30602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY k/•��
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30602 O V O Z
BUILDINGDIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J
BUILDINGADDRESS: BUILDING PROJECT IDENTIFICATION SANITARYNO. APPLICATION SUBMITTAL DATE
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NER'S AME: P NE: CO ,CfOR'S N MC: LIC NO:
NIC CONTROLp
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RC ITECTMNGINEE : V LIC NO: •If ADDRESS. ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P UM MECH
❑ 9 ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm mat I am licensor under provisions of Chapter 9(commencing JOB DESCRIPTION
�0CaZ with Section 7000)ef Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL,
0 in wr PERMIT ISSUANCE
fullforceClassdeRect ❑SFDWL ❑ CHEN REMODEL
-ZW Data Class 'Link APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
NZL Data Contractor
Z I-Oa my pnaARCHITECTS DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
1 underhand lashall basked a ..,its ords MODIFICATION
0Z--'0 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4l:j Licensed Professional 2(11-10WAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
6 I hereby affirm that I em exempt from the Contractors License Law for the
3 4 O following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0. which requires a permit to construct,after,improve,demolish,or repair uny strvcrre
prior to its issuance,also requires the applicant for such pernin to file a signed statement SPECIAL CIRCUIT/MISC.
'y mm he is license p...an(1.the provisions of Comracmr's License Law(Chaptef9
CSO (commencing with Section 7100)of Division 3 of the Busmidilmd Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
Not he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Secciun7031.5 hyanyapplicantfera pcmriuubjacti theapplwarat co..ivil penalty of POWER DEVICES
w 12 TEIIANI ❑FOOD SERVICE
Onot more man Eve hundred dollars lSSW). LVIROV NT
❑La the work, ddpe,usic,ormyemptendedwfthwagesmale(Saccompemmien, SWIMMING POOLELECTRIC ❑O R
will do the work,vnJ Ne structuress notintended Law
saletilly 7144,Business
W and Professions Cale:
The Concourses License Law docs not applys if owner of OUTLETS-SWITCHES-FIXTURES
m
�'3.r property who builds ter improves eremce
n,and who does such work himself or through
his own oweverces,provided that such improvements sere not intended or offered for NEW RFSIDEMIAL ELECfR SQ Ff.
sale,
wner-hnwevecmebuilthe burin of proving
is he did ntbuild rrfcemplecfomthe SQ.FT,FLOOR AREA ASQ.FT.
owner-builder will have the burden of proving nhvc he did not M1uiIJ or improve for per- i r
P f own)e S
of me pmpery am exclusively contracting with licensed commissions to TOTAL: A
onstruct the project(Sec.70,1 Business and Professions Calc:)The Commenes Li P n�
cents Law dons not apply r an owner of pmpevy who builds or improves thereon.and QTY, PLUMBING PERMIT FEE /� rar ,a
who contracts for such projeces with a recommittal licensed pursuant to the Contemnr's /%'LicenseI,
LicenLaw. PERMIT ISSUANCE - L vJ
❑1 am exempt under See ,B&P C for this reason Iti L
Own Data all, 0 ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKS tGpPPEp A' ATION BACK FLOW PROTECT.DEVICE
I holiday rm and r penury of perjury one of the following declarations:
•❑ l have and will maintain a Certificate ot'Coment to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF AREA,GOND, STORIES 11 TYPECONSTRUCIION
seder,ex provided for by Section 37M of me Labor Cede,for he performance of he
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
1100 of the Labor Cale,for the Performance of the work for which this pernd is issuor. GAS-FA.SYSTEM-,
INC.4 OUTLETS OCC.GROUP APN
My Wodcex Compensation Imumntt care,and Policy numherme. '
Cama: - Pullcy No, GAS-TA.SYSTEMOVER 4(G)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASVINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FRES
This sectierneor not be completed if Nc permit is totem hundraldollars(SIW) GREASETRAP
or less.) PLANCHECK FEE
I certify them in the psurlbnnance.fihe werk farwhich,his permit is issued,Ixhall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to become subject o the Workers'Compete ENERGY FEE
z ,Z section Laws of C.lifomia.Date WATER HEATER WNENT/ELECTR
Q Applicant GRADING FEE
r rN.o NOTICE TO APPLICANT:If,aOa making this Cendhate of Exemption,you shcad WATER SYSTHMITREATING
heceo msubject m chc Worker's Compensation provisions of the Labor Cale,you most SOILS FEB
WfoMwith comply with such provisionsar this permit shvl l be deemed revoked. ` WATER SERVICE
0
CONSTRUCTION LENDINdingAGENCY
e.y NEW RFSIDCMI'IAL PhMB. SQ.FT PAID
L) kforw which
that there iso issued
leading ng agency far performance of Data Raeiptk
the work for which Nis permit is issued(Sec.JW],Civ.CJ
0 (~ Lender's Name - TOTAL:
991.3 Lenders Addfesx
91. I certify the I have read this application and nam that the shove information is BUILDING FEE
W correct.l agree to comply with all city and county ordinances and state taws relating to QTY. MECHANICAL PERMIT FEE -
UZ building commuction,and hereby authorize representatives of this city to enter upon the SEISMIC 17EE
above mentioned property for impemion purposes, PERM IT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said CityALTER ORADD TO MECH.
in consequence of me imaging M this permit. PLUMBING FEE
VL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
r
Signature dApplictingCo musbDam EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNI'T(To 100,001],BTU)
as dclinal by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Sultry
Code,Section 23532(a)? I HEATING UNIT(OVER 100,004)BTU)
❑Yes ❑No VENTILATION FAN(S INGLE RESID) PAID
Will the applicant or future building t use equipment or devices which Dam Receipt k
pp gby the
quip BOILER-COMP(3HPOR 100.001ITID
emit hazardous sir contaminants as Jefned by the Bey Arca Air Quality Management TOTAL:
District?
Oyes ON. BOILER-COMP(OVER I00,0008TU)
- ,
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Solely Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nuc curemdy have.cement,thin it is my responsibility to notify the occupant
of me requirements which must be met prior to issuance oft Certificate of Occupancy. IV
Owner or auNonzed agent Date TOTAL: ISSUED BY:
TVAPV-
OFFICE