30145 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .BUILDING•ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING'PROJECT IDENTIFICATION - 30145'
UILDING ADDRESS: - SANITARY NO. APPLICATION SUHMITTAL DATE
98S C&A V iSe ALAI.Y Aba . G a ASx71a d -� 6
E?S NAME: PHONE: CONTRACTORO:
S NAME: LIC N
�C OLAvI CAM'i?IYf,I YOY 9i383P3 NIC CONTROL#
RCHITECT/ENGINEER: LIC NO ADDRESS: ❑
CONTACT PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT UMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE1 hereby off,,.that 1 ata licensed under provisions of chapter 9(commencing JOB DESCRIPTION
0Z with Section 9U00)of Division 3ofthe Businessand Professions Ctde,and my license 11 00 s RESIDENTIAL:
- PERMITISSUANCE
W in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�Uy License Chas Lica
Data Conuacmr APPLIANCES-RMIDENfIAL ❑ADDITION 0PLUMBING RE-PIPE
A.In Q
t/1 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOnz I understand my plans shall theater]us
puhlit records PANELSMODIFICATION
'0Z _ _ UP TO 200 AMPSEl INTERIOR El CHIMNEY REPAIR
I•�2 Licensed Pmlessionel 201&!"AMPS IMPROVEMENT
Y
OWNER BUILDER DECLARATION OVER IIM)OAMPS O BATH REMODEDREPAIR El DEMOLITION
K 1 hereby.(rirm that 1 am exempt from the Contractor's Co License Lew for the
OyU following reason.(Sennet]031.5,Business and Professions Code:Any<iry or countySIGNS ELECTRICAL ❑OTHER
s� O of which repaints a permit to constrvn,elte,noisiest,demolish nr repair any structure
EilyW prionoits issuance,also reyuirer the bpPliwntfo,mbpermittofil...ignedstatement SPECIAL CIRCUITRUSC.
5� that he is licensed pursural to the provisions of the Contractor's license Law(Chapter 9
a�p0 (commencing with Section 7")ofDivision 3 ofthe Business and Professions Coast or TEMP.METER OR IDLE INST. COMMERCIAL:
a that he is exempt therefrom unit the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 711 LS by any applicant fora permit,subjeen,the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
} not more than rive hundred dollars(E5W). IMPROVEMENT
E]1,as owner of me property,or any employees with wages as their sole compensation, SWIMM I NO POOL ELECTR
will do me work,and are mucture is not intended or offered for sale(Sec.91100,Business ,B OTHER
III �_ and Professions Code:The Convenors License Law does not apply to an owner of OUTLETS-SWITCHES-FI U
It.3 properly who builds or improves thereon,and who does such work himsdf or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR Fri.
sale.It,however,the building or improvement in sold within one year ofcompletion.the SQ.FFLOOR AREA $/SQ.FT.
owner-builder will have the hunlen of proving that he did not build or improve for par
E ose of sale J. B
❑1,us owner of me prpeny,am ealmiedy contracting with licensed contractors to TOT
49)
amend ct the project(See RH<,Hamm.anti Professions Coac.,The ContnnarI Lm- 03
renis law doe nm npPb man owner of pmpeny who builds orimpmvestMremn,and QTY. PLUMBINGPERMIT n 1
who contracts for such project,with a commissions)Lot pursuant me Contractors / 96j
License Law. PERMIT ISSUANCE '/�vhL ' "v
❑tum examScc. .B&P C far mis reason u(-
ALTER-DRAIN&VENT-WATER(EA) 'VALUATION
Owner Date
ORKER'S COMPEN N DECLARATION BACK FLOW PROTECT.DEVICE ,
1 hereby adman under Penalty of perjury one of me following declarations:
❑ I have unit will maintain aCenificam ofComent to self-insure for Workers Compem DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work far which this Permit is issued. FIXTURES-PER TRAP '
El I have and will maintain Worker's Compensation Imax amen,.reyuired by Section f
3/00 of the Labor Code,for the performance of the wok for which this permit is board. GAS-CA,SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WoRers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASIIINDUSTRL WASTP,INTERCCPTOR
COMPENSATION INSURANCE, BUILDING DIVISION PEES
(This onion need notbecnmpleted if the permit is for one hundred Jnllars(Slap GREASETRAP '
or less.) PLANCHECK FEE
I certify that in me performance unite work for which this permit is issued.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pecan in any manner an as to become subject to the Workeri Compem- ENERGY FEE
O z section Laws of California.[late ` WATER HEATER WNENI'/ELECTR
y O Applicant 'GRADING FEE.
q NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/TRCATING
become subject m me Workers Compensation pmnsiono of me Labor Code,you must _ SOILS FEE -
foMwim comply with such provision or this panni,shall be deemed revoked. WATER SERVICE
0. O .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O Date Receipt p
I farehy offirm that is n coni(See.
30 lending agency fnnhe performance of
the work far which this permit In issued(Sec.3119],Civ.CJ'
O ULenders ANamedd. ' TOTAL:
U Genitals Add..
�+ lLl BUILDING FEE
(r ly 1 ccnee that I have read thisty and court end stmt mat the move information g is
III canen.lagrtetoco, ad with all city end county ordinances and sate lawsr prone QTY MECHANICAL PERMIT FEE
L) � building construction,and hcrchy uumorize rcpresenm,iveo of this city mercer upon me SEISMIC EEE
above-mentioned'oapsm y for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify end keep harmless me City of Cupertino against ELECTRIC FEE .
liabilities,judgments,cosy and expenses which may in any way accmeugainst said City ALTER OR ADD TO MECH,
'n commis Ince ofthe gr
e anting of this per it. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DO 10,1100 CFM)
MECHANICAL FEE
SOURCE REGULATIONS. _ ,
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
I Signature of ApplicanVCon,nctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant en future building necupan,store orhandle hximpLas material HGTING UNIT(TO 100.0DO BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU)
❑yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID
Will,he applicant or future building t use tri t or devices which Date Receipt a
pp gbytheD eq Amen BOILER-COMPOHPOR 100.000BTU)
emit hmnNom air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District'
❑Yes . ❑No �, BOILER-COMP(OVER 100.000BTU) ,
Ihave read me haomkras materials requirements under Chapter 6.95 of the Cali AIRCONDITIONER ISSUANCE DATE
fund,Heald,&Safety Cods,Sections 25505,25533 and 25534.1 understand mat if me NEW RESIDENTIAL MECH. SQ.PT.
buildingdom not currently have a hand,mm it is my resymsibility to notify the occupant
of the requirements which must be mer prim to issuance oft,Certificate of 0scapancy.
Owner orouhmimd agent Date TOTAL: ISSUED BY: "V • J
OFFICE