30308 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30,308
� O /N`<J O/1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK VX
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATI NSUBMITTALDATE
M'S
O NAME: i)e A=t Hp E: CO ACTO :\NAME: IC NO:
NIC CONTROL#
�4RCHITECT/ENGIN i J LIC NO A R'S5: ❑ -
CONTACT - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ 5;, ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
OCZ I hereby affirm shat l am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
wird Se<bon 900(B of Division J of the Business and PnSfessimns Crede,and my liceme is RESIDENTIAL:
FOO in full(ores,and effect. PERMIT ISSUANCE.
m'E- ❑SFDWL [I KITCHEN REMODEL
Wt License Class Contr APPLIANCES-RESIDENTIAL :ADDITION ❑PLUMBING RE-PIPE
coi< Date Contmmm
ARCHITECTS DECLARATION ❑MULTI-UNIT C1 STRUCTURAL
Z p y Z T understand my plans shall rte used as public records PANELS MODIFICATION
OZNQI UP TO 200 AMPS [_3 INTERIOR ❑CHIMNEY REPAIR
F4t:W Licenced Professional 201-1000AMPS IMPROVEMENT
�Y=,'4j OWNER BUILDER DECLARATION OVER IqO AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
XO Owl< I hereby affirm that L an exempt from the Contractors License law for the
X O 6 U following mason.(Section 7071.5.Business and Professions Code:Any City or County SIGNS ELECTRICAL ❑ THER
hwhich requires permit io construct,east.improve,demolish,or repair any structureF'y�j prior to its issuance.also requires the applicant Initiation Perot to file u signed statement SPECIAL CIRCUIT/MISC.
8�9. Nal heislfcensecipursmanLLo the provisions ofthe Contractor's License Law(Chaptur9
li='00 (commencing with Section 9gN1)ofDivi.%ion3 of the Businessland Professions Ctde)or TE
MRMETER OR POLE( T. COMMERCIAL
6 4 e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xmla• Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
u1-rn []TENANT FOOD SERVICE
not more than five hundred dollars S500).
F Z Y IMPROVEMENT
_Q 7ldothe .,o, nd property,(it myemployees wiNwages asati,(Ser. 094.8 sins,n. SWIMMING POOL ELECTRIC
�p..0
will Bothe work,andth Thr,Contractor's
notintended or naw does
it)
[]OTHER
and Professions Cide:ITe Contractor's License Low docs nal apply to an owner of OUTLETS-SWITCHES-FIXTURES
4'3 property who builds or improves thereon,and who does.such work himself er through
his own employees,provided thus such impmvcmems arc not imcndcJ ur ol7ereJ far NEW RESIDENTIAL ELECTR SQ ET.
sale.If,bowevm,the building or imp...Orion -old withinone yv.O,fv a,1cdor,the SQ.FT.FLOOR AREA S/SQ.17
mer-builder will have the burden of proving that he did net build or inmmve for put-
pose of sale.).
❑ 1,as owner of the property,am exclusively contracting with conw
licensed clom m TOTAL.
co
oaSBucl the project(Sec.9014,Bnxinea and Poll cxsiona Cod,
:)The Conlmsaoe,I.i.
cense Use does not apply to an owner of property who builds or improves themon,and QTY. PLUMBING PERMIT FEE -
whocommasfn"n'th projects with a coolorl (s)Ilecnedl pursuina In the C aae,or's
t
Lie
eayse Law. PERMIT ISSUANCE aj
❑ I am exempt under Sec. ',It&P C lid this reasan
OwnerUam I ALTER-DRAIN&VENT-WATER(EA) VAI UAI'ION
PId KER COh PFNSATION DEL
ARATION BACK FLOW PROTECT.DEVICE ,
thereby notiu d p y ofperj ryof the falliovingdo t' r -
•ElIhave d will maintain aCnf I otC tt If'nsu f W k :Cnopen DRAINS-FLOOR,ROOF AREA.COND.
eutu: p id d 1 by Section 3700 of Ih Labor Code.fn thep 1 m'nee of the _ STORIES I'YI'C CONSTRUCTION
work for which this —it l,issued, FIXTURES PER'rRAP '
❑ 1 have and will maintain Worker'.%Compensation Insurance,as required by Section
37W or the Labor Code,for the performance of the work for which this crant is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP i APN
My Worker's Compensation Insurance carrier and Policy miniver are:
Carries Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATEOF EXEMPTION FROM WORKERS' -
COMPENSATIONINSURANCE GREASEINDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need roun
t he completed Blue permit is formic hdmd dollars IS 100) GREASETRAP
or less](This
FEE
I cmify that in the performance of the work for which this Pamir is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject w the Worker:Compen- ENERGY FEE
ZZ scion Laws of California.Date WATER HEATER WNENT ELE TR
2 Applicant GRADING FEE
to NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should WATER SYSTEM/17REATING
? become subject an the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
foMwida comply with such provisions or this permit shall be deemed revoked. WATER SERVICE I
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
Z - Das Receipt a
L)O (hereby affirm that there izaconnmaion lending agency for the performance of
H the work for which this Permit is issued(Sec.3099,Civ.C.)
u' Lender's Name {� TOTAL:
L) Ls,ndeh Address - TOTAL:
yI certify that I have read this application and state that the above information is BUILDING FEE
h .L correct.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT SETS I FEE 7 loot-
above
V Z building construction.and hereby asimmim representatives of thin city to enter upon Ne JZ
-mentioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC ME
(0.'e)agree to tease,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way uceme against said City ALTER OR ADD TO MUCH. PLUMBING FEErrC f}I if ykJ
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. /Y_�.
AIR HANDLING UNIT(OVER 10,000 CF.N) CONSTRUCTION TAX
Signmmc of Applica marembr Doc EXHAUST HOOD GVMUCT) HOUSING MITIGATION FEE
ZARDOUS M RIALS DISCLOSURE
Will the ap 1 ant or more buil occupamsmrc or handle harardousreamal HEATING UNIT(TO 100,000 BTU)
as define)M1y the upcnino Municipal Code,Chapmr 9.12,and the Health and Safety
CodaYon 255320%)! F1 No
HEATING UNI T{OVER 100.000 BTU)
0PAID
VEN ILA'LION CAN(SINGLE RESID) 1;n Rcemp'a
Will the apphe nl mi Rome building occapanl me equips con indevices whleh
�rmt h odous r commoinoO N'defined by the BL:
ay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) a TOTAL:
k
Unitnm9nyr,nlaBOILER-COMP(OVER 100,000 BTU)
s AIR CONDITIONER
Ih ad theh J t l: y t J CIvi,mr 695 f Ila,Calls - /HISS CrAN
m AI'L
teBend,&Solely ty C 1 S i .25505 25533 125594 1 a' I O t u I Nc NEW RESIDENTIAL MECH. ,SQ,FL / I �
huddi.,d t camead,h mular,met if y responsibilityl tily(lie cecapant
ofthe requirenems whichmust benct pr arm ssa.mcofa Cen cosofOcwpumy.
)
Owner mauthoriacdogcnl Date ' TOTAL: E Y:
OFFICE