30542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC71RICAL 1117RMITNO. Or
BUILDING DIVISION APPLICATION/PERNI1T PLUMBING-MECHANICAI, V1 L
BUILDING PROJECT IDENTIF'IC'ATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
0 8S- W. RoL rE pct Cu µ-ms Ido t Q rvoI A- C+6
OWNER'S NAME: PHONE: CONTRACTOR'SNAME: LIC NO:
1 1 Otgjy J'P irOC '/
NIC CONTROL#
'WARCHITECfl1 MNEER: 1'1 COIL L�o�J� ADDRESS: (.,-� h/ ^J V ❑ "') �'I �1
x ,,`ELI` �IAr PHONE: BUILDING PERM`IITT INFO
!/f' V Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(81$ DJ8 ❑ ❑ EDLICENSED CONI'RACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions
won of Chapter 9(commencing JOB DESCRIPTION
n wma See ..700dof Division3 afthe Businessund Professions Galc,and my license is
in full mostrand effeet. MIT
U O p PERISSUANCE RESIDENTIAL:
�IyF ❑SFVWL F1 KITCHEN REMODEL
6F.
U
License Class Lic.M V APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NGL Dale ContractorARCHITECT'S DECLARATION ❑MULTI-UNIT ]STRUCTURAL
N
MH PANELSZ p Z 1 unJeatand by plans shall be used as public rcnrNs MODIFICATION
oz— UPTO 211(1AMPS
[I INTERIOR El CHIMNEY REPAIR
I=�f"Iu Licensed Professional 7pyrfgxrsyNpL� IMPROVEMENT
OWNER-BUILDER DECLARATION
tY C Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER IINIUAMPS [:1 BATH REMODEUREPAIR DEMOLITION
�a(pLU following reonon.(Section 11131.5,BiancessemJ Profession,Code:Any city.,county SIGNS ELECTRICAL ❑OTHER
W 3 W y¢ which require%a permit I.Construct,alter,italons,demolish,oat repair any,Imcturc
F-LLpJ poor,.asi....am.slsoreyuim,theapplicam va,.,h permit ro file asigradiumemcnt SPECIAL CIRCUITIMISC.
f Y that be is licensed porsi anus the provisions of the Commences License Law(Chapter 9
ad Goo (commencing with Section 7001 Division 3 of the Business and Professions Code)or TEMP.MEfERORPOLE IN COMMERCIAL'
a E ca 4'tY that he is ex<mp thcmfmm unJ the basis for Ih<alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
_ Section 9031.5 byanyapplicant Earn permit subjects theapplicant toacivil pewltyof POWER DEVICES
not more than live hundred dollars l$500), ❑TENANT ❑FOODSERVICE
IMPROVEMENT
6ElIdo the work.lbe pr+pcuy,oe inyemployees woffmcd fraleinole wmMncame's SWIMMING POOL ELIiCIkIC
N� awillnd Probe work.and Neatmaurclatnot s License
La c does of apply.11Mi,Business ❑OTIi1.'R
m and property
irm Code:The Cnathica s License Law saes not apply himself owner d OVI'LHfS-SWII'CHGS-PI%TURFS
3— progeny who builds or improves theron,and who nts loch ware deedoror through
his awn employeese provided that such improvement,are nut intended or rit<ad for NEW RESIDENTIAL ELECTR SQ Ff.
sale.mer-however,the have'he
or Improvement issoldho
ithib one ild... completion,the SQ.FT.FLUOR AREA ESQ.PI'.
.-builder will have lM1e burden ofpmving lhtn hu did not huJd or in+pnrve for par-
pose of own.
