30078APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PERMIT NO.
30078
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
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SANITARY NO,
APPLICATION SUBMITTAL DATE
OWNER'S NAME:x PHONE: CONT ACTOR'S NAME LIC NO:
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ARCHIT /ENGINHER: LIC NO: ADDRESS:
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CONTACT. PHONE:
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BUILDING PERMIT INFO
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CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 heresy affirm that I am licensedander provisions of Chapter 9 (commencing
wish forceand Bec DivieionJOfine Business and Professions Cnde, and mylicenso is
full force and effect. - PERMIT ISSUANCE
License Class Lic.X
Dan Conlmmor AI'1'LIANCHS-RESIDENTIAL n
JOB DESCRI PTION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBINGRE-PIPE
CMULTI-UNIT ❑STRUCTURAL.
MODIFICATION
11 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
ARCHITECT'S DECLARATION PANELS
1 unaerstond my plans sM1all M ossa as public iecnNs
UPT02WAMP5
Licensed Pmfesstnnal 201-Ifg10pMP5
DECLARATION
L94OWNER-BUILDER
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I hereby affirm that 1 am exempt from me Contractor's License Law for Ne OVER 1000 AMPS
following reuaon. (Section ]031.5. Business and Professions Code: Any city or county SIGNS ELECTRICAL
which requires a permit to cnmgmrt, all". improve, demolish, or repair any smrcture
prinnoia issuencc. elu requires the epplicent far such pcnrauo Gleasigneatatement SPECIAL CIRCUIT/MISC.
that he is licensed pursunm to the provisions of Ne Comnmore License law (Chapar9
(commencing wlm Section 7000) of Division 3 of the Business and Pmfnaiont Core)Or TEMP, METER OR POLE INST. -6U
an
that be is exempt thcmfmm'd the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant In. civil penalty of POWER DEVICES
not mote thin five hundred dollars ($500). •
as owner of the property, or my employtts with wages es meirsolecompenmaan, SWIMMING POOL ELECTRIC
willdome work.ana the structure isnm immidialmoffered formle(Sec.]IN4, Business
❑ BATH REMODEUREPAIR 0 DEMOLITION
❑ OWER
COMM�AL-
❑NEW BLDG/ADDITION [I DEMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
a6C
and Professions Cate: The Connector's License Law does.nos apply to on owner of OUTLETS-SWITCHES-FIXTURES
property who hwlas or improves thereon, and who does such work himself through
his own employees, provided that such improvements ate not intendedor offered for NEW RESIDENTIAL ELECTS S
sale. ILhowever, the huilding or improvement ie sold within one year of camplaion,the
rwnervbuilder will have the burden of proving That he did not huild m improve for Aur-
posa of sale).
SQ. FT. FLOOR AREA
$/SQ. FT.
❑ I, as owner or the praNny, am exclusively contracting with licensed convectors to TOTAL:
construct the project (Sec. 7044, Rusioess and Professions Code,) The Connector', Li-
cenwLawdoesnotapplytounOwnerofpropertywhobuilds or impmves therron, and QTY. PLUMBINGPERMIT FEE
who contracts for such Projects with a contractons) licensed pursuant to the Contracou s
License Law.
1 am exempt under Sec. , B & P C for this rcumn PERMIT ISSUANCE
to
Owner ALTER- DRAIN & VENT- WATER EA)
Odle
VALUATION
WORKER'SCOMPFNSATION DECfARAT10N BACK FLOW PROTECT. DE VICE
Ihcall affirmunder penalty eperjuryoneofinefollowingdeclaretinns:
❑Ihnve anJ will mninain aCeruficme ofConsenuo elf-insure for Wohers Crmpen- FLOOR, ROOF AREA, CORD.
motion, as provided for by Section 37M of the labor Cade, for the performance of theSTORIES
work for which this permit is issued. -PER TRAP❑ I have and will maintain Workers Compensation Inximnre, as required by Section
J7W.f me LaborQWe. for the perfurroutceofthe work forwhichthix permit is issue. SYSTEM-1 INC. 4 OUTLETS
Workers Compensation Imumnce carie, and Policy number are:
TYPE CONSTRUCTION
OCC. GROUPMy
AIN
Cartir. Policy No.: SYSTEM OVER 4 (HA)CERTIFICATE
OF EXEMPTION FROM WORKERS'
MIA
COMPENSATION INSURANCE DUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRES
(Thisixetion need notbe completed if the pemit is future hundred dollars 1$100)
0
RAPor Less.)
toy anythat in in Perany manner of stobhe ec rrewhich Nix Perthe W ekes Cmiircnl ANITARY-STORM EA. 200 FT.nmoo Law any petumiaoDa manner se, astobecome suhject attic Warketa'CompenENERGYFEE
Laws of California. Dote -
PLANCHECK FEE
Aptatpli ATER WNENT/ELECTR
Applicant
GRADING FEE
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NOTICE TO APPLICANT: If, after making this Certificate, of Exemption, you should WATEN SYSTEM?REATING
become subject to the Worker's Compensation provisions of he Labor Cee; you must -
forthwith comply with such provisions or this permit shall lu deemed revoked." WATER SERVICE
CONSTRUCTION LENDING AGENCY h NEW RESIDENTIAL PLMB. SQ. Ff.
k far by abaffirtnmauhem isacd(See 097.ng agency for Pedosmunce of
the work for which this permit is issued (Sec. 409], Co,CCJ
lenders Name
SOILS FEE
PAID '
Date Rtteiplp
TOTAL:
Lenders Address
TOTAL:
1 ramify that 1 have read this application and state that me above information is
cmrecl.1 agree on comply with all city and county ordinances and state Iowa relating m QTY. MECHANICAL PERMIT FEE
building construction. and hereby moaae reptesenmtives ofmis city to enter upon the
above-mentirne property far inspection pmposi
(We) goad to save, indemnify and kce hmmless the Cil of Cu ninon PERMIT ISSUANCE
p y pc dainty
mems, gran and of this pe which may in any way accrue against said City
consequence of the gaming of this permit. ALTER OR ADD TO MECH.
consequence
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alµ 1{pNDL1NG UNIT (TO 10,000 CFM)
REGULATIONS.
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FRE
MECHANICALFEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCITONTAX
Signature
of Applicant/Crmmetor Date EXHAUST GOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE.
HOUSING MITIGATION PEE -
- as
-
Willtheapplicantorfumm buildingwcopantst.nemiandle hazmdousmateriul UNIT 100,000 BTU)
defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health trod Snlety
Code, Sectloo 25532(0)7 OVER 100,0(10 BTU)
-
PAID � h p
❑Ycs ❑No
N(SINGLERESID7
ECOMP
Date Rrceipt g
emit
Will the applicant or future building Occupant use equipment or devices which
haradous air contaminants as defined by the Bay Area Air Quality Management QHP OR 100,000 NTU)District?
❑Nr (OVER IW,g10 BTU)
J�❑Yes
fomi0
of
of
I have read the hmnrdous materials Chapter of the Cali- AIR CONDITIONER
requirements under
Health & Sv(ery Code, Seniors . that i is my and 255]4.1 understand slat q the NEW RESIDENTIAL MECH. SQ. FT.
th.ngdoes not currency have n anent. mato is ua ce ofaCerry to notify the occupant
Ne requirements which most h mel prim to issuance r(a Certificate r(Oraupwcy.
1 SUAN EOATE
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Owncraraulhonmdagem
ISSUED BY: __...
- Data _ TOTAL:
OFFICE