30151 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �O
BUILDING PROJECT IDENTIFICATION' J
BUILDINGADDRESS:- SANITARY NO. APPLICATION SUBMITTAL DATR
Wy
OWNER'SN B: PHONE: CONIWCTOR'S NAME: LIC NO:
6o N/C CONTROL If
(�ARCHI CT/ENG ER: LIC NO: J;RftSS;Z/�. bID
V4 A
CONTACT PHONE: or BUILDING PERMIT INFO
- ❑ CanSultant Feta Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affion that I tor licensed undeprovisions s of Chapter 9(commencing JOB DESCRIPTION
DOZ with Seco 7")of Division J fth Busi dP fesions Code andmy license ix RESIDENTIAL:
O PERMIT ISSUANCE
W P rnfullfrce and if a CSFDWL C:)KITCHEN REMODEL
CUF Ltecv Ch.. lie.# - d
HQL Date Crnvanur APPLIANCES-RESIDENTIAL ❑ADDITION 7/5'/'LUM14TNG RG PIPE
on ARCHITECTS DECLARATION ❑MULTI-UNIT `LJ STRUCTURAL
Z o' Z 1 understand my plans shall be used as public mcoNs PANELS MODIFICATION
OZ 1-a Up DD 2U1 AMPS ❑INTERIOR []CHIMNEY REPAIR
rt?E-6: Licensed Pmfcssional ?01-1000 AMPS IMPROVEMENT -
C6 W'/ OWNF,R-BUILDER DECLARATION
6 I hereby affirm that I am exempt from the Convmtor's Llecnce Law Iia the OVER 1(X0 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
6KI 3 iL F AdImsing reason.(Section 7031.5.Business and Professions Cm1c Any city or countySIGNS ELECfItICAL C OTHER
IA which requires a permit m concmam,alcor,improve,demolish,or repair any smacwre
Od itior to its issmmm,also requires theupplicant for such perria to file a signed statement SPECIAL CIRCUIT/MI
fNUJ that he is licensed puruaatro the Provisions of the Contractors License Law(Chapter 9 '
W u=l M (commencing with Se[lon 7000)of Division 3 of the Business and Professions Code)or TEMP.METER ORI COMMERCIAL•-
6.10 rY that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
m Section 7031.5 by any applicant for u pemtit subdue¢the applicant io a civil penalty of POWER DEVICES \ - ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(S500). IMPROVEMENT
�ZyQ ❑1,as ownerof the propcny,or my emplryces wiN wages us Neir sole compensation, SWIMMING POOL ELE CO s
will do the work,and the slmcture is nor intended or offered forsele(Sec.704a,Duainess ❑OTHER
D1 m and Professions Colo:The Corrosion's License law dues not apply m an owner of OUTLETS-SWITCHES-FI%'IC7�8S'N .
13 property who builds or improves thereon,and who does such work himself or through
his own cmployccs,provided that such improvements are not intended or offered roc NEW RESIDENTIAL ELECTRFT.
aide If,however the building animprwement is sold within one year efcompletion the SQ.IT.FLOOR AREA $/SQ.PT.
poerbuild-will have Ne burden of,-,ing Not he did not build or improve for par-
. of sole.).
1,as owner of the property,am exclusively examined,with licensed cremation ri TOTAL:
crnswct the project(Swr.7040.Business and Professions Gdc:)The Conrnctors Li.
use Law does not apply to an owner of propcny who builds or improves thc¢on.and QTY. PLUMBING PERMIT FEE
who crmrre1%for such projects with u corm mr(sl licensed purvuanno the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec .B&PC for Nis reason
Owner Dara ALTER-DRAIN&VENT-WATER HIA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afftmr under penalty of perjury one of the following declarations:
•I]Ihavcund will muimainu Cuttifmum of Conmmmcel(-insurcf rWodcds Compo+- DRAINS-FLOOR,ROOF,AREA,COND' S'TORIPS� 'TYPIi CONS'I'RUCTION
cation,as provided for by Section 3700 of Ne Libor Cad,for Ne Earn fmmanee of Ne
work for which this permit is issued. FIXTURES-PER TRAP
Fl I have and will maintain Worker's Compensation Insurance,as required by Section —
3700 of the Labor Code•for the perforn+ance of the work Air which this permit is issued. GAS-EA.SYSTEM-IINC.000TLEI:S UCC,GROUP APN
My WorkrdC m en iuo b rc� d Policy, b -
Cariee_ —Policy No.: O GAS-EA.SYSTEM OVER 4(EA)
AERTIFIC+ s NFTIu F`O ce FXI2MPTION MOM WORkERT
COMPENSATION INSURANCE GREASPIINDUSTRI.WASp'I22 INTERCEPTOR -
BUILDING DIVISION FBIS
(Thiusectionneed oro he complioindmite permit is fomae hundred do][.(SIM) GREASE TRAP
+ or less,) PLANCHECK FEE'
I certify that it Ne performerecrfthe work for which this permit is issued,lshall SEWER-SANITARY-STORM EA.200 FT.
