30431 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.LTRLCAL. PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1
BUILDING PROJECT IDENTIFICATION
BUILD GADDRESS' O x SANITARY NO. APPLICATION SUBMITTAL DATE
at
O 'S o ALTQR'. 1
o Ico�ts
a/WCA N NIC CONTRULk
AN 1{I ECT/ENGIN ER: Pf{ 1 11 LICNO: p S_ I ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ CanSRltant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME
❑ ❑ ❑
LICENSEDCONTRACTOR'S
ince, DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am(the Wunder provisions of Chapter 9(commences
JOB DESCRIPTION
�� in Section Division Business and Professions Gdc.and mylicenus PERMIT ISSUANCE RFCID� FN'Ttpl�;
�W nfull force^-d t ❑SFDWL ❑KITCHEN REMODEL.
Uj' Licenec LIc.M APPLIANCE'S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE.PIPE
N Rl Dale Cenlronor
FF�':)W ARCHITECT'S DECLARATION AAC PANELS ❑MULTI-UNIT []STRUCTURAL
Z p'/� 1 understand my plans shall he uuJ as Public weonds MODIFICATION
OZ^qq UPT02IXIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
CgLicensed Professional 201-I00AMPS IMPROVEMENT
Fa OWNCRdexemptf DECLARATION OV': TXXIAMPS ❑BATH REMODELfREPAIR ❑DEMOLITION
y YW1 1 hereby affirm that I am exempt fmm the Contractor's License Law for the
x3LU
following....(Section 7031.5,Businewtnd Professions Code:Any city.,county SIGNS ELECTRICAL ❑OTHER
IR C which requites a pen t to construct,cher,improve,demolish,or repair any snucmrc
m prior m its issuaaeealso regolres thcopplicant far such perms a,file.signed Womment SPECIAL CIRCUIT/MISC,
pr
but he is licensed pursuant m the powisionsof Me Contractor's License Law(Chapter 9
00 (commencing with Section 7(X1(11 of Division 3 of the Business and l'rvfessions Code)or TEMR METER OR POLE INS'L COMMERCIAL:
6y oa that he is exempt therefrom and the buses for the alleged exemption.Any violation of _
bg y LL ❑NEW BLDG/ADDITION ❑DEMOLITION
ffRW Section 7031.5 by any applicant for a permit objects the upplicanun17
acivil pen.lty of
POWER DEVICES []TENANT
C } not note than five hundred dollars(5501. [I FOOD SERVICE
Lvownerof Ne propcny,er my employees wind wages as their sole compcmmiwn. SWIMMING POOL ELECTRIC ROVEMENT
will An the work,and the suncture is not inmadedoroQered finale(Sce.760,Business THER
Iwx1^§ and Professions Code:The Commoners License Law does not apply to an owner of OITI1.13TS-SWITCHES-FIXTURES 7��
3^ property who builds or improves Merton,mot who does such work himself.,through
his own employees,provided thin mach improvemems are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
..It.If,however,the building or improvement is sold within one year of completion,the Q.A 4ZOARRA S/SQ.FT
ser builder will have the banded of proving that he did not build he improve for pro.
imse of sowne OCC.
