30343 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 30343
BUILDING ADDR855: - "e SANITARY NO.. APPLICATION SUBMITTAL-DATE
eOW R:S NA & _ NHpyli: CONTRACTOR'S NAME: LIC NO: -
�fl/L�`]•'' Z NIC CONTROL p
rRCHITEC /ENGINEER: LIC NO.,. ADDRESS: - ❑
CONTACT. PHONE- - BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG LECT PLUMB MECH
LICENSED CONTRAC'fOR'SDECLARATION QTY. ELECTRIC PERMIT FEE -
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JO DESCRIPTION
QaZ with Sation 9000d.f Ddvh,ma3 of the Business and Profession Code.and my license is -
f� O PERMIT ISSUANCE' " ,` RESIDENTIAL:
mmE force effect.'
Nu License Class .Lia# - - � ❑SFDWL ❑KITCHEN REMODEL
ya,WData Contractor APPLIANCES-RESIDENTIAL
Z - ❑ADDITION El PLUMBING RE-PIPE
a' ARCHITECT'S DECLARATION _ PANELS
[I MULTI-UNIT ❑STRUCTURAL
Oz- 1understand my plans shall he used as public records ,1 UP TO 200 AMPS El INTERIOR 11 CHIMNEY REPAIR
MODIFICATION
F� t�c License)Pmlessinnal ` 201-1000AMPS IMPROVEMENT
as^y^y'' OWNER-BUILDER DECLARATION^ pyFek IOW AMPS _
+W W st I hereby affirm that 1 am exempt floor the Convenor'..License Law for the ❑HATH REMODEUREPAIR ❑DEMOLITION
WX�tY U following reason.(Section 7031.5,Business and Prnfessionc Code:Any city or county SIGNS ELECTRICAL f ❑OTHER
tL a W'rEvvr"��4 which requires a permit to ri nrd omt,alter,improve,demolish,or repair may morencre _
I"'Lz70Q prior to its issuance,alstnemmm,theapplicem branch permitm file asignedstatemeat SPECIAL CIRCUIT/MISC. q
G� Nat he is licensed pursuan,1.the provisions a fine C.ntomon's License Law(Clecom,9
W480 (commencing with Section 91100)of Dl vision 3 oft he Business and Professions Code)or TIgvp METER OR POLE INST. COMMERCIAL:
14 y o y' that he is exempt therefrom and the basis for the alleged exeniptind Any violmien of ❑NEW BLDG/ADDITION ❑DEMOLITION
NaSection 9031.5 by anyapplieant fora permtsubjec6 theapplicant toe civil penalty of POWER DEVICES
not more than Eve htiudred dollars(SSW). L El TENANT ❑FOOD SERVICE
y�el ❑ L,as owner of the property,ora employees with wt.es as their sole cam IMPROVEMENT
yg ,pursuer, SWIMMING POOL ELECT
and Professions
and the s a Contre ra tors tended License offered apply to an owner
of
_ ❑OTHER
and Professions Cale:The Contractors a License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES - -
property who builds or improves thereon,and who dcea such work himself or through
his two employees,building that such improvements thin on intended or offered far NEW RESIDENTIAL ELECTR SQ I?.
sale.If,howeventhe
vethe burding or den
of provinlithat sold he itoinoneild or improve
the - SQ.FT.FLOOR AREA $ISQ.PI',
owner-builder will have the burden of proving that he did not build or improve Por par-
pas of sale)
I
owner of the pmpery,ant exclusively amtracting with licensed comamors m
wLet the project(Set.7044.Business and Professions Codes The Contra mo/s Li
cennsse aw does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such p Jews with a amtaulorp)licensed pursuant to the Capital
License Law. PERMIT ISSUANCE It
❑'lam rpt oder Sec.19, &P this reason
ALTER-DRAIN&VP,NT-WATER(EA)
a Date �ty AUG UATION
R'. COMPE SATION DECL ATION BACK FLOW PROTECT,DEVICE 1jr7 jsL I
I hereby affirm under penalty o perjury one of the('allowing declaration: L.UY'C h I Im J
❑
[have and will maintain aCemficnreofConsentroxclf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
saran,a,provided for by Section 39110 of tiro Labor Crate,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. y FIXTURES-PER TRAP
❑I have and will moiram Worker's Compensation Insurance:as required by Scction
3900.1 the Labor Cate.for the permonanccof the work for whichthia permit tx issued GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Wicker's Compensation Insinuative trader and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASPIINDUSTkL WASTE INTERCEPTOR
COMPENSATION INSURANCE -
(Outstation need a.,he completed ifthe purmil is fm
ose hands(dollar,IS 1 W) BUILDING DIVISION FEES
or less.? GREASE TRAP PLAN CK FEE
I certify that in the performance ofthe work for which this permit is issued,l stall SEWER-SANITARY-S'1'OkM EA.2W PT.
not employ any person In any manner so as to become subject(.the Workers'Compton- ENERGY PEE
.z .action Lows of California:Dram '
� O Applicant WATER HEATER W/VEN'1ILLECTR GRADING FEE
w-t '
NOTICE TO APPLICANC If,auermakin this Certifcateof Eacmt should h 6 p ion,you s ou WATER SYSTF.MITREA'C1NG
abecome subject m it Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W forthwhh comply with such provisions or this permit shell bedeemed revoked WATER SERVICE
aA
UO
CONSTRUCTION is.emNLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT 'PAID !
I hereby whitaffirsothis
that there isawoaec.30 len ding agency for thepuformance of Data ,Receipt#
{✓w F the work for which lM1E permit Is issued(Sec.3099,Civ.CJ - '
O Lender's Name - TOTAL:
W Leader's Address s TOTAL:
(� I certify that 1 have read this upplicmion and state that the above infnrmmion is BUILDING FEE
correct.l agree to comply with ad city and county odinamers and sate laws neatiogto QTY. MECHANICAL PERMIT FEE
V. huildingeonsconfirm,and hereby authorize representatives ofthi,city(.enter upon the SEISMIC PEE
above-aremioned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnity and keep hurmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any wayaccme against said City ALTER OR ADDTO MECH. PLUMBING FEEin consequence of the gaming of this permit.
. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT TO 10,100%1 CPM)
SOURCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING UNIT(OVER 14WBCPM) CONSTRUCTION TAX
`-
Signorina of ApplleauXontmnor 'Dote EXHAUST GOOD(W/DUCD HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicnnt-orfulum building oaapam,nre rhandle reminders mmerirl HEATING UNIT GO,IOU."H'rU)
" as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health sad Safety
Code,Secuen 25532pgl HEATING UNIT(OVER 100.000 BTU)
F-1 Yes No VENTILATION FAN(SINGLE RE ED PAID
Will the applicant-or future building occupant use equipment or devices which Data Rccelpt#
mil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP SHIP OR 100,000 BTU)
District? TOTAL
❑Yes No - BOILER-COME(OVER I00,000 BUD
I have read the heramous materials requirements tinder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDATE
forma Health'&Safety Code,Section 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
.1
building does not cummlyhave ction,that 1505tis my253 responsibility understand
o amity lhe dacupam
of Ne requirements which most he met prior to issuance of a CeniFlcale of paupancy. -
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE