30983 APPLICANTTO FILL.IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
Ff�R$N ME:- PHONE: CONTRACTOR'S NAME: LIC NO:
(�/S1H fl�'l NIC CONTNOLa
R�BITEC'T/�yG 1�E�R: LIC NO. ADDRESS: ❑
I�IL�rtl-1� t1 h 21
CONTACT. PHONE: BUILDING PERMIT INFEY
Consultant Fees Paid by Applicant(Initial) BLSE PLUMBLA FC4
LICENSED CONTRACTOR'S DECLARATION 1 QTY ELECTRIC PERMIT FEE IJ` tL3l!_•
1 hereby affvm that 1 an ed lincl runder provisions of Chapter 9(commencing JOB DESCRIPTION
f^0OoZ withSection]II00)of Division3of the Business and Profeasirira Cale,unJ my license is RESIDENTIAL:
0 PERMIT ISSUANCE
caW E in full force and effect.
a U UU License Cl. _ Lic.a ❑ WL ❑KITCHEN REMODEL
�Gy Da Contractor APPLIANCES-RESIDENTIAL *ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION MULTIUNIT ❑STRUCTURAL
Z p to Z I understand my plans shall W used as public records PANELS MODIFICATION
O Z J UP TO 2W AMPS
M [I INTERIOR ❑CHIMNEYREPAIR
�,�(_,' Licensed Prnfeaxional ]01-1""PS IMPROVEMENT
OWNER-BUILDER DECLARATION
y WW 1 hereby affirm that 1 am exempt from Ne Contractors License law for Ne OVER IWOAMPS ❑BATH REMODEIJRF.PAIR ❑DEMOLITION
fallowing reason.(Section 7031.5,Business and Pro ❑OTHER
Professions Code:Any city or county SIGNS ELECTRICAL - -
I- which requires u permit to con omet,alma,improve,demolish,or repair any structure
g.�0a1
prior o its issuance,also requires the applicant for such permit to file a signed amtement SPEC]AL Cl RCUIT/MISC.
Ythat he is lleemed no..,1.the provisions of the Conuucmrx License Law(Chapter 9
(commencing with Section 0000)of Envision 3 little Enamels and Professions Code)ar TEMP.METER OR POLE INST. 'COMMERCIAL: -
a.q m pC that he ix exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
4,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
^m ❑TENANT FOOD SERVICE
Cnot mare than Five hundred dollars(S500). IMPROVEMENT
F q ❑ I,os nwnerrif the properly,or my employees with wages as their sole compression. SWIMMING POOL ELECTRIC
will do the walk,and the xuucture is not intended mattered hostile(Sec.7044.Business ❑OTHER
sf02!�5� and Pmfesaions Code:The Contractors License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thaeor,and who dos such work himself or through
his own employees,provided Nat such improvements Are our intended or of feral for NEW RESIDENTIAL ELECIR SQ IT.
side.If,however.the building or improvement issold within one year ofcompla ion,the SQ.FT RFLt- ARISA, S/SQ.FT.
owner-
builderwill have the burden of proving that he did not build or improve for par- �� JD
Pace of sowner
w - - `J
❑1.pm ow r of the Property,ten exclusively Eradication,
with licensed contractors i- 1(�
constret the project(Sec.]Bfy Business and Professions CMeO The Contmmnrs Li- �[p u '
c mLawdoesnotupp]ymanownerofpmpcdywhoElildsorimprovmthrmimend QTY. P BINGPERMIT FEE JUL {moi
who contracts for such projects with a cxmtracmrls)licensed pursuant to the Common's
License Law. PERMIT ISS1 AN
❑l am exempt order See. .B At P C for this reason cny r vurr-K W
Owner Date ALTER-DRAIN&VE M(EA) VALUATION
WORKER'S C .atty of ATIUE CLARATION BACK FLOW PROMD IC 0t
' I hereby effum under Penalty of perjury.one of the following dedamtinm�.
,]l have and will maintain a Cent of Comcruo sell'-insure for Workera Compen- DRAINS-FLOOR,R P ,C ND. STORI TYPECONSTRUCTION
.bon,m provided for by Section 37W of the labor Code,for the performance of the
work f it which this peorn is ksmal. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,m required by Section 11 -
3]W of the Lubar Codq finale performance of the work for which this permit ix issued. GAS-EA.SYSTEM-1 INCAOUTLE-L Ir OCC.GROUP APN
My War Compensation Insurance carrier and Policy numbs art:
Carrier: Policy No.: OAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTWN FROM WORKERS'
COMPENSATION INSURANCE I GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not becompleted ifthe permit is marine hundred dollari(SIW) NUILDINGD ION FEES
or less) GREASETRAP PLANCHECK FEE I
I certify that in the peifortnarce.f Ne work far which this permit is issued,I shallSEWER-SANITARY-STORM EA21111 FT.
rat employ any person it any manner so as to bccone subject m the Workeri Com .pen- ENERGY PER
O z xatian laws of CWifomie.Date WATER HEATER WNENpELp
Z Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
F become subject to the Workers Compensation provisions of the Labor Cod
Code,you must SOILS PER
forthwith comply with such provisions or this Permit shall be darned revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,PC PAID
U Q I hereby option that them is a construction lending agency for the performance of Date Receipts
!-m the work far which Nis permit is issued(Sat.3t�],Civ.C.) -
aV Lenders Name TOTAL:
Lenders Address
0. I<mify Not 1 have read this application and stem that the uMrvc information is BUILDING FEE �
t�-s V1 correct.l agree to comply with all city and county ordinances and stare laws relating m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
VZ building combination.and hereby authorise representatives of this city pa enter upon the
/ t^ tiii—
alone-mentioned pm,mo,far inspaction purposm'
(We)agree to save,indemnify and kap harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
linbi]itieajudgmcnts,costs and expenses which may in any wayaccrueagaimtsaid City ALTERORADDTOMECU
in corscclopme of the granting of this permit.in FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MEC]fANICAL FF.E
AIR HANDLING UNIT(OVF,R.10,000 CFM) CONSTRUCTION TAX
Signature of ApplicarUComarlor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS bExrHRIALS DISCLOSURE
Will the applicant or future building oceupmtsmal nr handle hamrdom nmmrial HEATING UNIT(TO I W, 0BTU)
as;defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)] s HEA9'ING UNIT(OVER 100.0Ig)BTU)
❑Yen ON. VENTILATION FAN(SINGLE RESID) PAID
Data Receipt a
Will the applicant or future building occupant use equipment or devices which
Ili t hnaatdin,air contaminants m defined by the Bay Amo Air Quality Management BOILER-COMP CHIP OR 100,000 BTU) -
)tstna] BOILER-COVE(OVER 100,000 BTU)
❑Yes ON.
I bave read the hazadrim materials requirements order Chapter 6.95 of the Call- AIR CONDITIONER
ISSUANCE DATE
poria Health&Safety Cade,Sections 25505,25533 and 25534.1 undcrsmed that if Nc NEW RESIDENTIAL MECIL SQ.ET.
Wilding opera not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occuparcy.
Owner or authonred agent Data % ISSUED BY:
OFFICE