co L a ownerofthe property,umexclusively contracting with:)TheNaanrtaanm TOTAL: NVIHa 1996
connmm the project(Sec.7104,Business and Professions Code:)The Comrunora Li_
came Law does not apply to an owner of Property who builds or impones thereon,and QTY, PLUMBING PERMIT FEE c' [J
who contracts for such projects with a contmm
cr(s)licensed pursuant to the Contractor's UP VUr (IN(J
e1
Licenu Law. PERMIT ISSUANCE CFf
El mexamen m exeunder Sec. ,B&P C for this roan
ALTER-DRAIN&VENT-WATER IDA)Owner Dote VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1 herehy affirm under Penalty of perjury one of the Following declarations:
❑IhuvennJ will main[ainn Certificate of Cmmsemmself-insumfor Worker's Comped- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TVPI3 CONSTRUC'f10N
.smom,as provided for by Section 37(X1 of the Labor Code,for the pormonumce of the
Wyk for which this permit is issued FIXTURES-PER TRAP
i}J I have and will maintain Worker's Compensation Insurance,us required by Section
0 of the labor Code,for the perforembou of the work for which this permit is Estuary GAS-1A.SYSTEM-i INC.4 OUTLETS PCC.GROUP APN
My Work np I msec currier and Policy
Carrico Policy No.: GAS-G.SYSTEMOVER 4 BEA)
CERTIFICA OFEXEMPfION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need net hecompletcd ifthepermit is foronchundted dolixrx(SlO) BUILDING DIVISION IDES
GREASETRAP
carlest.) PIANCHECK FEE
Toy any that inthe pedany anner.the wmkfne,tme this he Wi ken,'Cmurfaml SEWCR-SANITARY-STORM FA.20 PT.
not ample any person in any manner so ur w hemme.whjcd m the WorAcrF Comped' ENERGY FEE
�.. sheenanws of California.Date
O
Applicant WATER HEATER W/VENT/ELCCI'R
P GRADING FEE
tol NOTICE TO APPLICANT.If,after making this Chemin f of Exemption,youshould
tat
become suh'anothe Workers Com atonias revisions of the LahorCode. n WATER$YSTEM/1'REATING SOILS FF.F.
ae 1 pe p you mus
fIJ
forthwith comply with such provisions or this permit shelf Mdecided revoked, WATfiH SERVICE
d
.U. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
C.)0
Dam Receipt g
LL. P: the work for winch thespcnnit is issued(See,3097,Ci¢CJ
O Lender's Name
TOTAL:
W Lenders Address TOTAL:
ps I certify that I have read this upplicution and state that the above information is BUILDING FEE
fA correct.I agree to comply with all city and county ordinances and state laws relining to QTY, MECHANICAL PERMIT FEE
U building construction.and hereby outhorlu representatives of this city m enter upon the SEISMICFEP.
abnve-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamless the City of Cupertino against ELECTRIC ME
thildiities,judgmeas,casts and exNalow which may irony way recrucaguinn said City ALTER OR ADD TO MECH.
Inc sequence of the gowning of this permit. PLUMBING FEE
APP.ICANT UNDERSTANDS ANR WILL COMPLY WITH AL1.NON.POINI' AIR HANDLING UNIT(TO 1B00CFM)
OD r EGULAI ONS MECHANICAL FEE �•
AIR HANDLING UNIT(OVER 10,00 CPM) CONSTRUCTIONTAX
Signature.Applicanmacmr Data EXHAUST HOOD(W/DUCq HOUSING MITIGATION PEC
1 BOGUS MATERIALS DISCLOSURE
Willnheappl' ant or future building occupant store or handle hazardous material HHATINGUNITODIIX,001 '1'U)
u defined by the Cuperina Municipal Code.Chapter 9.12,end the Heahh and Safety
Code.Section 25532(a)? BATING UNIT(OVER 10100 BTU)
❑Yea f-1 No
VENTILATION FAN(SINGLE RES ED) PAID
Will the applicant orrons a building by
morning use equipment or devices which
Data Receipt a
emit hazardous air connotations as aeOned by The Bay Arco Air Quality Management BOILER-CGh(P(JHP OR 10,0011 BTU)
Dlslrin? TOTAL:
L
❑No BOILER-COMP(OVER 10,00 BTU)
rwd the hazeAIRCONDITIONER ISSUANCE DATE
&Safety Code,Seconds 25505,25533 and 25534,1 understand that if the NEW REENDEN9'IAL MUCH. SQ,IT.non currently have a tennm,that it is my responsibility m notifytheoee.paments which must he man prior m issuanceofaCertiOeme ofUceuprdry,
unted agent Data TOTAL: ISSUED BY:
OFFICE