30618 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. 30618 O 6 as 8
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J{ FV�lI VX
BUILDING PROJECT IDENTIFICATION
BUILDINGDDRESS: - WQ� SANITARY NO. APP L]CATION
SSSU��BMITTALDAn
OWNER'S NAME: PHONE: CppNTRACfOR'RN E: LIC NO: —
a 0" r 6 3 N/C CONTROL#
%RCHITECf/BNGINEER: LIC NO: AUU ESS: ❑
mo e ale
CONTACT: PHONE: - BUILDING PERMIT INFO
EDC on..lumt Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
QA�I i ears S-/6 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby of inn now I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
5y wiNSection7")of Division3of Ne Business.nd Rofessions Code,atdmylicenseis
❑p —X1-6-- 623._ _ PERMIT ISSUANCE RESIDENTIAL: '
�VEE in full force and cif r 3—}�y�
Li License Inas Liap - ❑SFDWL ❑KITCHEN REMODEL
Fs.Za tE� Dau ConuamorLQ�n aS ON c-y/ APPLIANCES-RPSIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
=h ARCHITECT'S DECLARATION / PANELS ❑MULTI-UNIT ❑STRUCTURAL
02r� l understand my plans shell be used es public records MODIFICATION
-3 UPT02MAMPS
❑ ❑INTERIOR NEY REPAIR
[74 t Licensed Professional 201-1(X10 AMPS IMPROVEMENT
y
OWNER m BUILexempt
DECLARATION OVER I"AMPS ❑BATH REMODEIJREPAIR DEMOLITION
1 merso affirm msr I em exempt from Ne Contractor's Co License Law for the
36U following.e.a minus tocOJLmarl,ancssandrve,deiom Code:Any
ximan or county SIGNS ELECTRICAL ❑OTHER
tt4444rr777777 Y. which rtquirex n pcnNo re conswa,alta,i t for such
demolish, file
repair any swcmm
��0� prior to issuance,also reactions the applicant for such Pemmiuolile aligned statement SPECIAL CIRCUIT/MISC.
g "y dentalislicenscdp....nno the provisionsofthe Cmoraaora License Law(Chapter 9
u� ❑O (cOmmeMtngwith Section 7000)ofDivision 3ofthedoctors, itProfessionsCode)or EMI'.METER OH POLE INST. COMMERCIAL:
d o q that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^^y Seeman 7031.5 by ony.pplicamfar.penmt,mbjcc,,the applicantm.civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE'
not more Nan five hundred dollars($500).FIMPROVEMENT 6 � SWIMMING POOL ELECTRIC
I,azownerof the pmpeny,or my employeeswith wages as their sale compensation,
❑ will do the work.and the swcture is Out intended orofferel famine(Sec.]044,Business ❑OTHER
and Professions Code:The Contmeor's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTU
rgae
pmPerty who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS
sac.If.however.the building or improvement is sold withinone yearnfemopleirm,he SQ.FT.FLOOR AREA $/SQ.IT
owner-builder will Have the burden of proving that he did not build or improve for pur-
pose of sale.). vc�
❑1,as owner of the pmpeny,am exclusively contracting with licensed contractors to TOTAL: 9
construct the project(Sec.7044,Business and Professions Code)The Contractor's Li- ��
Li-
cense property Law does not apply to an owner of propy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 1 0
whoconuace for such Projects with acuntmemt(O licensed pursuant to the Contractors /1 } �
License Law, PERMIT ISSUANCE 199v
##II lr
❑ 1 am exempt under Sec. ,B&P C for Nis reason
Owner Dote ALTER-DRAIN&VENT-WATER(EA)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Y4I/ oO
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR.BOOR AREA,COND.
.anon,in Provided for by Section 37W of Ne Labor Code,for the Performance Of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
E] /
I have and will maintain Wa kermn
s Compensation Imuce,ss required by Section '
37M ofthe Labor Cale,for the performance ofthe work for which this permit is issued. - GAS-EA.SYSTEM-1 INC.4 OUTLETS OCOGROUP APN
My WorkerdotmW,1Asumnc{co mer end Pat icy rau M.�tC
Carrier. .1l#lti'( h..HeA Policy No.:/�1 17 gy GAS-EA:SYSTEM-OVER 4 CA,)
CERTIFICATE,OF EXEMPTION FROM WORKERS' r
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed ifthe permit is for onehundrel dollars($10(h) GREASE TRAP
or less.) PLANCHECK ME
I emifythat in Ne pedgrmance of Ne work forwhich this Permit is issued,)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner on as to become subject to the Workers'Compen- ENERGY FEC
Oz ..tion Laws of C.lifnmia.Dam WATER HEATER WNENT/ELECTR
Applicant - .GRADING FEE
ti NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
h become subject to the Worker's Compensation Provisions of the Labor Code,you must SOILS FEE
W2 forthwith comply with such provisions or this Femn shall#deemed revoked. WATER SERVICE. -
CONSTRUCTION LENDING AGENCY NEWRMIDENTIALPLMB. SQ.Flt PAID
V Q I hereby affirm that there is u constriction lending agency for the Performance of Receipt#
Liaf� the work for which this Permit is issued(Sec.30al Civ.C.)
F� Lenders Name TOTAL:
,�s Lenders Address TOTAL: -
I ccnify that I have¢ad Nix application and state Not Nma
e above information is BUILDING FEE
LrA correct,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 7- building construction.and hemby authorize representatives ofthis city to enter uponthe SEISMIC FEE
above-metniuned property for inspection pumlxwes. PERMIT ISSUANCE '
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilitics.judgmous.costs and expenses which may in any any account against said City ALTER OR ADD TO MECH.
in comegmenc,of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS LNG COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO l),0(10 CFM) MECHANICAL FEE
tJ V SOURCE REGULATI
X� 0 _p` AIR HANDLING UNIT(OVER IO,Igl)CFM) CONSTRUCTION TAX
/D
tgnature mf Applicant(Conuemor Dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE .
HAZARDOUS MATERIALS DISCLOSURE
Will Ne.pplicintor future building occupant stomor handle actuations matedvl HEATING UNIT(TO 100.000 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER Ifff"BTU)
❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use component or devices which Dam Receipt M
pp dby the
ea Amen BOILER_COMP OR 100,000 BTU)
emit hvallous dr conmminants m defined by the Bey Are.Air Quality Management � TOTAL:
Dismal? BOILER-COMP(OVER 100,W0 BTU)
El yes C1 No
-
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
form.Health&Safety Code,Sections 25505.25577 end 25534.1 undersNnd that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not urrently have a tenant,that it is my responsibility m notify the occupant
of the requirements which muet be met poor to iss ance of v Certificate of Occupancy. ,
Owner or uuthuoud agent - Date TOTAL: ISSUED BY:
OFFICE 1