30957 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL_POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL r ^PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT - 11 PLUMBING-MECHANICAL I3oQ5T-
BIIILDINGPROJECTIDENTIFICATION N V
BUILDINGADDRESS: 0., SANITARY IN APPLICATION SUBMITTAL DATE
j_S AME: " PHONE: CONfRAC NAME: LIC NO: N/C CONTROL#
AR IE NGINEER:, „` 1 LIC NO: ADDRESS: • - " 0.
CONTACT: _ PHONE:' - - „ - - BUILDING PERMIT INFO
�- LICENSED CONTRALTO ED Consultant Fees Paid by Applican[(Initial) DG' ELECT PLUMB "MUCH
RSDECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm th t 1 m licensed unde p f Chapter 9(ormmene g ]OB DESCRIPTION
KMatz with Sx[mn]WO)ofD Sof the Bui nese and Professions Cade and.,licamcis OO in full fares and effect - PMNHfISSUANCU -RESIDENTIAL
UE� ❑SFDWC ❑KITCHENREMODELT'
aVU Drd, eClass LION APPLIANCES'-RESIDENTIAL EIADDITION El PLUMBING RE-PIPE '
F Ir] Date CIComES mQaf -
r ARCHI'TECT'S DECLARATION ° PANELS
pN.,p y •' - ❑MULTI-UNIT ❑STRUCTURAL
Z O y,�j
[understand my plan.shall b tad as public rccoNx ,r MODIFICATION
O Z'-'0 UPT0 2M AMPS -
�,r/� E3Line d Proles o 1 INTERIOR 11 CHIMNEY REPAIR
f3�] ° OWNERBUILDER DECLARATION 201-1000 AMPS PROVEMENT
yy IS:Q 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ATHREMODELTEPAIR [I DEMOLITION
)430.F folio g ea n (Sect ]0315 Business and Professions Code Any city or county, SIGNS ELECTRICAL OTHER
WW w1.which requires a permit te coutmet.alteL improve,demolish, r repair any structure _
L9 ¢ prix t its issuance also q e.the applicantf hpermit t file g d statement SPECIAL CIRCUIT/MISC.
that he is licensed pt to the previsions ofth C wet 's License Law(Chapter9 '
�O (commencing wrth Secu n]000) fDivisio J flheBminess and Professions Cale)or TEMP.ME POLE INST. COMMERCIAL:
1:1,p,ea oG that he is exempt there! m d thebasis for the alleged exemption Any violation of [I NEW BLDG/ADDITION ElDEMOLITION
W M w Sect 7031.5 by any applicant for a permit subjects The applicant t e 1 penalty df FEWER D .S ❑TENANT [I FOOD SERVICE
�., not re than f e h died dollars(8500) IMPROVEMENT
Q a woe fth poperty,or my employees wrth wages as Ther. lecompensation, SWIMMI GP ECTRIC
e`2 F+ will he work,and the structures,not nrendedmoffead for:I (Site]044B ss ❑OTHER
end P f ten Code The w C T r'License Law does not apply to mi owner of OUTLET - C FIX RES '
pmp ty h builds r improvesth and who does such work himself or Through 4
his own employees,provided That near improvements to not intended or offered for NEW REST L EEE SQ F1'.
sale.If,however,the buildingof malimsement issold widurrimeyeafof cempletion;dhehQ '.'
stra,builder will have the burden of proving that he did not build or improve for pun SQ.PT.FOOR AREA $ISQ.FE
p
pose rT els) , i, A b
1 as owner of the property,am exclusively contracting wit licensed contractors[o TOTAL: FIE&
construct the project(Sec 7044 Business and Professions Code)The Contractor Li-
cense Law does not apply[ an ownerf property who builds or improves thereon and QTY. PLUMBINGP IT FEE , '1 K RCAe/}
who contracts for suchp j ets with a contractors)licensed IT o,mmmthe Contract ds E fl
License Law. ` PERMIT ISSUANCE CRY tit-' +'
❑I un rS . ,B&PCT this ��NEN
Owner x a�
ALTER-DRAIN&VENT-WATER(EA) ' F _ _VALUATIO
WORK OMPENSATION DECLARATION
the affirmunder malt f BACK FLOW PROTECT.DEVICE
pe yo perjury one of fallowing declarations: `
Ihmvean will maintain a Certificate of Consent to self-insure for Worker's Cooper. DRAINS-FLOOR,ROOF,AREA,GOND.
serum,as provided for by Section 3]00 of the Labor Code,for the performance of the ..,r STORIES TYPE CONSTRUCTION
work for which this permit is issuW. - FIXTURES-PER TRAP _
I have and will maintain Workers Compensation Insurance,as required ley Section
37Wof the Labor Code,bane perfmancnceof the work for which this permit is issued. GAS-EA.SYSTEMd INC.4 OUTLETS OCC,GROUP
APN
My Worker's Compensation Insurance carrier and Policy number are: - rpt .
