30500 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 30500
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
OWN?R'SNAMD PHONE: CONTRACTOR'SME, LIC NO: '
N/C CONTROL#
RCHITECT/FNGINF.ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ -�97
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Cz with Seatinn]f1f10)nf Uivixion3 of the Business and l'ndessinns C� le,ucWm license is
00 y PERMIT ISSUANCE RESIDENTIAL, -
�U�s Licene full Cle and rJf 36% OSFDWL ❑KITCHEN REMODEL
U ID. License Cleass" Lie APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
In<� Dem TS DELL
,_,Dot K. I ARCHITECTS OECLA ATION PANIiLS ❑MULTI-UNIT ❑STRUCTURAL
z O K. I understand my plans shell he wcJ as public maords MODIFICATION
O Z�O UPI 0200AMT'S ❑INTERIOR ❑CHIMNEY REPAIR
Gn,iFJ Licensed Professional 201dlXp AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
a ', OVER IOm AMT'S ❑BATH REMODEUREPAIR ❑DEMOLITION
Q I reaso affirm on I am exempt from the e,xi m Co License Law for Ne
O U following reason(Section]031.5,Businessmpr Professions Cade:Any city orrsunny tum SIGNS EhECTRICAI. ❑OTHER
which its requires issuance,coni(it)re construe,,iter,improve,dnnmsh.or repair any stmcmrc
that hosliendpurs reatto res thavisio so for Cort etas License
La (stammrnt SPECIAL CINCUI'I'/MISC.
} that he is licensed pursuammthe provision of Ne Conwaors License law(Chapter9
00 (commencing with Section]000)of Divisinn3 of the Uusincss and Pmfensions Cale)or TEMP.METER OR POLE INST COMMERCIAL:
that he is exemia therefrom and the hams for an alleged exemption.Any vwhalion of ❑NEW BLDG/ADDITION ❑DEMOLITION
x'�"•
Section 7031.5 by anyapplicant for a permit subjects the applicant an.civil penalty of POWER DEVICES
D1 m ❑IENANT ❑FOOD SERVICE
yc not mom than rive hundred dollars($500).
Mal.as owner of the propcny,or mycmpiny«swish wages as oheirmlc compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
shy G will do the work,and the xuueum is not intended oroffered formic(S«.]DLI,Business ❑OTHER
It. and Professions Code:The Conuaanr's License Low does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
" property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvememx are not intended or offered for NEW RESIDE N9'JAL ELECT 'SQ 1;4
sale.If.however the building or improvement is sold within one year ofeompletion.the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put.
pose of so
1,as owner of the property,con exclusively contracting with licensed contract m TOTAL:
consumer the project(See.71144,Business and Professions Code:)no Commodes Li. PA pp
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE -` y
wherantrans for such projects with a commands)licensed pursuant to the ConuOcoors
LiceaTaw.
❑ PERMITISSUANCE OV
lam e2 took,xempt under Sea ,B&PCfor this rcosnn
OwnerDam ALTER-DRAIN&VENT-WATIM(EA) wry Ur" CUIC VAL
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE +
I hereby affirm under penalty of perjury one afore following declarations: �h I HyV
I haveand will maintains CenificmmnfConxnuoxelL,ries,for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND.
salon,as provided for by Section 37W or tire Labor Code,for the performance of the STORIES TYPE CONS'1'NUCTION
work far which this permit is issued. FIXTII RES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
300 ofthelabnr Codpfic"Imperfamunceof Newarkforwhichthispemdtixisxued. GAS-RA.SYSTEM-I INC.4OUTLE7S OCC.GROUP APN
My Workee Co tint urenceentroaand Polieynumhrareh 1 •�
CatrieeI ;� ,/q11/- Policy No.:.�, ,gL[ GAS-EA.SYSTEM-OVER4 HIM
' CERTIFICATE IT EXHMP'I ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Phis section aced not be,completed ifthe pemut is fm one hundreddollars(SIf10) BUILDINGDIVISION FEES
mless.) I GRFASETRAP PLANCHECK FEE
_ I certify that intoe pedmormarofthe work for which this permit is mated,lshnll SHWER-SANITARY-STORM LA.2W Fr.
not employ any person in any manner so as m become suhi"I to the Workers'Compen- ENERGY FEE
Z said.Laws of Califom..Data
zO Applicant WATER HEATER WNENT/P.LCCfR GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS1 EMIMPAT]N0
Insecure xubjen to the Workers Compenxtion provisions of the Labor Code,you most SOILS FEE
forthwith comply with.such provisions or this permit shall bedmined revoked, WADER SERVICE
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ.FT. PAID
U 0 hereby afmon th0nhere iso conxwed.lendingogency for the performenaof Date Receipt#
Da l.r the work for wheli ffi x permit is issued(See 3097,Cih,C.)
0 U Lender's Name TOTAL:
L1a Lender's Address TOTAL;
I r nify that I have mad this application and state that the above information is BUILDING FEE
V) correct.l agree tocomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building constmetion,and hereby authorizerepmsetnmives ofthis city to enter upon the SEISMIC FEE
above mentioned propeny for inspection purposes. PHRMI'TISSUANCE
pgwr
(We)agree tesave,indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE
liabilities,judgmems.costs ad expenses which may in any way accrue ogainstsaid City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND\y .L COMPLY WITH ALT.NON-POINT AIR HANDLING UNIT(TO 10,0(I0CFM)
SOURCES GUI TIONS. / MECHANICAL FEE
AIR HANDLING 11NIT(OVP.N 10.(MCFM)
1 CONSTNUCTION TA%
gnat p maauCt I-tor ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA7 US MATERIALS DISCLOSURE 1, r.
Will the applicant or marc building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU) Lk
os defined by the Cupertino Municipal Code,Chapter 9.12,and the Healb and Somi,
Coda,Section 25532(0)'/ HEATING UNT'f(OVER 100,000 HTU)
❑Yes VENTILATION PAN(SINGLE RPMD) PAID
Data Receipt#
visWill the applicant it future building tau equipment or devices which BOILER-COMP(3HP OR I00Jp0 HTU)
hnvunhmmmia air connants as Acfinby the ed by the Boy Arca Air Qnuliry Management TOTAL:
istrictl
JC)yea RNn BOILER-COMP(OVER 100.000BTU)
I have sad the hazardo77usll materiels requirements ander,Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Seroonn 25505,25533 and 25534.1 undecmnd thm if the NEW RESIDENT[A),MECIL SQ.FT.
building doss not cuumady huve commit,that it Is my resremsibilitym notify the occupm t
office requirenanrs which must bo met prim to issuance are Certificate"of which must fret prim to issuance of a upancy�
Ownerm.miscrieedagcnt Date 4 ISSUED BY:
OFFICE