30660 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O 6 6 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL x4J \hth
BUILDING PROJECT IDENTIFICATION
UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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PHONE:^' CONTRCTOR'SN ME:O 1 LIi NO:i �CkAl
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CONTACT:- PHONE: BUILDING PERMIT INFO
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El Consultant Fees Paid by Applicant(Initial) BLD ELO •PLU❑MB MECH
�/�(� LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE s
1 hereby tiff rm that 1 nm licensed under pmvisions of Chapter 9(commencing - JOB DESCRIPTION
"Z with Section? )of Di xmn3ofthe Bos essr fessiousC � mylicenaeis RESIDENTIAL:
+1a700 �P od{4n PERMIT ISSUANCE '
6 U r m full force an en.. Lt(•��i( 3 ❑SFDWL El KITCHEN REMODEL_
vFi< etese
Contract., APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBINGRE-PIPE
F 5 'A CHITECTS DECLARATION PANELS 0 MULTI-UNIT 0 STRUCTURAL
Z O _ I understand my plans shall he used as public records MODIFICATION
OZ p - UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
4 W Licensed Professional 201-IOWAMPS IMPROVEMENT
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SJ OWNER-BUILDER DECLARATION OVER["AMPS ❑ H REMODEL(REPAIR [I DEMOLITION
t3 y that 1 tan exempt from the Contractor's License Law for the
0 eds U following reI herebaffirm tie so.(Section 7031.5,Business and m
Professions Code:Any city or umy SIGNS ELECTRICAL OTHER
P
a
LLL which requins a permit to construct,alter,improve,demolish,or repair any structure
0 prior to its issuance,also acquires the applicant ror such permit no file.signed statement SPECIAL CIRCUITIMISC.
�yy } Nat he is licensed Panama,to the provisions of the Connector's License Law(Chapter 9
Q (commencing with Sanion]000)of Division Sof the Business end Professions Cnde)or TEMP.METER OR POLE INST. 'COMMERCIAL:
d ra 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION O DEMOLITION
fl
mSeoian]031.5 by any 4pplicant for a permitsubjects the ul,thes al to a civil penalty of POWER DEVICES OTENANT 0 FOOD SERVICE
tmore thanfive hundreddollars(5500). - IMPROVEMENT 01,asowner of the property,or my employees with wageses theirsole compensation, SWIMMING POOL ELECTRICwill do the work.and thestructre is not intended oroffered for sale(See 7044,Business ❑OTHER
and Professions Cade:The Contractor's Liaame Law does not apply to na owner of OUTLETS-SWITCHES-F T S PA
aD
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property who butldi or improves thereon,and who does such work himself or through - -
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELE SQ F-C
sale.If,however,the building or improvement is said within one year ofcompletim-1- Q., SQ.Er.E� CIC $ISQ.FT.
owner-builder will have the burden of proving that he did not build or Improve for par. I[[ is o�
pose of sale.). - - L: �ay� V
0 I,as owner of the propmy,am exclusively contracting with licensed contractors to y,� 'C'Ty l
construct the project(Sea ]04M1,Business send Professions Code:)The Contractor's Li- INT f Ut' WPEH I INO
me Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projats with a conmacmrad licensed pursuant to the Contractors >
- -
License Law. PER ISSUANCE
0 I um exempt under See. ,B&P C fordds reason
ALTER-DRAIN V AMR(EA) VALUATION
wrorDote ^ �-•�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECL DEVI E jnG)/R /y`)J^vq�-•��
I hereby a�nn tarnunder penalty teperjury one of the fallowing declarations:
Hoover
as and will for byneCion 370 ofConseran inLabor
Code.salf-inscredue Workers Campers- DRAINS-FLOOR,BOOP,AREA,CO STORIES TYPE CONSTRUCTION
satioq on provided for by Section 7]00 of the Labor Code,for the Performance of the'
work for which this permit is issued. FIXTURES-PERTRAP
I have and will mnintein Workers Compensation Insurance,as required by Section
3700 of the Labor Cale,for the performance of the work for which this permit is issued. GAS-[A.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
an Work y��t,y�arance came l e ,jTgzz-1 �^ GAS-EA.SYSTEM-OVER 4(EA)
---1..e��yyy��---...BBB$,.,.,rr�tt�MPTION FROM WORKERS'..
•- rs COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
BUILUI DTVI FEES
(This section need nmbe completed time permit is for one hundred dollars l$1007 GRBASE TRAP - •
or less.) PLANCHECK FEE
Iearn fy,that in the performance of the work for which this permit is issued,)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to brume subject to the WorkersCompro- TPLUMBING
EE
z ,7„ sation Laws of Cnlifomis.Dam WATER HEATER WNENTMLECTR
O Applicant FE
—, V) NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should WATER SYSTEMaREATING
,FO 'r' betaine subject to the Workers Compensation provisions of the Labor Cade,yon must
forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE s
Q CONSTRUCTION LENDING AGENCY ,' NEW RESIDENTIAL PLMB. SQ.ET.
.W I hereby affirm that is a construction lending agency for the performance of _ Receipt#
k the work for which this permit is issued(Sec.RAA.Cls.C.)
Lenders Name
Q V Lender,Address TOTAL:.
1 emify that I have read this application and xmm that the above information is FEB
o-y cn coned l agree to comply with all city and county ordinances and state laws reading m QTY, MECHANICAL PERMIT FEEE
V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
--'r (We)agree to save,indemn' d keep harmless the City of Cupmimr against FEE
liahilities,judgmente.ms ands c wfich may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of[hag Ing thlas .nit.
APPLI N UNDE AN SAN WILL COMPLY WITH ALLN -POINT AIR HANDLING UNIT(TO 10.00)CFM)
SOUR i 'GU Tl - MECt{pNICAL E
AIR HANDLINGUNIT(OVER 10.0bi CONSTRUCTION TAX
'gnature of pplicantlCon Date EXHAUST HOOD(WIDUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store ar handle hazardous material HEATING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Saito.25532(n)P HEATING UNIT(OVER 100,000 BTU)
M
Oyes - ON. s VENTILATION FAN(SINGLE RESID) PAID
Date 'Receipt#
Wslims ll slar,mant orfuturebuilding accupnnt use Bay Area
Air Qualitment or y
anargees hich BOILER-COMP QHP OR 100.001 BTU)'
thazallous air conmminamts az defined by the Bey Area Air Quality Management ,
ev ct7
DYes, No BOILER-COMP(OVER 100,000 BTU)
throats,ad the hicardmis materials iegvirements under Chapter 61.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Boom Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that it is my responsibility to notify the occupant "
of the requirements which most be met prior,to issuance of.Certlfrnte of Occumpay.
Owner er authmimd agent Date it TOTAL: ISSUEDBY:
�`zt OFFICE