30967 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
'a CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAI; 30967
BUILIIING PROJECT IDENiTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
OWNEN'S NAME,: PHONE CONTRACTOR'S NAME: LIC NO:
ISD Z.:JS3� N/C CONTROL#
ARCHIITLT/ENGINEER: .IC NO: ADDRESS: 1'Z21,#elj SA T'O 5r'/1;{e ❑
�CjQ
CONTACT: PHONE I BUILDING PERMIT INFO
C'%�44(a-1913 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
IICENSEDCONTRACTOR:4DEc TI QTY ELECTRIC PERMIT FEE
1 hereby affirm that I an,licensed.coder pn,.i.ia s n f 9(comm cing JOB DESCRIPTION
FW.ZOO
Data
tin full furtce andlllvislmnlo(tbe Oarinurand Pn,fn ni n surd n,Y cnrc is PI?RMTI'ISSUANCE RESIDENTIAL,
OZ w
�UF' License Class officer. Lic.x ❑SFDWL ❑KITCHEN REMODEL
NQL oro Commaor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FOy ARCHITECTS DECLAR ' PANELS ❑MUIJI,UNIT [I STRUCTURAL
I understand my plansshall be used a.pu MODIFICATION
OZ- O UPT02W AMY5 ❑INTERIOR ❑CHIMNEY REPAIR
P °J3 t:W I.,ernsed Pmfcro al 281.1000AMPS IMPROVEMENT
04IYd'a thereby offw OmN am exelmptf DECLA,R
Oofs License Law for the OVER UWAMPS 11REMODEUREPAIR ❑DEMOLITION
ax a U following rcoson.(Section 7031.5.Business and Pr..feseimes Code:Any city lir county SIGNS ELECTRICAL TITER
W'3
0 y which requirenrun
,a permit I,mn ,alcor.Improve,demolish,nr repair any saucmre
priorto its issuance.also requires the applicant forsuch permit o file.signed statement SPECIAL CIRCUHUMISC.
E(!{} that he is licensed porsuanuo the ptovi,mr s ofthe Contractors License Law(Chapmr 9
W���O (commerical,with Sect inn?(XXgof Division 3nB fthe reins,and Pndcrsioos Cwle)a TEMP.METER OR POLE INST. COMMERCIAL:
III.d c C than he is exempt therefrom entire basis for the alleged exemption.Any vadak n of ❑NEW BLDGIADDITION ❑D17MOLITION
�2y Section 7031.5 by any applicam for a permit subjects the applicant to a civil penalty of POWER DEVICES 1w. ❑TENANT ❑FOOD SERVICE
F. an,more than five hundred dollars($500). IMPROVEMENT
ESG 0Losawnerof ma,m),zrty,ormy employees with wages ax their smtheon,air,a,se, SWIMMING POOL ELECr C El OTHER
I.., structure do the work.and the scture is not imcmJed or ffered for sale(See.76X,Businaxs
L 3 mand Profusions Com:The Contractors License Law das not apply to an owner of OUTLETS-SWITCH' - TURES
property who builds or improves ther en,and who docs such work hitrvclb or through
his own employees,provided that.inch impmvamenrr arc not intended or nferrd for NEW RESE)CN UAL ELECTR S
sale.If,howfvef.the building o
r improvement is sold within one yearofcomPletiun,the fSQ.FI'.F10�1(t AREA &SU FT
owner-huilder will have the burden of moving that he did not build or improve for par- �� L�� L/
prose ofsakJ' '1' TAL:
1.a%owner of the popery,am exclusively convecting with licensed contractors to �x
conswct the project(Sm.7nDU,Basil and Profession Cale:)The Comtaeremrr la- FEBCD 1 2 A!•�°®
cense Law does not apply ,an owner of propeny who bui lots or improves theon.and QTY. PLUMBINGPERMIT FEE ^�
who conttae¢hasnch p.jec,,with a contract (a)licensed pursuant or the Contractor's
Licensx Law. PERMIT ISSUANCE 31L1 Y lir L"OH CHIINO
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I herchyobfo,under pel perjury.,of fthe following deelurmmar:
❑Ihave and will maintain aCenifcam of Cnnsenuosetb-Insure for Worker's Cnmpen- DRAINS-FLOOR,ROOF.AREA,CONE). STORIES TYPE CONST RUM ON
scion,os provided far by Smile.3700 of the Labor Code,fur the performance of th
?"'lave
which this permit is issued. FIXTURES-PER TRAP
w 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Coda for me pedornarr
ec IS work in,which this permit is issued. GAS-EA,SYSTEM*I INC.4 OUTLEI:S OCC,GROUP AI'N
My Walk Comppeete�madon
�Is a cam r and Policy ny _Q,
Cocoa:^hR1Te 49r I� 'Policy No.:Ty1—,(O •�� GAS-EA.SYSTEM OVER 4(EA)
C17RI]FICA1'If OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASE/INDUSTRL WASTE LNTERCEY1Ok BUILDING DIVISION FEES
(Thin section need not be completed iflie permit is before hundreddollars(SI0B GREASETRAP
or less.) PLANCHECK FEE
toy any that in the anymaninrol ice workas
for whichthispewit is okesued.I shall'Creative- GEWF.R-SANITARY-STORM T:A.2(X)FT.
