30202 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30202
] O Z O Z
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION J
BUILUINoGAIONF7 1 �� ���� b� SANITARY NO. APPLICATI`O�N S{•rU,�BMITTAL DATE
OWNERS NAhIE 77 PHONE: COM'RACTOR'S NAME: LIC NO: I A " w
AftS �G8. b ra eCar NIC CONTROL#
ARCHITECDENGINEER: LIC NO: ADDRESS' t ElO.1' %�/
CONTACT: PHONE:
/� ( BUILDING PERMIT INFO
D I/!.`� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
IIIJV N ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9 ayfi1rncing JOB DESCRIPTION
�OQ with Semlpn7(d elof Division3 of the Boniness and fessinnsC de.and my licensein PERMIT ISSUANCE RESIDENTIAL
=UIF lnfall eae"onJ diect.Q gr/ �las
QUU LianseCass ' Lic.# f l! ❑SFDWL ❑KITCHIiN kIiMODEI:
hQL Date Cnmrac (aQ P/ APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS FOm ❑MULTI-UNIT El STRUCTURAL
OZ4- lundnnund my glare shunt he used as public rewds MODIFICATION
OZ..� IIP FO 200 AMPS
F F W Llcenad Yrolcssmnal ❑INTERIOR ❑CHIMNEY REPAIR
Q 201-1000AMPS IMPROVEMENT
C Wcit Oat I am exempt fr m Ce Conti ON OVER 1000AMP5
Q 1 hereby affirm thm 1 am exempt from the Comracmh License Law for the ❑BATH REMODEIIREPAIR DEMOLITION
3 a U following reason,(Section 703 L5.Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
4 C mQ which requires a pnmit to eonnrun,some improve.demolish,or repai.......arc
Fern.] prior to iu issuance,alsaaquires the applicant for such permino kleasigned statement SPECIAL CIRCUIT/MISC.
CQS that he is licensed!Pursuant to provisions offle Contractors License Law(Chapter 9
H00 (commencing with Section 7")of Division 3 ofthe Business and Professions Cale)af TEMP.METER OR POLE INST COMMERCIAL-
61 c K that he is exempt thereon.and the basis for Ne alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
_m Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of I'OW ER DEV ICES
F Z'Yt moa man five hundred dollars F$500). ❑TENANT FOOD SERVICE
❑Las owner at me property.or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F. will do the work.and the strucmrc is not intended proffered forsale(See JIW.Business ')THER ITL QpQF1 t 41
2 3 m
and Profusions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES /� Q 1 E,eN
progeny,who builds or improves!hereon,and who does such work himself or through
his own employees,provided that.such improverni are not intended or offered for NEN'RESIDENTIAL ElSQ EL Illka-kote
Q.-e
sale If,however,the buildisti impmvementy%old within one year ofcompletion.the - SQ.FT.FLOOR AREA 8/SQ.1-f.
r of olldcr will hxvc me harden(if proving than he did not build or intpnrvc for our- l /V
pose osowti
❑ L as owner of the property,.I exclusively contracting with licensed cpntmema i-
cense La the es noct apply
o(an Business and Professions Pda)Thr Cnmmcan', Li-
cense Law Jou wuch Plymts with
ofprctors who
eemedfsorimprovcmcmmn.and QTY. PLUMBING PERMIT IaEG °�l
who enmmne Pasuch pmjul wire a conrumnr(s)licensed pursmm m the Cnnwmnrs
License Law. PERMIT ISSUANCE s JUL
Z
1 am exempt under Sec. B&P C for this reason J.
ALTER-DRAIN&VENT-WA
Owner Dam till ('.IJVALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEV /s Vr r.-
I hereby affirm under Penalty of perjury one of rhe following decimations: IIIJJJ 00Q 11)hl vu
❑I have and will maintain o Cenificate ofConscnuo self-insure for Workers Compcn. DRAINS-FLOOR,ROOF.AREA.GOND,
cation as provided for by Section 77M of the Labor Code,for me performance of the STORIES TYPE CONSTRUCTION
work fpr which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation lreurvncc,as required by Section
37W of me Lahsn Code.nfanhe peffornance of me work for whichq zthCis permit is issued, GAS-EA.SYSTEM-I INC,a OUTLETS OCC
CamMy�r:r�pf /Jbf,on maromcecamePoley No.Y A(,r .)��f;� APN
.) GAS-EA.SYSTEM-OVER A(EA)
CERTIII—� CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
(This section need not be completed kms Forms is fomnc hundred dollars(SI W) BUILDING DIVISION FP,IIS
or less.) GREASETRAP
I certify that in the performance of the work for which this permit is issued,I shall PLANCHECK FEE
nor pladoyi ylrn,oninlay anournsu as to become suM1jensome Workeri Cnmpcn- SEWER-SANITARY-STORM EA.200 FT.
Q z satlon Laws of California.Date ENERGY FEE
O Applicant WATER HEAT ER WNENTIELECTR GRADING FEE
NOTICE 11)APPLICAN'n Ir,after making this Certificate of Exemption,you should WATER SYSTEM?BEATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you rust SOILS FEF.
a Qforthwith comply with such provisionsor this peonit shall be deemed o vokrd.
WATER SERVICE
7z CONSTRUCTION LENDING AGENCY' NEW RESIDENTIAL PLMB. SQ,Fr. PAID
L) O therchyaffirmthurmerti.Csr zw nlending agency fonhe perfonnancc of Dam Receipt#
the wpb for which this pemi d(( 3WJ.
� r. tender's Name f
III tenders AJdmss TOTAL:
FyI certify that 1 have rcu✓this application road sure mat the above information is TOTAL. O
-' IA correct.1 agree to comply with all city and county ordinances and sate laws existing to BUILDING FEE �r
U ,Z buildingruction.and hereby g QTY MECHANICAL PERMIT FEE
esa. yamhorip rposes, utives o(mis city enter upon me SEISMIC FEE
atwvenrcmianed pmpeny fur inspection purposes.
(We)-,me msave,indemnify and keep harmless me City of Cup,fiam against PERMIT ISSUANCE ELECTRIC FEE
Iiabilities,judgments.costs and expenses which may in any way seems against said City ALTER OR ADO TO SUCH.in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO l0,OD0 CFM)
SOURC. EGULATIO !� 1 ���111 / MECHANICAL FEE
I (�/I�h AIR HANDLING UNIT(OVER I0.000CFM) CONSTRUCTION TAX
Signature ofgppluaomiumbachur C(_ {{{[)are V EXHAUST HOOD(WIDUC'1)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or l'uum M1uildingoceupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupcnino Muaieipal Code,Chapter 9.12,aad the Health and Safety
Cale,Serono 25532(u)I HEATING UNIT(OVER 100.000 BTU)
❑Yes Wo
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit haeardous air eummainams as defined by the Be,Area Air Quality Management BOILER-COMP DHP OR 100,000 BTU)
DisrkC'
❑Yes ❑No BOILER-COMP(OVER tarpons)BTU) TOTAL:
1 have read the h r Mous materials mdriremena under Chapter fi 95 of me Calf AIR CONDITIONER
fmnia Health&Safety Code,Sections 25505,25533 and 2553G.1 understand mat if me ISSUANCE DATE
buildingdoesnot currently have a tenant.that his mymsponsubliytonnifyrhemeripant NEW RESIDENTIALMECH. SQ.EL
offs,medications which must be met prior ro issuanceof a Cenificare of Ccenja ncy.
Owner or wa nnu.agent Dme TOTAL: ISSUED BY,
OFFICE —