30693 (2) f/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL P12RMI'r NO.
(/ BUILDING DIVISION APPLICATION/PERMIT PLUM BING-MECDANICAL 30693
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
OWN:R'S NAhI' P ONE: O RA lR'S NAME LIC O�
r7 /E �•/r/ (�r(pU
NIC coNl'Rol•a
RCIIITE / GINI?ER: LIC NO'. _'1 as_FW I M{- s� O sIc ❑
CON'IACr: PHONE: z BUILDING PERMIT INFO
( U
1xii ❑ Consultant Fees Paid by Applicant(Initial) BLDG ?LET PL MECH
ai
LICENSED CONTT RAC'rOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am Beensed onde,provisions.f Chapter 9(eammeneing JOB DESCRIPTION
{{Dyyv'Z with Sectior,700 af4RCDITECTS
' Business wd'mfessions Code,and my licence is RESIDENTIAL:
F�r in full force and effect. �/ -D PERMIT ISSUANCE
U C�U] License Class Lic.N • O [Is W I. ❑KITCHEN REMODEL
4 a Date Camracmr APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
DECLARATION PANELS ❑MULD-UNIT ❑ CT
STRUURAL
Z w lunde wad rypluns shall be used as FuMic rontrds MODIFICATION
OZ�� UPT02MAMPS ❑INTERIOR Pt❑ HIMNEYREPAIR
1-4�u1 Licensed Professional 2014000AMPS - IMPROVEMENT {V'��
QY .•...•.4111 OWNER-BUILDER DECLARATION OVER IIxp AMPS ❑BATH REMODE PAIR DEI AION
fCp�(�aC
Wu I hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 L U following reason.(Sceu.0]031 5,Business and Professions Code:Any city or county SIGNS E.ECfRICM. ❑OTHER
Pit
4]`B, which requirex a permit to construct,alter,improve,demolish,or repair any structure(: prinnoim ismance,ulxo«ynine.the applicam for suchperma In tile.signed statement SPECIAL CIRCUITIMISC.
1;!lad that he islicensedinowantto the provisions ofthe Conlmetors License law(Chapmr9 Yfl-
^QO (commencing with Sutton7001po(Uivisian3ultheBusinessandProfessionvCoJe7.r TEMPMETERORP ST. COMMERCIAL: ULk(./�
Gy n eG that he is exempt thercfmm and the hasix for the alleged exemption.Any violation o! ❑NEW BLDG/ADDITION ❑OEUtjRJN
X..y Sation]OJ LS by any applicam fora permit subjects Ne applicam toacivil Penahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
LLFW7Zy not more than five hundred ddlars($50(d. IMPROVEMENT
QC]T.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECFRLC
will do the work,said the omcmre is not intended oroffered for sale(Sec.7U44,Business []OTHER
an and Professions Cale:The Conlmclnts License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
L pmprty,who hmids or improves thereon,end who does such work himself or through
his own employees,provided that such intprovemcntx arc not intended or offered for NEW RLSIDENFIAL ELECfR SQ FT.
rale.If,however,the building or improvement is said within one your of completion.the SQ.11C FLUOR ARI?A USQ.Pn
owner-builder will have the burden ofproving that he did not build or improve for pur-
poss m sale.).
1,as owner of the propny,am exclusively contracting with licensed contractors Lu
construct the project(Sec.7044.Business and Professions Code:)The Comracmis Li-
cams,Law Jces not apply to an owner a]property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such prijems with a cammclobs)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
C] m I uexemplunder Sec.. ,B&P C fonhis reasun
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dem
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC DEVICE
I halt affum under penalty of perjury one of the following declarations:
I havemtd will maintain aCeniOcamofConsent mself-dra a for W.rka.Compem DRAINS-FLOOR,RODE AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 7700 of the Labor Cale,for the performance of the
work far which this Formal is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,es repaired!by Section
3700(ahhe Labor Cade,for eprlnflhe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP APSE
My War r
in
tsera 'Mncurtierandlblioy —C '
Cartier. P.hcy No.: f62 GAS-L'A.SYSTIiMOVCR4(CA)
ER'fIFIC THOVOMPE SATIO I NPROM WOR RS' GREASHIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION Fl?ES
(This sectionneed nm he cumplemd ifthe permit is hours,hundred chiller,($I00) GREASETRAP
or less) PLANCHECK FEE
I unit,drat in theperfournmeofthe work far which this permit is iuued.10.11 SEWER-SANITARY-STORM EA.2W FT
oat employ any person in.ny munncr so aWorker
as to be, subject,.the 'Compete ENERGY FEF. � �
Z ration Laws of California.Dat. WATER HEATER WNENT/ELECfR
Applicant GRADING FEE
yNOTICE TO APPLICANT.If,atter making this Cenificate of Exemption,you should WATER SYSTEM/BEATING
become subjecttothe Worker's Compensation provisions fthe labor Cade.you most SOILS pE•E
(Sa forthwith comply with such provision,.,this prmitshall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGF.NCY NEW RESIDIiM'IAI.PCMB, SQ.PF. PAID
L)Q Iherthy affirm that there isac.nswaion lrnding agency for the prfonnanu of Uam Receipts
the work for which this Permit is issued(Sec,3097.Civ.CJ
0 V lendcds Nametil
TOTAL:
lenders Address ,.a
C 1 unify that I have read this application and state that the above information is BUILDING PEE '` asits
Ud correct.l agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICALPrRMIT FEE
V Z building construction,and hereby authorize representatives ofthis city In enter upon the SEISMIC TEE
above-mentioned propny,for inspection purposes. PERMIT ISSUANCE
(We)agree textile,indemnify send keep harmless the City of Cupertino against ELECTRIC FEE
iahilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence ofthe granting of this permit PLUMBING FEE
APPLIC TUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
S0 � '..' DNS
.�� i eLs MECHANICHONAL T
_� 15 /�LfL Lam_ AIR HANDLING UNIT(OVER Io,(XxI CTM) CONSTRUCf10N TAX
Sgammo ppplliccant/Contmctor Uam EXHAUST HOOD CNMUCT) HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE.
Will the applicam or far..building exapant.l.m.,handle hazardous material HHAI'ING UNIT U 0]BURF0 BTU)
as definal by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safny
Cale,Sectio.255320)'1 1 HEATING UNIT(OVER I(M.000 BTU)
❑Yes ❑No VENTILA]'ION PAN(SINGLE RESIDE PAID 2
Date Rcceiplp
Will the applicant m futuioN a building ed by'heeB use equipment of devices which BOILER-COMP(3HP OR 100,000 BTU)
mtit huzurduuv air um minnnts as deEneA by the Puy Arcu Air Quality Managemcm TOTAL:
District? BOILER-COMP(OVER 1ODdMx)BTU)
❑Yes F07 No
I have real the Nvart,Se materials 1.25533 a under Chapter h95 of the ifthe
AIR CONDITIONER ISSUANCE DATE
(.tilde Health&Safety Cade,Sections. 255J1 and 8534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Er.
building doe ICo mnanl. lis my rtxpnaihiliry to notify the acupum //���//////
oft reyui onzach mw tel Fri r isnunnce nfa C�i�nlpn�O�pancy.
Own memh ed agat�•OC /�i� ISSUED BY
OFFICE