30426 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30 p2C
BUHAING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J (�,Cv
NUIIDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY N0. APPLICATION SUBMITTAL DAD
L 6"j
OW 'SNAME: WHpNN � COM' CTORS NA - LIC NO:
\7 Ib 14.1.0 CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ 9- ❑
C m Z I hereby affirm that 1 am licensed under pmvinions of Chapter 9(commencing JOB DESCRIPTION
R300 1hS<ction7IXM1)of Uivision3of the Businessand ProfcuinnsCode.and myliccnse is RESIDENTIAL:
FF , '.full fawroud effuv PERMITISSUANCE
<UgU Uvenm Class Lisa ❑SFDWL El KITCHEN REMODEL
yQW Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
I,-py ARCHITECTS DECLARATION AL,
PANELS ❑MULTI-UNIT ❑STRUCTUR
Zpn 1 understand my plans,hull be used.public records . MODIFICATION
OZ^ pp UPT0 Ip AMPS ❑INTERIOR ❑CHIMNEY REPAIR
5qr,r/4I•]Iil Licensed Professional 206 gI AMPS IMPROVEMENT
6 Ads OWNER-BUILDER DECLARATION
�j iWS t�' 'I hereby affirm that 1 am exempt from the Contractor's License Law for the .R 1000AMPS ❑BATH REMODEURF.PAIR DEMOLITION
xx CU following reason.(Sccaon 7031.5,Bulinus end ProPossions Codc:Any city or county NS ELECfRICAI. ❑OTHER #
4
W C I. which requires a permit m comm
acl,aper,improve,dawlish,or repot,any swcmre
yy Prior to its iss......1.6tequirenhe epplicmn for such pertain. le.signed xlnmment SPE CIRCUIT/MISC.
MHOthat he is licensed puomanuo the pmvismr,of the Gmtmcmr'x License Law(Chapter 9 09
MHO (commencing with Sccnion 700B.f Division 3 of the Business and professions Code)or TEMP.M RPOLEI COMMERCIAL:
4 0 that he is exempt therefrom and the busts for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
yx
Section 1071.5 by any applicant for a permit subjects use applicant to a civil pomahy ofWEN DEVICES
[]TENANT ❑FOOD SERVICE
not more than rive hundred dollars(85(10). IMPROVEMENT
Ca (]Lazowner of me property.or my employ«,with wagcsm hast,sole compensation. :S�±JRGPOOL ELECTRIC
GLS will do the work.and the sm¢wre is nm intended orolered lin sale(See,7(WL Business []OTHER
Wand Professions Code:The ConttictaYs License Law does not apply to an owner of OUT WIT ES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not imen ted or offered for NEW RJEsIDR6IR SQ IT. -
sale.IL however,the building.,improvement is sold within one year of compleianmeJ�F&ESQ,FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden ofpmving that he did not build or improve for pur- ..� ^ •#
pose of sale,).
❑I.as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
.meet the project(Sce.7044,Business and Profiaelona Code:)The Commnor's Li- rs��
cense Law docs n
m apply to an owner of property who builds or improves daemon,and QTY. PLUMBING PERMIT FEE /•UI g 199C
who contracts for such projects with a cenunmods)licensed putamen to mo Comm tors
License law. PERMIT ISSUANCE ( ( �7
❑ I am exempt under Sec. ' ,B&P C fonikoca,nn ��ut- C
ALTER-DRAIN&VENT-WATER(EA) ^ �"VALLIAn0N
e Dam � �
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE.
I hereby affirm under p mita,of perjury one of the following dcclarrimmo:
•❑Unwound will maintain uCcoificareofConsenuosclf-more for Wnrkefs Compen- DRAINS-FLOOR,RUDE AREA,COND. STORIES TYPCCONSTRULTION
satin.,as provided for by Section 370 of the labor Cale,bar the pa,bur once of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance.as required by Section
370 of the labor Code,for the performance ufthe work for which this permit is issued, GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC,GROUP - APN
My Worker's Compcnsafinn Insurance artier and Policy number are:
Conies Policy No.: GAS-P.A.SYSTLM-OVER 4 HDD
CERTIFICATE OF LXEM FTION FROM WORSE RS'
COMPENSATION INSURANCE; GRBA$ RNDUSTRL WASTE.INTERCEPTOR BUILDING DIVISION FEES
Glisasfionnwd net be completed Bull,Permit is porous handral dollars($100) GREMISTRAP
or less.) PLANCHECK HE
I certify that in me permanence of the wort forwhich this permit is issued Droll SEWER-SANITARY-STORM Not.20 FT.
not emflny any person in any nwnrter sa m to booms nuhjce m the Workers'Compete ENERGY HE
Z sallonlawswf Celifncia Data
O Applicant WATER HEATER W/Vf:NT/ELECTR GRADING FEE
y NOTICE TO APPIACAMU IL after making hair Cenifcatc of Exemption,you should WATER SYSTLMaREA'1'INC,
abecome subject to the Worker's Compensation provisions of the Lubar Code,you must SOILS FEE ,
(tl G forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION iso c0NLENUINGAGENCY NEW RESIDENTIAL PLMB. SQ,IT. PAID
iU0 I for by whipaffirm memerc issued(Se,30 lending agency bathe performance of Dote Receipt
{1ti H me work for which this permit is issued(Sec.Jlyd],Civ.CJ
0 U Lender's Name TOTAL:
Lkl Lender's Address 'TOTAL:
FYI I cent fy that I have read this application and state that he above information is BUILDING FEE
W correct,L agree to comply with all city and county ordinances andslate laws relating he QTY. MECHANICAL PERMIT FEE
U 4 building construction,and herebyauthodxe representalivesofthis city menterupnn the SEISMIC FEE
abovemrendoned propeny for inspection purposes. PERMIT ISSUANCE.
(We)agree br save,indemnify and keep hornless the City of Cupertino against ELECTRIC FEL Is
liabilides,judgments,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
n co
insequence of the grunting of this formic PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 11,(1011 CFM)
SOURCE REGULATIONS. MECHANICAL FEC
AIR HANDLING UNITIOVER I0,00CFM) CONSTRUCTIONTAX
Signature of ApplicaaUContracmr Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FFP
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicenlar furore buildingoccupert store or handle harallous material HEATING UNIT(TO 10,000 BTU)
as defined by the Cuponino Municipal Code,Chapter 9.12,and the Health unit Safety
Code,Section 25532(sU HEATING UNIT(OVER 10,000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RCSID) PAID -
Will the applicant or future building cecupant use equipment of devices which Dam Reaip M
tart hmurdous air contaminants as defned by has Bay Are.Air Quality M...games, BOILER-COMP OHP OR HILWI BTU)
Dialect?
C]Yes ❑Nu BOILER-COMP(GVHR 100.000 BTU)
I have mad the haurdous materials teluitements muter Chapter 6.95 of the Cali. AIRCONDHIONER ISSUANCE DATE
fomia Health&Salary Code,Sections 25505,25533 and 25534,I understand That if tho NEW RESIDENTIAL MECII. SQ,FT.
building does ria currently have a anent,shat u is uw co of a Ceoirila nmify m<oceupant
of the rcyulrcmems which must he nun prior 1.ixsumme afu CenlOrate of Oanupanay,
Owner or authorized agent Date
\ ISSUED BY.
OFFICE