nut employ any prawn in any manner w as to herome mbje a m Ne Workers Compero / ENERGY FEB
Zz nutiva Luwsuf California.Dam WATER HEATER WNE.NT/ELECTR
O nppllcam GRAVING THE
= NOTICE BO APPLICANT:If,after making this Cerifate of Exemption,you should WATER SYSTEAI/TREATING
F^ become subject to the Worker's Compensation provisions of are Labor Code,you const SOILS FEE
q forthwithmunply with such provisions or his pcnnit had be decontrol revoked. WATER SERVICE;
W Q
V4 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT PAID
y Ihcrebyaffirm the there isacrnsrmainn lcndingugenryfrNeperformance of Datc Reeeiptp
the winds winds forwhich this penitis Iasral(Sea.3097,Civ.C)
1"t Lcmi Name tOTAI.:
y�V lender:AdJ es TOTAL: ��a V+
[' a iffyb In with': pplicaY d tt thtth ar f fin in - - BUILDING FEB
t" W corect l agree meomply with all city and ro ry rdinames anJ:wte laws remtingm QTY. MECHANICAL PERMIT FEE
L) z building crnaructirv,andherebyntnhorizereprcandit fives ofthisdit,toatterupnn the SEISMIC FEE
moveonemtioned property for inspection purposes, PERMIT ISSUANCE, "
(We)agree m save,inlcmnify,and keep harmless the City of Cupertino against ELECTRIC PEE
1labilities.judgments.costs and expenses which may in any way accrue againds id City ALTERORADDTOMECH. PLUMBING FEE
is xque of the gm I oHit'pemtit.
APPLIC UNDERSTANDS AND ..COMPLY WITH ALL NON sOINT AIR HANDLING UNITED)Brood)CPMJ MECHANICALFEE
SOUR❑ GUL T / _
n-X AIR HANDLING UNIT(OVER 10,f00CFM) CONSTRUCTION TAX (=a I L
Sigiallorren Appicant/Co e 1 Date EXHAUSTHO0D(W/DUCD
HAZARDOUS MATERIALS DISCLOSU HOUSING MITIGATION FEF.
n
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO IOOdXO BTU) JUL
us defncd by the Cupertino Municrytl CMe.Chapter 1.12,and the Ilealth unl Safety
Code,Seclrn 25532(a)? - HEATING UNIT(OVER 100,1100 BID)
❑Yes ON. PAID CII I Ur vur•Cr IINU
VENTILATION[AN(SINGLE BESIDE Date Receipt.#
Will the applicant infuture bonding by the B use equipment or devices Management
t hazallous air commrinants az Jeftno-1 by the Bay Area Air Quality Management BOILER-COMP(3HP OR IW.(IW BTU)
District? "TOTAL:
❑Yes Fl No BOILER-COMP(OVER IIXk000 BTU) -
I have real Nc hazardous materials requirements unr Chapter 695 of the CONDITIONERc Cali- ISSUANCE DATE ,
buiipi
l H Its ta Safety Code Section,255(15 is ny, rmHi I d t l than if the NEW RCSIDEN'1'IAL MF.CII. SQ.FT. + � �
build'II t fety Cy b to a 1550.l. ) d 255 4.1 a nshtafy d that if the
of N q to which t be et prim t e f a Cerofc o f Occupancy.
Came unhurried.,cut Date TOTAL: ISSUEUE
OFFICE