30849 APPLICANTTO FILL.IN,INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - t
CITY OF CUPERTINO - BUILDING-ELF.CTRICAI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAL 30849
BUII"DING PROTF,CT IDENTIFICATION
BUILDING ADDRESS: vnj� - , SANITARY NO, APPLICATION SUBMITTAL DATI
0191 �3a//,h Lv Koa_.. . ujOGrTnag C )4
OWNGR'S NAME: P�ryryooNE: — CONTRACTOR'S NAME: LIC NO:
West V Ile PresL. feraw Ckurc 1. o✓pav we cory oLa
HITECiTNGINEER: - LICNO: _ "ADDRESS:
CONTACT: PHONE:
e-Bs vel 1'USS�fgtN(O$; C&— � BUILDING PER?
IT INFO
Russ LwasoAj El Consultant Fees Paid by Applicant(Initial)
zo' BLDG ELECTPLUMB MECH
6
LICENSED CONTRACTORR '4fo
'S DECLARATION
1 hereby affirm mm l am fmcBd under provisions of Chapter 9(commencing QTY' ELECTRIC PERMIT FEE
aZ
� with Sectirn]CQ3)of Division3ofthe Business and Professions Cole,and my licensers "' JOB DESCRIPTION
in full fn mid effect. PERMIT ISSUANCE- RESIDENTIAL
Z ❑KITCHEN REMODEL
U(0 License Class Lic.0 El
h6L Date Crmracmr APPLIANCES-RESIDENTIAL ❑ADDITION C1PLUMBING RE-PIPE
p.vDv2,>zi ARCHITECT'S DECLARATION PANELS t .. ❑MULTFUNIT
O Z:4❑ T understand my plans shall be used as public records El STRUCTURAL
O UP TO 203 AMPS MODIFICATION
E.m: Lrtensed Professumnl ID INTERIOR El CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT 1.
'yy�"d day t Iohereby affirm that 1 am exempt fmm Nfme Contractor's License Law the OVER 1000 AMPS El BATH REMODEUREPAIR [I DEMOLITION
W 3 w u following reason.(Section]031 5,Business and Professions Carle:Any city or county. SIGNS ELECTRICAL C1OTHER "
4l �¢n which requires a permit to cunswa,alter,improve,demolish.or repair any sanctum0.1 prior to its Issuance,also requires the applicam forsrch permit file.signed,mmment
2Czyy;y"�,i� Nat he is licensed pursuant to the Provisions of the Cnnlmetor's License Law(Chapter 9 SPECIAL CIRCUIT/MISC.
sN pO (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR FOUR INST. OMM R IA :
L y M ev that he is exempt therefrom and the basis for me alleged exemption.Any violation of -
W m
Section 7111,1 by any applicant fora permit subjects the applicant to.civil penalty of POWER DEVICES ❑NEWBLDG/ADDITION C1 DEMOLITION
not more than five hundred dollars($503). ANT • Ea FOOD SERVICE'
FSi Q �-mrommerofthepropeny,or my employees with wagesus their sole campensmmn. SWIMMING POOL ELECTRIC IMPROVEMENT
y will do the work,and the structure is nest intended oroffered forsale(Sea.7bul Business OTHER
a � and Professions Code'.The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who bonds or improves thereon,and who dues such work himself or through
his own employees,provided that such improvements sre not intended or Offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however the building or improvement issold within oneyearufemapletirn.Jhe SQ.PT.FLOG ARFrA
pose S/SQ.FC
.. owner-builder will have the burden Of proving that he did not build or improve for par- H
e of sale.). _ I D
-
❑1,as owner Of the property,am exclusively contracting with licensed contractors to t
construct the project(Sec.]044,Business and Professions Code)The Contractors Li-
verseFEB Law does not apply to an owner of propeny who builds Or improves thereon,and F
who contracts for such projects with a eontracmrof licensed PERMIT
License Law, pursuant m the Contractor QTY' PLUMBING tv11T ISSUANCE
CITY
,
❑l am exempt under Sec. .B&P C far Ncommit ason PERIIIYv V(' Vu rt:({II
O ✓ b�,z D 3 ALTER-DRAIN&VENT-WATER(EA) - VALUATION r�
WORKER'S COMMSATION DECLARATION BACK FLOW PROTECT.DEVICE I.
