30523APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
30 V^r�
Z�
RUILDINGADDRESS:
0
SANITARY NO.
APPLICATION SUBMITTAL DAT
b
OWNER AME: PHONE:
"r -e- p
COYTRACTOR'S NAME: LIC ^NO
, :
er+ ^�� \ Lay r Vf S-
NIC
❑
CONTROL #
ARCHTEC'VHNGINEER: LIC NO:
1e,.. 4 Ass II•
ADDRESS: \
381 ... ,
CONTACT. PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PL MECH
❑ ❑ � ❑
LICENSED that ID CONTRACnder p DECLARATION
1 heresy amen that 1 antlicenseddI under provisions of chanter 9 (commencingb,I,
with Seorce and effect 3 of the ftusiness and Pro&scions CNc, and my license is
i n full a force and effect
j Licenu Class t1, Liap C7CIS3'C/
I Dmc Comate ?+-5�"�'
ARCHITECT'S DECLARATION
1 maternal my pians shall be used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑DW, ❑ KITCHEN REMODEL
[]ADDITION QPLUMBING RE -PIPE
EI MULTI -UNIT []STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR CI DEMOLITION
El OTHER
'
PERMIT ISSUANCE
AI'PLIANCF,S- RESIDENTIAL
PANELS
UPTO 2011 AMPS
1 License)Professional -
OWNER-BUILDERexemptD[CLARATION
I hereby affirm that 11. exempt from the Contractors Code: Any city .,county
j which rtquirca a Permit ui conxtmet ober, improves, demoli,M1, nr rteair any xtrvdurc
prior to its issuance. also Irctimsthe applicantfor such permit to file a signed statement
Nat he is licensed pursuaprov6iomofthc Contractors(commenwith retaofDivinion3ofthe Bsinessand T'rmfessions Code)mTEMP.
that he' tet tit •rcot basin fn alleged escrinu i Any violation of
9U3Les lap It subjects the applicant to a civil Penalty of
thn1� b(s B.IMPROVEMENT
s prs ployees with wages az their sole compensation,
will do a %yi tit snout, u not intended uroffened forxule(Sec.]IU4, Business
i and Profess nm Code: The Cnmmea is License Use does not apply to an owner of
property who builds or improves thereon, and who dress such work himself or through
his own employees, larval Nm such improvements are not intended or offered for
sale. If. however, the building or improvement is sold within one yearofcomplction,the
er-hoilder will have the burden of proving that he did not build or improve, for puts
p11.af tale,,
I, owner of the progeny, am exclusively contracting with licensed contractors to
construct the project (See. 704al, Business and Professions Code:) The Contractors Li-
cense Law does not apply m an ownaofpropery whir bands or implovex themes,and
who ntmmals for such projecu with a ttmtractor(s) licensed p....anuo the Coatroom's
License law.
❑ I am exempt under Sec. , B & P C for this reason
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
METER OR POLE INST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
❑OTHER
POWER DEVICES
SWIMMING ECI'RIC
OU'T'LETS -S C FIXTURES
NEW RESIDEN IA ELIiCr SQ
SQ. FF. FLOOR AREA
966199 113S
1
S/SQ. FT.
TAL
QTY PLUMBING PERMIT PEE
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER IRA)
BACK FLOW -PROTECT. DEVICE
Owner Date
VALUATION
.
' WORKER'S COMPENSATION DECLARATION
I hereby M. under Penalty of perjury one of the following declarations:
Ifnave and will maintain a Certificate of Consent) self -insure for Worker n Comfort.UkAINS-FhOOR.
as provided fur by Section 39(X1 of the Labor Crile, for the performance of the
wak for which this permit is issued.
I have and will maintain Workers Compensation Insurance. as requital by Section
r3lB ofthe Labor CtMe.forthe performance ofNe work fm which this permit is issued.
Workefy.J"my'a' ion hLsurnncc carricrund l'Nicy DUZMrulf.14k,...n�
.ti� Policy No.: WfeD 'Iwd
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nisxenionneed our M completed ifthepermit is fumne hundred dollars($FVh
or lass)
1 memfy that in the hourly manna o m,1 work for which Nis permit is issued, I shall
and empiny any person in any manner sn as u,bee ome vubjem tat the Workm'Cnmpen-
tabes laws of California, Data
Applicata
ROOh.ANEA,CON
STORIES
SEP 23 lain
.�UCCGROUP
P•I v�ricc
s� / tli (aUl'tittl lltt
TYPE CONSTRUCTION
,
APN
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS- F:A. SYSTEM -OVER
GRhASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 2011 FT.
ENERGY FEE
WATER HEATER WNEN VELEC R
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Excmpmn, you shouldIWATEREATING
become subject m the Workers Compensation provisions ofthe Tabor Cade, you must
Sent, hh comply with such pmvisiensur this per it shall Ire damned revoked. CONSTRUCTION LENDING AGENCY
the work for which this permit is isnW (Sce. 309], Civ. C)
Lcnda,sNameUndds
SOILS FEE
PAID
Date Receipt#
PLA E. SQ. Fr.
AddressTOTAL:
I verify that 1 have mad this application and state that the above information is
agreeur comply with all thyandmusty ordinances and .sum laws mlain6m
building o ... not iota, cod hatch, authorize mpmmmatives of this city to enter upon the
above-mentioned property for inspection proposes.
(We).9. m save. indemnify and keep gain
p tumults, the City of Cupertino against
liabilities,judgments, costs and expenses which may in any wayacerum against said City
in a n,egae.ec of the granting of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
/1111', o /f Q_
BUILDING FEF.normal.I
ICALPERMI'r FEE
SEISMIC FEE
PERMIT ISSUANCE
PERMIT
FEE
AINER OR ADD IO MECIL
PLUMBING FEE'
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,M) CPM)
CONSTRUCI'[ON TAX
Signature ofaf ApplianpContraeutrZ
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant nom or handle hazardous material
as defined by the Cupertino Municipal Calc, Chapter 9. 12. and the Health and Safety
Code, Section 25532(x)2
❑Yes C3No
Will the alplietm or future building oceupmn use equillorm ur devices which
knoll hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Ya No
I have read the hecarders materials refdoetwrm under Chapter 6,95 of the Call-
hemi. Health & Safety Code. Sections 25505, 25533 mal 25534. I understand that d the
Wilding dees not cmmndy have i tech that it is my tap noddliry m notify the acupant
ofthe mquimmen, which sawn be at pian because ofa Ceroul,reuftlear,mr,
EXHAUST HOOD (W)DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (D) 100,(0(10 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Dmc Receipt # -
VpILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER- COMP (OVER I W,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
-
Owner ur i mit aimc! agent Date
TOTAL:
OFFICE