30720APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE
-- CITY.O.',,CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
ME
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LICENSED CONT'RACTOR'S DECLARATION
hereby urfirn, that I am licensed under prnvisloas of chapter
Q00 with Section 7000)of Division 3 olio Business en 'mics is nnCNe
a F In full force and ell W�
Q U U Lice.1�(�Q�('}'�j}{
NQ cw Del[ Comore'
ARCHITECTS DECLARATION
O 'Dion 1 understoodmy plans shall be exist az public records
F� O Licrrwd Professional
0
POINT'ENEN'' LY
BUD DING -I •CTRICAL -
PLUMBING -.S •CHANICAL
❑ Consultant Fees Paid by Applicant (Initial)
IT'Y. - ELECTRIC PERMIT
l• PERMITISSUANCI?
APPLIANCES - RESIDENTIAL
UP TO 200 AMPS
�a GGCC
OWNINBUILDER DFCIARA['ION
..
OVER IIHMIAMI'S '
a
I hereby ff i (fit I ane exempt from the Contractors 1'_ e Law for Elm
fallowing newn. (Section 7031 5 Business ad Pnolvoi,ma Code Any c ly fu
c my
--
SIGNS ELRICAI.
LCT
LLU
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which req' aPermit c I I alter. p 1 IsM1 p ys cure
- ❑STRUCTURAL '
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���77777
prior to its' uance, also onimes the applicant for mch permit to file a signed statement
SPCCIALCIRCUHUMISC
�y,Y
that he is licensed purmanno the provisions of the Contractors License Law (Chopirr9
'.
W OO
(commencing with Section 7")of Division 3 clam Business and Professions Code)or
TEMP. METFR OR POLE INST.,
M d e Y
that he is exempt therefrom and the basis bertha alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects theapplicanno a civil penally of.
POWER DEVICES
�2y
H G Q
not more than five hundred dollars (E50T).
1 hereby SRrm under penalty of pe jury one of the following ciedarntion
Ti
FEE
s—
O ❑ I, as ownermt the property, or my employees with wages nx,our sole compans.,I i SWIMMING ['()Of, ELECTRIC ,.
wind the k IthI t' t d d ❑ Ir Ic (Sec 7(9a B s s'
� • � and Proffe, ions Code IlmContractors Lice..c 1 does not pplyt _ t r of OUTLETS-SWI'I'CliEb ,IXTURES `�..
nonfatal e 1 o builds or imps es thsremn, and on
he ds such work h mself or through
imoffered""
- -
his own employees, provided that such improvements am not ended or offered far NEW RESIDENTIAL FLF,CTR SQ Fp. ,
HAZARDOUS MATERIALS DISCLOSURE' '
Will the applicant or furore building mainland sum or handle harerdmis material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532m)? y
❑Yes. [I No
Will the applicant or future building occupant use ululpmmat or de tees which
t hanrdcus air commitments rots a: dcfi tied by the Hay Arca Air Quality Management
1D. I '
❑Yes ❑No
1 have read 0e on,
memriale mr,immetns under Chapter h95 of the Cali-
_-
..is Health'& Softly Cede, Sections 25505, 25533 and 255311 undernmnd ohm if the
building Jas nal currently have a met prior
is my re id'a Certificate
foo notify the macupam
vfehartovirement which mol M mel prior m issuance of v Cenifca¢ of Occupvlcy.
EXHAUST HOOD (W/DUCT). -
HEATING UNIT (TO 100.00 BTU)
HEATING UNIT (OVER 10,000 BTU) -
VENTILATION FAN (SINGLE RESID)
BOILER- COMP QHP OR IMAX) BTU) '
BOILER'-COMP(OVER 100MOBTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. EL
"" 30720
fV /N
sale. If, however, the building or improvement is sold within one year of completion, the
• SOBDESCRIPTION, '
RESIDENTIAL, -
owner -builder, will have the music. of proving that he did not build or improve for par -
❑ KITCHEN REMODEL
Arse of
El PLUMBING RE-PIPB
I, aw owner of the progeny, um exclusively contracting with licensed committers to r
- ❑STRUCTURAL '
construct the pmjem (Sea 7094, [business and Professions CNet) The --a- s Li.
MODIFICATION
abase Ww dnex nm apply to nn owner of propercy who tui Wx nr unproven lhemnn,and QTY PLUMBING PERMIT
C3 CHIMNEY REPAIR
who contracts Ramon maircl,with.commemgs) rctnowdparvo immtne Commeturs "
'.
License law. 1.PERMITISSUANCI[
-
❑ I .m exempt under Sec. , B & P C for this reams
'
ALTER - DRAIN&VENT-WATE E
Owner ' Date
WORKERS COMPENSATION DECLARATION. BACK FLOW PROTECT. DEVICE
�hnve
1 hereby SRrm under penalty of pe jury one of the following ciedarntion
antl will nuin.ninvCenificme of Conserv mxdf-inmmfur Worker's Compen- _ DRAINS- FLOOR, R(IOP. AREA. COND.
