 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Seetion 255320)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. VENTILATION PAN(SINGLE,RESID) 5 PAID
Will the applicant or future building bytheB A.use equipment oTNvim Date Z.ipt#
m
which
eir hezw,ous air camaminants u define)by the Bey AAir Quality MenagmnBOILER-COMP LIMPOR 100,000 BTU)
entTOTAL:
District? BOILER-COMP(OVER 1111000 BTU)
L�,.m
E]No ,
ad the hm Joos mmedals ta under Chapter 6.95 of the Cali- AIRCONDITIONER
r5,2553 en p UANCE D
Rod- Safety Cade,Sections 25505.25533 and 25534.I wderstand Net if the / / /
current) have.tmand,Nm it is m NEW RESIDENTIAL MECH. SQ.FT, t/Ln L/
Y Yrespnnsibiliry ro mtifY the nts which must he met prior to issuance of a Ceni&ate of Occupy«y.iaedagcm Ilam "/.is V' �, ISSUED BY:
OFFICE