Carrier: PolicyNo: GAS-EA.SYSTEM-OVER4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GNEASF/INDUSTRL WASTE INTERCEPTOR' _ BUILDING DNISION PUES
(Thi. e u nn ed tba pl rodTf the perrnn is ford h dredd Ilaw(EI00) GREASETRAP I '
cones). - PLANCHECK FEE u -
1 codifythr in the perfrmncefthe work for which this Permit.issued,]shall SEWER'-SANITARY-STORM CA.200 FT. -
nota ply y person i y o as m become subject t theWorkers'Compeo- - ENERGY FEE
artmer Laws ofCaram Data
O A I cant - WATER HEATER WNENf/ELECTR "
O - - - - GRADING EEE
y NOTICE TObj APPLICANT If,after making Certificate Th Exemption you should WATER SYSTEM?RUATING
F•' 5 become subject m the Worker's sorthis
Compensation Previsions of The labor Code,you most SOILS FEE
forthwith comply with such provisions or chis permn shall he deemed revoked. - WATER SERVICE .
Q 4
�O CONSTRUCTION LENDING AGENCYrI NEW RESIDENTIAL PLM. . SQ.PT. PAID
affirm t
I hereby arm that there is u construction lending agency for the permereancc of Date ;ReceiptI ,
Lks F-'
The work for which this permit is issued(Sec.3197,Civ.C.) '
Q U Lender's Name _ - - TOTAL: '
� Lender's Address' - • - 1 k
Iy, 1 certify that I have read this application add state That the above information is - - - 'BUILDING FEE.
LI) I agree to comply with all city and county ordinances and state laws relining to QTY MECHANICAL PERMIT FEE
V building conswclion,and hereby authorize representatives of Nis city In enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. - ^
(We)agree to save,indemnify end keep harmless the City of Cupertino against, PERMIT ISSUANCE ELECfRICFEE
.Iiabilities,judgmems,costs and expenses which may in any way accme against said City ALTER OR ADO TO MECH.
onsegaerice Nte brant ng of permit. n - PLUMBING ME
APPLICANT DERSTANOS AND t .L CON PLY WITH ALL NON T PIR HANDLING UNIT(TO 10.000 CFM)
SOU ERF' LATE , I ^ - MECHANICAL FEE' _
N/ Al AIR-HANDLINGUNIT(OVER1g0MCFNH CONSTRUMONTAX
Slgnamre fApPHc.JV we r Date EXHAUST HOOD(W/DUCT)', HOUSING MITIGATION FEE -
1 � HAZARDOUS MATERIALS DISCLOSURE -.
Wtftheap "rant or future building.cupan Tom of handle hazardous material HEATING UNIT DO 100,000 OTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety -
Cada Section 25532(0)? ,' 'I - HEATING UNIT(OVER 100,000 BTO) .,
DYes ,•F E]No ,VENTILATION PAN(SINGLE RESID) PAID - y -
Date Receipt#
Willlineapplicant mr innture building occupant use equipment ordevices which BOILER=CGMP(3HPOR 100,000BTU)
emir hazardous air contaminants ms s defined M1y the Bay Aren A(Quality Management TOTAL:
Dinner) _ BOILER-COME(OVER 100,000 BTU) ,
. ❑Yes ON.I'I� � ' . ..•
- I have read the hazardous materia,re ca rider Chapter 6.95 of the C f- ' PIR CONDITIONER -
9 p - ISSUANCE DATE
forma H Rh&Safety Code S t s 2550 25533and 25534 1 'd nderel that'f the NEW RESIDENTIAL MECH. 'SQ.FT
build' it Tctam lyh eatenanL is p ibd nionoy�y t
- of IN c an met o'su eeofaCe TIr a f
Own amhorire m n `1 Date TOTAL: ISSUED BY:
'OFFICE