. ion, as provided fon by Section 37M of the Labor Corfu, Iia the padmaaace m the
work for which this permit is issued, - FIXTURES - Hall RAP
s
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section,
3700of the Labor Code. ft>.r the performance of the work I which this permit is i ... u.i. r1, GAS' EA.SYS'I'I!M-I INC40UTLETS"
MyW sCsfttmy�roll urance canicr nnJ and .If y
PPolicyPNo whmt,;-mIS GAS-EA.SYSTEM-OVER4(EA),
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUS'FRI. WASTE INTERCEPTOR
(This section need hat be completed ifdte .it is tomo, hundred delta.(SH10)
GREASE TRAP
o'niwa) '
-
Icomify that in the performance ofthe work for which this permit is issued,Ishan
SEWER - SANITARY - STORM EA.2IM Up
not employ any person in any manner so as to become subject to the Workers'Pear - -
• O,z
O
action Laws of California. Ilam WATER I IEA'I' ER W/VENTTLECTR
Applicant A i s
z
r. M
NOTICE TO APPLICANT. 11; after making this Cenilicule of Exemption, you should WATER SYS '1'IiM/fRIiATING
.'�7
become subject to the Workeis Compensation provisions of the labor Cede, you must
forthwith comply with such this he deemed
Q
provisions or permit shall revoked, WATER SERVICE
7z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL-PLMIL SQ. FT.
U O
l hereby affirm that them is a concoction lending agency for the performance of
• iL F
'he work for which this permit is issued(See 3097, Civ. C) „
Lenders Namee•
Q U
Londe Add :IDIAL.
_ _
FdI
certify that z hIlhi, application nd,rmll itbc.bnve informationis',
v]
correct. I vgree m comply w m all sit, and amanyorolmorce,and site laws relm'ng,, QTY MECHANICALPERMIT
U
building concoction, and hereby mdam,wmpresemmivnofthin city mercer upon the'
above-mentioned properly for inspection purposes. •' PERMIT ISSUANCE
(We) agrre to save, indemnify and keep harmless the City of Cupertino against'
liabilities, judgments, costs and expenses which may in any way sccrve against mid City ALTER OR ADD TO MECH.
in consequence of the granting of this permit.
.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING ON IT('10 10,000 CFM)
S F,R['G;LIETIONft� as.,H. /,,:/4 A[R HAN DLI NO UNFF(OVER 10,000 CFNH
HAZARDOUS MATERIALS DISCLOSURE' '
Will the applicant or furore building mainland sum or handle harerdmis material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532m)? y
❑Yes. [I No
Will the applicant or future building occupant use ululpmmat or de tees which
t hanrdcus air commitments rots a: dcfi tied by the Hay Arca Air Quality Management
1D. I '
❑Yes ❑No
1 have read 0e on,
memriale mr,immetns under Chapter h95 of the Cali-
_-
..is Health'& Softly Cede, Sections 25505, 25533 and 255311 undernmnd ohm if the
building Jas nal currently have a met prior
is my re id'a Certificate
foo notify the macupam
vfehartovirement which mol M mel prior m issuance of v Cenifca¢ of Occupvlcy.
EXHAUST HOOD (W/DUCT). -
HEATING UNIT (TO 100.00 BTU)
HEATING UNIT (OVER 10,000 BTU) -
VENTILATION FAN (SINGLE RESID)
BOILER- COMP QHP OR IMAX) BTU) '
BOILER'-COMP(OVER 100MOBTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. EL
"" 30720
fV /N
❑-"
• SOBDESCRIPTION, '
RESIDENTIAL, -
❑SFDWL -
❑ KITCHEN REMODEL
[]ADDITION
El PLUMBING RE-PIPB
OMULD-UNIT
- ❑STRUCTURAL '
MODIFICATION
❑INTERIOR
C3 CHIMNEY REPAIR
- IMPROVEMENT
'.
❑ BATA REMODEUREPAIR ❑ DEMOLITION
❑ OTHER '
COMMERCIAL:
❑NI?W BLDG/ADDITION ❑DEMOLITION
M
ty�-agtNANT ❑ FOOD SERVICE
PROVEMENT
❑ OTHER
FEE / �{I •�l. B 1996Uh��Ur�n°�(ryCi
FEE
T
VALUATION
STORIES TYPFC(
OCC. GROUP
BUILDING DIVISION FEES
PLANCHECK FEE It
ENERGY FEE r
GRADING FEE
SOILS FEE
CONS 'I'RUM ION TAX
HOUSING MITIGATION FEE
PAID
Data ReceiplN
IOTAL:
ISSUANCE' DATE
r'•ume I • l ....`V—r/
tt1`V rl I IssuED BY: V x
OFFICE ,
PAID
Date
RecciplX
• ..
TOTAL:
BUILDING FEF.
SEISMIC PEG
ELECTRIC EEE
PLUMBING FEE
MECHANICAL FEE
to I/^
CONS 'I'RUM ION TAX
HOUSING MITIGATION FEE
PAID
Data ReceiplN
IOTAL:
ISSUANCE' DATE
r'•ume I • l ....`V—r/
tt1`V rl I IssuED BY: V x
OFFICE ,