I hereby affirm under penalty of perjury one of the following declarations: IT
elkIhave and will mninneina Certificate of Consemmself.insure for Worker's Camper- DRAINS-FLOOR.ROOF.AREA.COND. 11 1 I
cation,as provided for by Section 3]00 of the Labor Code,for the performance of the' - STORIES TYPE CONSTRUCTION
work for which Nis permit isiesued.' FIXTURES-PER TRAP
❑I have end will m.natn Workers Compensation Insurance,as required by Section
3]000fine Labor Crile,for the pertrrmance of the work for which this permit is issued. GAS-EA.SYSTEM-IINC.40UTLETS
My Wrrkcr'a Compensation lnsumnce canier.nd Policy number ere: OCC.GROUP- Apry t
Carrico Policy No.: GAS-CA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' - '
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE,INTERCEPTOR'
(Thismctionneod not beeomplemd ifthepemtitisforonehundmddollars(M W) BUIL G ON PEF,S
.or less.) GREASETRAP "
I certify that in the performance ofthework for which this PLANCHECK FE
permit ikem' ompenll
net employ nLwanyalfinninany manner so asmhernme subject to the Worker4 Compen- SEWER_SANITARY-STORM EA.200 FT.
OZ cation Laws of Califomis,Date ENERGY FE
O Applicata WATER HEATER W/VENT/ELECTR
G � NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should GRADIN
a % WATER SYSTEM/TREATING
; become subject m the Worker's Compensation provisions of the Lnbor Code,you must - SOILS FE
LT) forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
a, Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. ,PAID
[�Q I hereby affirm that there is a construction lending agency for the performance of be ,ReceiptN
the wmk for which this permit Is issued(Seo.3097,Civ.C.)
Q U Lenders Name
WLender's Address TOTAL: TOTAL:
at I canify that 1 have read this application and.cute that the above information is BUILDI FEE
ti hcorrect l agree to comply with.11 city and county mainanees and state laws reining at QTY MECHANICAL PERMIT
U 9 building construction.and hereFEEby authorize representatives nflhis city to enter upon the SEISMIC FEE
above-mentioned propeny for inspection purposes.
(We)agree to save,indemnify end keep harness the City of Cupertino f Cu a PERMIT ISSUANCE
against ELECTRIC ME
liabilities,judgments,granting of thisexpenses which may in anyway.come ageinsist id City ALTERORADDTOMECH.
m APPLICANT
UNDEf the RSTtingANDS
SthisDWIL - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCB REGULATIONS. MECHANICAL FEE
C 2AIR HANDLING UNIT(OVER IO,OPM)CFM) CONSTRUCTION TAX
Sign.tum to ,ppartin,midow"'. ate EXHAUST HOOD OVMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant suneor handle hezafdous mmMal HEATING UNIT(TO 100,030 BTU)
,as defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety
Code,Station 25532(a)7 HEATING UNIT 100,000 BTU)
[:1 Yes
VENTILATION FAN(SINGLE RESfD) PAID
Will,the applicant or future building Occupant use equipment or devices which Date Receipt8
' t hazardous air comaminums as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100.000 BTU)
District? TOTAL:
Yes [ BOILER-COMP(OVER I00,0001ITU)
I have read me hazmdnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health&Safety Crile,Sections 25505,25533 and 25534.1 understand for if the �" - ISSUANCE DATE
building drakmo currently have.tenan:m.t it is my resprm,bdhyro notify the rwcupam - NEW RESIDENTIAL MECH. SQ.FIE -
eftherequiremems high be met prim to issuance ofa Certificsaa Oce piney. t
Owner nr euthonz agent Datil TOTAL: ISSUED BY:
OFFICE