30545 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. 30545
BUILDING PROJECT IDENTIFICATION
HUILUING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DATE
OWNt NAME: PHONE: CONTRACTOR'$NAME: LIC NO: >9 6
NIC CONTROL#
ARC ITEC/ENGINBER: LIC NO: ADDRESS: ❑
CONTACT PHONE, BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG MF.I.I:CI' PLUMB MCCH
,� El L__1 E3LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arm that 1 am licensed under provisions of shaper 9(commencing JOB DESCRIPTION
�0Z with Section ofDivisienJofthe Business and Professions Cade,and my license is
ADO ) y PERMIT ISSUANCE RESIDENTIAL:
F in full force and effect.
aUU License Cross Lic.p ❑SFDWL (_1 KITCHEN REMODEL
yQL
p.GComanche,Conaacr, APPLIANCES-RESIDENTIAL ❑ ❑
ADDITION PLUMBING RE-PIPE
ARCHITECT S DECLARATION PANELS
❑MULTI-UNIT ❑STRDCTHRAI.
Z p n 7^t. I understand my plans shall be used as public records MgDIFICATION
O Z�-, UP TO 200 AMPS •f��l(
l- E'LLl
Licensed Professional [I INTERIOR HIMNEY REPAIR
201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
Q I herehy affirm that 1 am exempt from the Contractor's License Law for the
ax134 F following reason,(Section 7031.5.Business and Professions Code:Any city of county SIGNS ELECTRICAL. DOTTER
y which requires a permit construct,t consct,alimprove,demolish,or repair any structure, _
F-�-O�
prior to it issuance.also requires the applicant for such Permit m file a signedstatement SPECIAL CIRCUITIMISC.
f�} that he is licensed pursuant to Ne provisions office Contractors License Law(Chapter 9
(commencing with Section]fID0)of Division J of Ne Business and Professions Cale)ur TIME METER OR POLE INST. COMMERCIAL
as a ro that he is exempt therefrom and the basis for the alleged exemption.Any violation of -1 NEW BLDG/ADDITION ❑DEMOLITION
Stction 7031.5 by any applicant for apermit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more Nan fee hundred dollars($510).-� IMPROVEMENT Q1.as owner of the property,or my employees with wages as their sold compensation, SWIMMING POOL ELECTRIC
CC2LL E" will do the work,and the structure is not intended mNfefed inside(Site.]IW4.Businca OTHER
2 'm and Professions Code:'Dc Contractors I-icense Law does not apply to an owner of OUTLETS-SW ITCHES-FIXTURES
property who builds or improves thereon,and who docs such work hintsef or through af
his own employees,provided Eat such improvements are not madided or offered for NEW RESIDENTIAL ELEC'rR SQ FT.
sale.If.however,the building or improvement is sold within me year of completion,the SQ.FT.F 00R AREA $/SQ.Fr.
mer-builder will have the burden of proving that he did not build or improve for put- I -
're of salt.). s ,
F11,as owner of the properly,am exclusiscly contracting wed licensed contrachon to TOTAL: I ��
construct the project(See,]M4,Business and Proksoons Code:)The Condemn s Id
ocip,Law does not apply to an owner of property who builds or improves thcteon,and QTY. PLUMBING PERMIT FEE 3 99
who contracts for such projects with a csmeacosrtp licensed pursuant to the Contractor's /: r 9 6
License law. PERMIT ISSUANCE "I L f {l
❑ I am exempt under Sec. ,B&PCI thixreimn z4
Owner DateALTER-DNAIN&VF,NT-WATER(FA) 'VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROFECT.DEVICE
I hereby affirm under sually ofperjury one of the following declarations:
I have and will maintain a Cenifcmc of Consent m self-insure Ter Worker's Compact- DRAINS-FLOOR,RODE AREA.COND. TYPE CONSTRUCTION
$.tion,as Provided for by Seen..37M of the Lahr Codo
Code,for the pec munce of the STORIES
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3710 of the Labor Cade,for the performance of the work for which this Permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GKOUP APN
My Workers Compensation unarmed,carrier and Policy number am:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENS/O]ON INSURANCE GREASEINDUSTRI.WASTE INTERCEPTOR
( hissection need not he completed ifthe Permit is fomoe hundred dollars($lot)) BUILDING DIVISION FEES
lar Icxal GREASETRAP PLANCHECK FEE
Loy mytPrismaa. tperfmnsinvol ad,-)a,to alk became which
this permitisixvudlsft- SEWER-SANITARY-STORM EA.200 FT.
