30576 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 3057
J O S 17
O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/rfRr &,bb aAT Ct tCtCt
'( OWNER'S NAME: PHONE: CONTRACTORS NAME: LIC NO:
RJ'h/7- QN »S'Stfi a�/e •Q ,� ye N/G CONTROL»
RCHITECVENGINEER: _ LIC NO: ADDRESS: !. ❑
yo 0 seen uGt &-d /4j.
OM'ACP PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG' ELECT PLUMB MECH
❑ ❑ ❑
LICENSED [p-
CONTRACT'OR'S UECON QTY ELECTRIC PERMIT FEE
1 hereby eBirm thin I um IicensW under provisionsonsof of Chapter 9(commencing JOB DESCRIPTION
IIgy00 withllfran]1II1B1ofUivision3ofthe Business and professions Code.and myliamels RESIDENTIAL:
FWO License
and eRat PERMIT ISSUANC�,
�U Wcrnu Class Lie.M i OSFDWL' [I KITCHEN REMODEL
Cantmcmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
a' ARCHITECTS DECLA ION ❑MULTI-UNIT OSTRUCTURAL
Z O E2Z 1 understand my plans shall be used as public records PANELS MODIFICATION
oz-- UPTO 2W AMPS
CI - ❑INTERIOR El CHIMNEY REPAIR
F.y. W Licensed Professional 201.10110AMPS IMPROVEMENT
yt r 'OWNER-BUILDER DECLARATION
Contr ON OVER H W AMPS O BATH REMODELREPAIR ❑DEMOLITION
yyx PG I hereby affirm that 1 1. exempt from the Contrns Co License Law for the
W a6F followingreason(Section]on tree Business and improve.
demob Code:Any city orcountySIGNS ELECTRICAL ❑OTHER _
ul LL. which requires a permit m construct,al¢r,improve,Jemnliit t fi repair any swcmre
pir
that
he
licensed
e,ulsorequires thasismiwntfor Cwturai License Law luitnent SPECIAL.CIftCU1T/MISC.
that he is(commencing
pursuant m Ne provisions of Ne is Bm tcr's nd Pore law(Chnpmr9
`0 (cot he
acrapt therefrom
and
of basis far ofthet,ged sacr Prof n,violation
ia Gds)or TEMP.METER OR POLE INST. 0NEW BLDGAL:
n, C thee io i7 exempt thcrcGom ant the basis for the alleged applicant to Any l Penalty of ❑NEW BLDG/ADDITION ❑DEMOLITION
12 m Section]BJLS by any applicant for a permit mbjans the applicant m a civil penalty of POWER DEVICES O TENANT .O FOOD SERVICE
.F.Z�. wo more than five hundred dollars($500). IMPROVEMENT
O 1,as owner ofthe propi or my employees with wages as their sale compensation, SWIMMING POOL ELFCf .r
See 0 will do the work,and the structure is not intended or offered formic(Sm.]D14,Business .❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FT
property who builds or improves thereon,and who does such work himself or through
his own employees,pa idesi that such improvements arc not intcndmi or offered for NEW RESIDENTIAL ELECT R SQ
sale.If,however Ne building or improvement is mild within one year ofeempledon,the SQ.PT.FLOOR AREA VSQ.FT.
er-builder will have the burden of proving that he did not build or improve for pur-
pose ofsale.).
I,m owner of the propeny,um exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.76,14.Business and Profeesiom Cade:)The Contmemes Li-
cense law does not apply to an owner of propcny woo builds m improves nc�rerm,and QTY. PLUMBING PERMIT FEE
whocuntaets for such projects with a contractons)licensed pursuant)the Comma sei Sep License Law. PERMIT ISSUANCE
E]lamexemptundw Sm. ,B&PCfur Nisreamn /�
ALTER-DRAIN&VENT-WATER(EA) VA_Uf1AT?ON
Owner Dam t
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Aire
j Ihereby affirm under penalty of perjury one of the following decimations: k' L
I have and will maintain a Certificate of Consent to self-inmre for Worker's Compo- DRAINS-FLOOR,ROOF AR EA,CORD. STORIES TYPE CONSTRUCTION
inion:ns provided fm by Sation 3700of Ne Later Cale,far the peff...m of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,us requires]by Sation
3700af the Labor Code for the pefformace of the work for which thispermit is boost. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
M Wota'¢Cyym cation Immures carrier and Polic
Carrier: S./ Policy No.:numbg{-' ;gFe GAS-EA.SYSTEM-OVER4 TA)
' CERTIFICATE OF EXEMPTION FROM WORKERS' )
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This action need not be completed if the permit is forone hundred dollars(SIM) BUILDING DIVISION FEES
or las.) GREASE.TRAP PLANCHECK HE
I certify that in the perfommrem of Ne work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 PT.
nm employ any person in any manner so as to become suhjem to the Workers'Crusader- - ENERGY FEE
OZ station Laws of California.Date WATER HEATER W/VENT/ELECTR
0 Applicant GRADING HE
q NOTICE TO APPLICANT:Reber making this Certificate of Exemption,you should WATER SYSTEM/TREATING
1a^ ' become subject to the Worker's Compensation provisions of the Lebo Cole,you must SOILS FEE
LIIforthwith comply withuch sprovisions or this permit shall be devoted!revoked. WATER SERVICE
0. 9z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLIdu SQ.FT. PAID -
V O I hereby affirm that there is o construction lending agency l'orthe performance of Date Receipt#
L6 — the work for which this permit is issued(Sec.3097,Civ.C.) -
Lender s Name TOTAL:
{U Lender's Address TOTAL:
i3e I certify that l have read this application and state that the above informs ioa is BUILDING FEE
h moral,l agree to comply with all city and county ordinances ad state laws mining to QTY. MECHANICAL PERMIT FEE
V building construction,and hereby outhoriu repreatmttives ofthis city to turner upon the SEISMIC HE
above-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify wd keep hmmless the City of Cupertino against ELECTRIC HE
Iiabilides,judgments.toms and expenses which may in any way accrue against said City ALTER ORADDTO MECH.
I.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOREGUI/q�IONS. AIR HANDLING UNIT(TO to,"CFM) MO
UR
MECHANICAL FEE VV
// AIR HANDLING UNIT(OVER Hy"CFM) CONSTRUCTION TAX
Si muaf AinfucnMCoarmatr - Date `I EXHAUST HOOD(W/DUCT) HOUSING MTTIGAT'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT CUT IW,"BTU)
as defined by No CLpcnino Municipal Cade.Chapter 9.12,and the Health and Safety
_ CWC Sation 25532m)? HEATING UNIT(OVER I03,000 BTU)
❑Yes Ell No
VENTILATION PAN(SINGLE RESIDE PAID
Will Nee Brant nr future baildin n use e t ar devices which Dare Receipt or
pp dby them An.
BOILER-COMP(3HPORIoo.t111BBTU)
it haznNous sir canmminants as defined by the Roy Ama Air Quality Mnnegcmcm
ionic.? TOTAL:
❑Yes ❑No BOILER-COMP(OVER 100,001)BTU)
-' -I have head the hamahms materials¢quitvments under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
Lima Heath&Safety Code.Sections 255115.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. s
building does oat currently have a mount,Nat it is my responsibility to notify the mcupom
afore requiremcra which most be mi prior a ass...of a Certificate of Occupancy. ��..a a)
Owner or authorized agent Date ISSUED BY: Q//-•
OFFICE