I.as owner of the progeny,.B sinus and contracting with licensedCcnmmaors U. TOTAL:
ova1.3
consteat the project(Smapply
to an Rosiness and Professions ds or improves
Contractor's Li
cense Law does not apply m an owner of property who builds or improves thereon.and QTY. LE B G PERMIT FEE
who mmrans for such projects with a crntranart.p licemed pursuant rr the Crnaactors
License Law. PERMIT ISSNCL
EJ 1 am exempt under Sec. .B&1'C for thin rm,un
Owner Date ALTER-DRAIN&VENT- IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW PROTEGE •VICE ^� .N�/-�
Iberehy union under Penalty of perjury one of the following declarations: (.. WV
❑thave and will maintain aCcniticaeof Convent to self insure for Workers Compen- DRAINS-FLOOR,RO .AR ,GOND. STORIES TY 1;CONSTRUCTION
cation,as provided for by Section 3900of the Labor Code,for N.....form........the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code.for the twd.mance ofthe weak for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTL T. OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-FA.SYSTEMOVER Y(EA)
CERTIFICATE OI'EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE GREASHANDUSTRLWASTE INTERCEIzI'Ok
BUILDING DIVISION Flil'"
ffhi,section need nm he completed Kith,permit is forms,hundred it.][.P$100) OR FSE TRAP �1 0
or less) PLANCHECK FEE L�✓
I certify that in the Performance claim work for which this Permit is issued.l,hall SEWER-SANITARY-STORM EA.200 FIE
not employ any person in any manner so as m become subjmt to the Workoo Compen. ENERGY PEE
ZZ salon Laws of Califumia.Date WATIfR HEATER WNENTIELECTR
Q Applicant - GRADING FEE
NOTICE TO APPLICANT.If,after making this Cmificam of Exemption,you should WATER SYSTEM/TREATING a S014S ITE; become subject to the Worker's Compensation provisions of the Labor Cafe,you must _
Forthwith comply with such previsions or this permit shall W d«coed revoked. WATER SERVICE
aQ
iU. Z CONSTRUCTION NEW RESIDENTIAL PLMP, SQ.FT. PAID Date Receipt#
I heathy affirm that
them is s ao mnswminn lending agency for the performance of
LUL . the work for which this permit is issued(Site 3099.C1¢C)
l-' Lenders Name TOTAL:
V 1<sdcrs AJdrss TOTAL:
�+ {Ll I / BUILDING FEE
I cenify that 1 have mad this application and state that the above information is
F h cored.l agate to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
Ll building can%troaion,and hereby authorize representatives ofthi.sony to enterupm the SEISMIC FEE 2
abrve-nte+ni.aid pmpmy lin inspection purpnas. PERMIT ISSUANCE 01
(We)agree In save,indemnify and keep hand,„the City of Cupertino against ELECTRIC FEE O
liabilities,judgments.costs and expenses which may in any way accrue agaimstraid City ALTER OR ADD TO MECH, PLUMBING FEE r A '
in mnuqucnce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) �)
SOURCE REGULATIONS CONSINLCAL FEE VV
AIR HANDLING ON]'1'(OVER I40)f)CEN) CONS'TNU X
Signature of ApplicanuContracmr Date EXHAUST HOOD OVIDUCT) HOUSINGMLTIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazallous material HEAT]NO UNIT(TO 1110,011)BTU)
us defined by the Cupcnion Municipal Cale.Chapter 9.12,and the Health and Safe,
Cale,Section 25532(0)'1 HEATING UNIT(OVER 110,010 BTU)
❑Yea 0 N VF.NTI LATION FAN(SINGLE RES ID) PAID
Date Racip#
Will the applicant innts a building occupant use use equipment of devices which
emvait hnlcontaminantsus aircontaminantsa,defined by the Day Area Air Quality Management BOILER-COMP(JHP OR 100,000 BTU)
A '
District?
❑Yes 0 N BOILER-COMP(OVER 100.000 BTU) IF-sa.07
I las a read the hazardous matenalsrtyuir,nan is under Chapter 6.95 of the Cali AIR CONI BTIONER ISSUANCE DATE
omnia Health&Safety Carl Season 11505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.I?.
Wilding does not currently have a tenant,Nat it is any responsibility to ratify the occupant
of the re tairent<mu which must W met prior to issuance of a Cernficam of Occupancy. alp
Ow net or authorized agent Date 'T'OT'AL: ISSUED It Y:
OFFICE