nm employ any pcnon in any manner so ere m hcttfine subject m the Workers'Cempen-
O ,Z safe.LawsLaws of Califomin.Date WATER HEATER WNENT/ELECTR ENERGY FEE
� Applicant Z
A.. NOTICE TO APPLICANT.If,after makingthis Certificate of Exemption. GRADING FEE
pion,you should WATER SYSTEM?RCATING
> became h comp the Workers Compensation Provisions of Ne labor Coke,you must SOILS FEE
forthwith comply with such provisinmmthis pennif$hull he deemed revoked. WATER SERVICE
a0
U
CONSTRUCTION LENDING AGENCY z NEW RElIDENT1Al.PCMB. SQ.FT. PAID
V work
which thi that there isnennswnian len ding agency for the perfnrmanm of Date Receipt#
U. the work Na which this permit is issued(Sec.J(1)],Civ.C)
Lenders Name
V louder$Address - TOTAL: TOTAL
d I certify that 1 have read this a"Iitmion and sate that the above infonunion is v
BUILDING FEE
(A nnrca.lagreemcomply
and herebyth lotyana countyordinancesof and sate Mwtrelating pm QTY. MECHANICAL PERMIT FEE
U 'z amsingcntionedtiroand hereby archon porpoises.
Lives of Eiscity to enter upon the SEISMIC FEE
aMrve(We)lin propene for inspection lose,hs. PERM IT ISSUANCE
(We)agree m save,indemnify end keep harmless the City of accrue
s againty ELECTRIC FEE
incoities,judg of ts.the Sensing of thisexpenses
Enwhich may in any way attme ageinn said City ALTER OR ADDTO MECH.
in amequrnm of the granting of this perrnit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iff"CFM)
U EREGULA ON. MECHANICAL FEF.
��-/-3 -7� AIR HANDLING UNIT(OVER 10,Wp CPM) CONSTRUCI'ION'1'AX
Sign ufcnf Applitransfuntminor Dat. EXHAUST HOOU(W/DUCIl
HAZARDOUS M TERIALS DISCLOSURE HOUSING MITIGATION FCC
Will the applicant or future building occupant stmeorhendle hazarnus material HEATING ON]I'(10 IW.OfD BTU)
as dcfincd by the Cupertino Municipal Coale,Chapter 9.12,and the Health and Safety
Code Section 25532(x)^ HEATING UNIT(OVER 100.010 BTU)
0Yu E]No
VENTILATION FAN(SINGLE RESID) PAID
WII Ne ePPlicam or furore building recupum use cyui,ra nt ardesives which Date Receipt#
emit hauNous air comandments as defined by the Bay Area Air Quality Management 80ILER-COMP(3HPOR Ifan"IffU)
DinricR TOTAL:
O Yes ❑No BOILER-COMP(OVER 180,000 BTU)
1 have read the hazardous mmermN requitement,under Chapter 6,95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
ftmia Health&Safdy Crede,Sections 255115,2s niy and ,lNlay mndersmth Nm If the NEW RESIDENTIAL MECH. SQ.FT.
building Jce.not currently hove a tenant,Eat It is my res(xmsibiliry to nmily the wcupunt
of the mqu adremv which cola,,hent,prior m Ivxaanee of a Cenificnte of Occupancy.
Owner nr authorized agent Dae TOTAL: ISSUED BY:
OFFICE