30347 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING -ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT, PLUMBING - MECHANICAL 30347
BUILDING PROJECT IDENTIFICATION
FEE
BUILDING P17RMIT INFO
BLDGELECT PLUMB MEC
.K, ❑ ❑ ❑
JOB DESCRIPTION
CON'1'AC'f. PHONE:
,
❑SFDWL
❑ KITCHEN REMODEL
❑ Consultant Fees Paid by Applicant (Initial)
WOO
F1_
Q U U
HQY
pm
Z ~
O Z — C
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provision.. of Chapter 9 (commencing
with ScOio0700BafDivision 3 ifthe Bumacs,add Prufessiom Cudc. and my license is
infullfoaeandeff /� (
License Cl. s Lie. , N_! �(7 m
Date�Commence
RCHITECTS DECLARATION
1 understand my plans shall be used as public ¢cords
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANF.IS
UP 1`0 200 AMPS
Fit-Ise1a,creed
t C C Q
a0e..0
3 � r .whish
�0.1
y
Ho
Hd
l'rofea.ional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor License Law for the
following rcumm,(Section 90315. Businev<mW Profession, Cade: Any city or wunty
termer,, it permit to Conmrma.:.)ter, impnwe, dell6h, or repair any structure
prior to its issuance, also requires the applicant for such permit to file u signed statement
that he is licensed por.uznt to the provisions of e Cont mm
th crw
', License ln(Chapter9
20I-1000AMPS
OVER 1100 AMPS
SIGNS HLECTRICAL
SPECIAL CIRCUIOMISC.
THM P. METER OR POLE INST.
�Q
(Commm�cing with Section 70W)of Divisinn3nf the ltusincss and Profes<ions Code)or
%o K
WM,
F Z Y
ESp(]I,
p.
Wm
a 3 —
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
t more dead five hundred dollars ($500).
as owner of the progeny. or my employecswith wage. os their sole compensation,
will Jo the work.ond the srmannefloor mirmlediummicl forsnle(Sce. 70,14. Business
and Professions Code: The Contrsnor's License Law costs not apply to an owner of
progeny who builds or improves theaon, and who does such work himself or through
POWER DEVICES
SLAMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
❑ FOOD SERVICE
his own employees, provided that such improvements am not intended or offered for
NEW RESIDENTIAL ELECTS SQ ET.
❑OTHER
sale, If, huwevec the building or improvement is sold within one year of completion, the
wnenbuilder will have the burden of proving that he did not build of improve for pur-
Pv¢ or sale.).
TOTAL
I, its owner of the property, am exclusively contracting with licensed contractors to
consulate, no project (Sec. 9044, Bovines, and Poulic,ianr, Cale:) The Contractor's li-
QTY PLUMBING PERMIT
neLawdoesnotapplytoadownerofpmpertywhobuildsorhnprovosthereon,and
who contracts for such prof with u commeba s) licensed pursuant to the Commemev
PERMIT ISSUANCE135
License Law.
C]I am exempt under See ,B&P C for this maven
ALTER - DRAIN & VENT- WATER (EA)
Owner Ilse
WORKER'S COMPENSATION DECLARATION
I hereby aliifm under penalty of perjury one of the following declarations:
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR. RODE AREA, COND.
I have and will maintain a Cenificave ofConsent¢self-insure for Workers Comped-
setion, as provided for by Section 37M of the Labor Code, for the performance of the
FIXTURES - PER TRAP
work far which this petted, is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
GAS - EA. SYSTEM -I INC. 4 OUTLETS
3700 of the labor Gyle, for the Performance of the work lit which this permit is issued.
My Worker's Compensation Insurance ednier and Policy number are
Carden Policy No
GAS - IA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASIANDUSIRL WASTE INTERCEPTOR
COMPENSAr10N INSURANCE
or less.) ('this section need not be completed if the permit is for one hundred dollurs($ffad
GREASETRAP
z
I codify that in the performmnce ofthe work for which this Permit i6 issued, Ishall
not employ cony any manner sags til ecoy yuhject bathe Workeri Cnmpen-
cation Incas Iifom mate /Y—p �7 [
11— sa.eF
SEWER - SANITARY - STORM EA. 2M FT.
WATER HEATER WNENT/ELECTR
rm�Avvhe,m
h NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
a; become sobjecTm the Workers Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or this permit shall be Jreted revoked.
WATER SYSTEM?BEATING
WATER SERVICE
y01
CONSTRUCTION LtionalNG AGENCY
UG 1 hereby affirm that is s ed Se, i30 lending agency for the perfomuntt of
fL the work for which this permit is issued (Scc.3(197, CIV, CJ
`�' �.cnJerx Nume
NEW RESIDENTIAL PCMB. SQ, FT.
[U
Fr^ ds
v1
U Z
1andcrs AJJrena
I certify that I have read this application and some that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building Construction,. and hereby nuthoriee representatives ofthi.s city to enter upon the
TOl'AL:
QTY MECHANICAL PERMIT
uhovamctdioned properly for inspection pugsu,
(We) agree naive. indemnify and keep harmless the City of Cupertino against
PIiRMIT ISSUANCE
ALTER OR ADD TO MECH.
Iiahilitieejidgmem, costs and expenses which toy inany wayaceme against said City
I. conuyucnce of the gr mmg of this pc.it.
AIR HANDLING UNIT (TO 10.000 CF.N)
APPLICANT UNDERSTANDS AND WILL CO&JfLY WITH ALL NON -POINT
SOU :GULATIONS. w
AIR HANDLING UNIT (OVER 10,10(s) CFM),
✓.-s�—f
/
SignamreufA,fi oVC: tmcmr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCO
HEATING UNIT TO I W,000 BTU)
Will he applicant or future building occupant some or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and toe Health and Safety
Colo, Section 25532(a)P -
HEATING UNIT (OVER 100,00) Bq' U)
Yea DNo
YEAH I I.AfION PAN (SINGLE RES ID)
Will the tape icum or future building occupant use c,luipment ar devices which
emit hazaNnus air Contaminants as defined by the Bay Area Air Quality Management
BOILER -COMP CHIP OR 100,000 BTU)
District?
BOILER- COMP(OVER 100.000 BTU)
❑Yes ❑No
AIR CONDITIONER
1 have mad the hastudous materials requirements under Chapter 6.95 of the Cali-
f rmia Health & Safety Code, Sections 25505. M533 and 8534. 1 understand that if the
building does not currently have a tenant and it is my responsibility m notify the occupant
of the rcyuimmenu which mumbo met prior to issuance of a CeniGcme of OccupmMy.
NEW RESIDENTIAL MECH. SQ. El�
Owner or authorized agent Date
TOTAL:
OFFICE
FEE
BUILDING P17RMIT INFO
BLDGELECT PLUMB MEC
.K, ❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
11 PLUMBING RE -PIPE
11 MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REM OU' IkEPA1R
DEMOLITION
El OTHER
COMMERCIAL -
OMMERCIAL❑NEW
El NEWBLDG/ADDITION
El DEMOLITION
[_1 TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SQ. H7. FLOOR AREA $/SQ. Fr.
Fv Q •.
AUG
L/yy Lr VAL A,*8
V ✓J
STORIES 1P.TYPECONSTRUFFIO
PLANCHECKFEE
ENERGY FEE
GRADING HE
SOILS FEF,
PAID
Date Recciptk
TOTAL:
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dom Recciptk
TOTAL:
ISSUANCE DATE
m
ra
o
-41
N
SJR
I
s rt
1
m
ra