30525 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMrf PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
°,5S5 a 6
OWNI;IyS�NAMG:b���g HONE: CO:dTRACTOR'S NAME: LIC NO:
ARCHITEC ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ,LUG ELECT PLUMB MECH
�I�S�]' ❑ ❑ El CONTRACTOR DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby infirm Inns 1 pm foremost!s
rnxrneer vratixinn.nr Chapter 9 aatlttlluming JOB DESCRIPTION
Woo with Section7NXqof Diskhm 3orme Busincssand Profc,iom Coda.undmy li,emes RESIDENTIAL:
F i dull fimeardetfse. PERMIT ISSUANCE
aUF License Clmv Lic.M
.< U ❑SFUWL El Kill REMODEL
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
NZW Dam Contactor
F D V, ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCfUNAf.
Z C d,Z 1 understand my pans shall be used as public records MODIFICATION
UPT)200AMPS C3 INTERIOR ❑CHIMNEY REPAIR
Licensed Pmfessinual 201-1000AMPS/ IMPROVEMENT
�WadOWNER-BUILDER DECLARATION OVERT M C)BATH REMODEL REPAIR ❑DEMOLITION
C 0.'Q 1 hereby offinn Thal I um exempt from the Contracmrs License Low far the
ad3 c.U following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS EL RICAL ❑OTHER
W "y which requires u permit m construct.altar.improve,demolish,or repair any suucmrc
F"�cQ prior to its issuance.also requires the applicant for such Permit to file a signed settlement SPECT RC /MISC.
$�Y'J that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
ad (commencing with Section 7000)ofDivision 3 ofthe Business and Professions Code)or TEMP. EIEROR INST.
a 0.c 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ',W BLDG/ADDITION [IDEMOLITION
�w Section 7031.5 by any applicant for a peach subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
=� not more than f se hundred dollars Sion). IMPROVE
01.as owner of the prnpeny,or any employe,with wages as their sole cnmpcnmtion, SWIMMING POOL ELI?CI'RIC ❑OTHER
P. will do the work,and the structure is not intended or offered for side(Sec.944,Business
and i'mfe,sions Code: The Cnntraaar'v Licenses Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTU ?S
a' property who builds or improves thereon,and who does such work hit x f oo thrnngh
his own orgdoy'as,provided that such improvements ate nm intended or offered for NEW RESIDENTIAL BLECTR Fr.
aide,If,hawevar.the be ldingarlmproven emis sold wahi none ycurnrcompletion.the SQ.FT.FLOOR AREA $/SQ.IT..
owner-hadWer will have the burden of proving that he did not builder improve mope,
pose of atle.).
I,as owner of the property,am exclusively contracting with licensed cnmractmr to TO'T'AL:
construct the project(See.7044.Business and Proesmo s Codi)inc Comrao,on,1-
«eve law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBINGPERMIT FEE
who,onand s forsucM1 projects with of cotiwemds)licemsed punuam m the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under St .B&PCfar this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Data
WORKERSCOMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE
affirm 1 hereby armunder Penalty of Perjury one of the following derker's a
•ice.as prowled for byneCenif7M of Con Labor Code.
for Worker's ComPam DRAINS—FLOOR,RWP.AREA,COND. STORKS TYPE CONSTRUCTION
scion, r provided far by Section 3]00 of the Lahr Cade,for the performance of the
work for which thin permit is issued. FIXTURES—PER TRAP
❑ 1 have and will ode.for he arfor her,Compensation Insurance,h his Isecd by Section
J]tNl ofthe Lunar GWc.for the performance ofthe work for whim this permit is issued GAS—EA.SYSTEM-]INC.4OUTLETS OCC.GROUP APN
My Worker's Condensation Insurance carrier and Policy number are:
Currier: Policy No,: GAS—EA.SYSTEM-OVER 4(EA)
cE10IFICA9'E OF CXEM PTION FROM WOR K ERS' GREASFJINUU$'I'RI.WASTE IN'TIiRCCPI'oN
COMPENSATION INSURANCE BUII,DING DIVISION FEES
(Tbiasectio.orednot the completed Bar,permit is inert hundneddollars($Felt CREASE.TRAP
nr Icxs.1 PLANCUECK hili
terrify that in thepbrfunnanceoftbeworkforwhichthisinnnit i.si...d.Ishull SEWER—SANITARY—STORM CA.200 17
troy l
not employ any person in y mner so as In became subjoh n,the Wn sets'Compen- ENERGY FEE
O Z gotten laws of California.Date WATER HEATER W'NENT/ELECTR GRADING FEE
Z O Applicant
NOTICE TO APPLICANT:If.afar making Nis Certificate of Exemption.ymishauld WATER SYSTENiTtEATING
(•' ; become subject to the Workers Compen.mtion provisions of the labor Code.you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q Iherchy affirm the thea is uconswcdon lending agency for the perfowancc of Dae Receipt
the work for which this Permit is issued(Sec.3097,Civ.C.)
TOTAL:
Lenders Name
V lenders Address TUq'AL:
�" Q] BUILDING FFai
6. I certify that I have read this niun ono dm that
athe starve informon
atiis
rq corCrect 1 Agreemmpl
coy withal)cityty aandd county ordinances And state laws relating e QTY. MECHANICAL PERMIT FEE
Zbuilding conntmerinn,tied hereby Authnrizr representof cels city uicnrnr uryin the SEISMIC PEC
ubuve-mentioned pmparry In Inspection Isoln". PERMIT ISSUANCE
t We)agree m save,indemnify and keep harndcss the C'ay of Cupenlno Against ELECTRIC FEE
liabilirm.v,judgmants,coasnnd rip...a,which may many way ace .,ain't sato City ALTER OR ADD TO MECH.
PLUMBING PIiC
incmuryue cofthcgmnting Sthis permit.
APPLICANT UNDP ,NUS ANU LL COMPLY WITH ALL N•PUINT AIR HANDLING UNIT(TO III,gX)CPM) MECHANICAL IAC
SOURCC RIiGUI 'ION .
9 4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
'ignpurc nt ApPl' .nJ asoma Date EXHAUST HOOD(W/DUCI HOUSING MITIGATION FEE
HA]ARDOUS MATERIALS DISCLOSURE
Willdert,dcantorfdire buildingocer,am smremleardle hazardous material HEATING UNIT(TO 100.000 BTU)
es defined by the Cupertino Municipal Crile,Cooper 9.12,and tic Hulth..it Safety
Cade.Section 25532(.)? HEATING UNIT(OVER 100,01X1 BTU)
❑Yes [:I No VENTILATION FAN(SINGLE RrMIH PAID
Date Receipt of
Will the npplicwt nr future building occupant use equipment or devices which
emit hazardous air c=1.::mats os defined by the Bay Area Air Quality Management BOILER—COUP fJHP OR I W.IX1B NTD) TOTAL.
District? BOILER—COMP(OVER 100.000 BTI])
❑Yes 0 N
1 have read the hazardous materiels requirements under Chapter 6q5 of the Cali AIR CONDITIONER ISSUANCE DATE
hems Health&Safely Coxae.Sections 25505.25573 and 25534.1 understand that it the NEW RESIDENTIAL MliCH. SQ,PT
building does not currently have a tenant,that it is my responoibil'ny it,notiay the occep irl
of the re.lretnemv wean soma he met print m Issuance of a Cenlfcam of(haq+mlay.
Owner or pulborimd agent Date TOTAL: ISSUED BY:
OFFICE