30140APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO
RESIDENTIAL:
O SFDWL
IIL'II.IIING- ELECTRICAL
❑ADDITION
PERMIT No
BUILDING 1) ISION
APPLICATIONIPERMIT
PLUMBING - MECHANICAL
MODIFICATION
30140
0CHIMNEY REPAIR
IMPROVEMENT
BUILDING PROJECT IDENTIFICATION
C BATH REMODEUREPAIR C DEMOLITION
C OTHER
IBUILDINGADDRESS:
SANITARYNO.
APPLICATION SUUMITTALDATI
` �
1 N R'S NAMES
3�
PHO E:
/J �i
L—
CONTRACPOK'S NAME- LIC NO'.
NIC
❑
COfTROLe
RAH C GI EER: LIC NO:
gDUNESS:
CONTACT:
PHONE:
BUD -D W G PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG
ELECT PLUMB MfEECCHH
1 hereby affirm Na I am licensed under provisions of Chapter 9 mommencias
AGOwiNSauon]OW)of Divisionlnf Ne BusinessanJ Pmfesxians Cssle.and my license is
in full force and eff..
z-�
J F License Clan Lic. a
�Z2 D. Co.
_My ARCHITECTS DECLARATION
z w _Z I uMmund my plan. spall he stud. public mead,
z
n F yl Liee seal Professional
y oc � OWNER -BUILDER DECLARATION
ae.% UI hereby If= the 1 am exempt from the Contractor's License law for the
3 a following mount. (Section 703". Bardeen W Pmfcesia. Code: My city or county
Vj which require I Panel to contract. alter, improve, demalish. or repair any .maim
O priorm its announce. also measures the applicant forsuch pemut to At ... igned statement
Ny Out be u limned promant to the provisions of the Consruw. License Law (Chapter 9
C?� (commenting with Station TODD) of Division 3 of Ne Business and Professions Code) or
X rho he is except therefrom and Ne hour for the alleged exemption. Any violation of
?� Section ]031.5 by any applimt for a pemur subjects the applicant to a civil Penally of
Fz} ore mom dun five handled dollen(5500).
< C I.00wcr olds popmy.amy employees with waPcsothcir sole campe.mion.
willdothewmt.adthemmmisnatimeddmoHeredfmWe(Sm.]BW,Business
L3 W Profession. Code: The Conuareh Lt... Law dos on apply to an owner of
property who build, or improves thereon. and who dos such wort himself or through
his own employees- Provided Wt such improvements are nm intended or .(feted for
ale: TL however. We building or improvement oared within ane year of cona,leuon. the
manerbuUder will have thc Chari of proving that be did oat build or improve for Pa-
Pou of We.).
0 T. as ownor of the property, on exclusively contacting with licensed contractors to
... the project (Sec. ]Ota. Badness and Professions Code:) The Conuamora U-
.. law don n. apply to an awner of pmopery who builds or improv. Narcan, ad
who mntracutorah projects with.cuntactorls) licensed psrsuanno the Crua ora
Limo Law.
❑ I.ea mpts Sa. B&PCI 's san
D.14614
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCCS - RESIDENTIAL
PANELS
L'PTO200AMPS
201 -lam AMPS
SIGNS ELECOUCAL
SPECIAL CIRCL'ITIM C
TEMP. METER OR raw
POWER DEVICES
SWIMMING POOL ELECMl
OUTLETS-SWITCHES-RxTuREs
NEW RESIDENTIAL ELECM SQ FT.
❑ Ihave "will maintain a Cenifcam electrical to self-ionam forWatal Compen.
utiom ss provided far by Section 3]00 at the labs Cade, fm Ne perfomance of the
work for which din, pemdr is issued.
C 1 have whadLa will maintain Worker's uteofComplacence. wells
I. we.. rtqu'tred by Savors
3]00of the Labor Cade.fartheusuc center
want fnu whichthis pemut is issued.
My Worker's Compensation Inauraae cortin req Polity number ere:
Corti¢ Policy O
CERTIFICATE OFCOMPENSATION
IEXEMPTION FRON WORKERS'
COMPENSATION or perm ANCE
f Ilia sudors
named nm be completed door pemdr ix fa ane hundred dollen (5100)
or Im.l
Iany titer in do, performance of Nw
eark far which NPrevent padt is issuedshin
. I ..
tun employ, any Califon I. any tnannv so win. become subjm to dm Workai Complain..
Q Z sedan laws of Califamia. Dam
Z O Applicant
y NOTICE TO APPLICANT: If. aDair making dins Ccrdfcaue of Excep iom you should
5 ; become subject Io the Worker's Campemaian p.visia. of the lab. Cine, you must
fadtwith comply with such provisions a this permit shall he domed revoked.
=Z CONSTRUCnON LENDING AGENCY
U OI T hereby aRtm Nat them is a construction lending agency for the Performance of
U. — he tout (a which ad. pemul is issued IS.. 3097. Civ. C.)
Q 17- Lenden's Name
U L<der's Address
Uj
L` 1 eternity door 1 have read this ri'licatian and sec that the above inf.. is
N comet I spec m comply with all city and caunp adinances and amm lawn relating to QTY,
V Z building consrmnion. and hereby authorize rtpreunmtives o(this city to mtaupon the
— .hove -mentioned ptopeny for inspection puriaaea.
f Wm agree on me, indemnify and kap harmless the City of Cupertino against
liabili majud,romts.,ons and expn.es which may in env w.y a,,.c...mo aid City
in conseq��ee��RR ��f Ne ttmtrin6 of thio pumit.
APYLIj.KjGL.GLIERSTANDS AND WILL COMPLY WITH ALL -NON -POINT
�RALIRDOUS MATERIALS DISCLOSURE
Will the applicant ar future building acupunt store or hedle to arcous material
as defined by the Cupeninu Municipal Cede, Chapter 9.12. and the Health ad Safety
Cade. Section ]5532(.,".
El Yet ❑No
Will the applicant or future building acupant use eauipmeta or device which
.mit W-naws air cotmmatm r as defned by the Be, Art. Air Quality Management
Disnict?
C Yes Cl No
I have rad ft luoudo....It requirements oder Chapter hos of the Cali-
fonua Health & Sdinv Cd.. Sections 25505. 25533 ad 255M.1 s den,vd the if tK
building doss nes cumntly have a snort, the itis my re"n odulay m nmify the ..turn,
of ds reaaireorms which must Ie ren Pea to issuance of a Certificate of Ocia,ur .
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAW & VENT- WATER IEA)
BACK FLOW PROTECL DEVICE
DRAINS - FLOOR ROOK AREA. COW.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. a OIlRPTS
GAS -EA. SYSTEM -OVER 4EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WNENTNELECTR
WATER SYSTEMITLEATING
WATERSERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT(OVER 10.0011 CFMI
EXHAUST HOOD IWMUCT)
HEATING UNIT TO 100.100 BTU)
HEATING UNIT(OVER IM.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (]HP OR 100.000 BTU)
BOILER - COMP (OVER IMAM BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Fr.
OFFICE
FEE
JOB DESCRIPTION
RESIDENTIAL:
O SFDWL
C KITCHEN REMODEL
❑ADDITION
CPLUMBING RE -PIPE
C MULTI -UNIT
CSTRUCTURAL
MODIFICATION
C3 INTERIOR
0CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIR C DEMOLITION
C OTHER
BLDG/ADDITION CDEMOLITION
M C FOOD SERVICE
uI 0 j 70-'-
&0FEE
BUILDING DWTSION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data Receipt N
BUILDING FEE
FEB SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Rei
ISSUANCE