at employ any pervm in any twnncr.w,o.to become subjttuo m<Workers'Compcn- ENERGY FEE
Z ,alio.Law.,of California Date WATER HEATER WNENDMLECTR
Z 0 Applicant GRADING FEE
a ,) NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should WATER SYS'I EMITREATING SOILS FER
become subject to the Worker's Compensation provision of the Labor Code,you roan
w
forthwith comply wish such pruvi cions or this permit shall be decmW revoked. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RES 1 LPLMB. 5 PAID
V� Thereby aflinn thauhcrt isacnnstmnion lending ug<ncy finite,pernrmunce of Dam ReceiptM
the work lin which this pyrlpIoSmTD'rnl.:
u' E' LenderI-
,Name C IDEi .rn � )��Q �a�
O WLender,Address TOTAL:
ly I certify that I have read this application and state that the above informminn in BUILDING FEE
I,, correct.l agree mcomply with all city and county ordinances and state laws offering m QTY. MECHANICAL PERMIT PEE
V Z building conrwnion.std hereby ole rcpmummirer of this city menses upon the SEISMIC PEE
above-nsntione sty for' ,actio puHxnes, PERMIT ISSUANCE
(W,)u fe nJcmmfy rod keep harmless @e City of Cupertino against ELECTRIC FEE
I amilies.j ars and expo res which may in any way
cocoa,against said City Ai,TER OR ADD TO MECH.
PLUMBING FEE
' conscqu ce rot.. .ming of us permit.
APPLIC T STAN AN I WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.(M CFM) MECHANICAL RLE
SOUR - :G I'10N. 2�13� AIR HANDLING UNIT(OVER W."CFM)
7 N CONSTRUCTION TAX
Stgnat til Applla. UCon(ucmr Umc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
ZAkDOUS MATERIALS DISCLOSURE
W Itheapplic t or future building acuprostom or handle haterdous material HEATING UNIT(T0100.000 B'TU)
lir of tied by the C rtina Municipal Code,Chapter 9.12,and the Health and Safety
C Sc io .,21e)^. �/ HEATING UNIT(OVER IN),M)BTU)
Yes NNo VENTILATION FAN(SINGLE RESID) PAID
Will the a Iicant or from bui lin t lire a ul t I) Devices whs.h to Receipt#
pp gbytheB q Air
fl011.ER-COMP(3HI'OR IBO,IXNI BTU)
emit hmanNoar air corm inam.r� Jcfi by the flay Area Air Quality Management TOTAL:
Distrinl / BOILER-COMP(OVER I00,0sKBTU)
❑Yes No
Ihsee the randoms chat, AI R CONDI'1'IONER ISSUANCED
reyuirurcnu under Chapter 6.95 of dse Gli-
tomin Heat h Saf otle,Sc ons 25505,25533 am125534.I unJcrsutxl that if the NEW RESIDENTIAL MECH. SQ.ET.
hoilJing ds otter .moons shot it i,my resrymsihility ununify the acupam
of the ley whi t be stmt priono isxmncc of a Cmifcum of tXcupancy
44 a 3
Ow error t ort t Date TOTAL ISSUED BY:
i OFFICE -- - — -