30929 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30929 9 O ^ ^/N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J< `9 L
BUILDING FRQIRCT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
.R'S A E: PHO CON'1'RAC'1'OR'S NA - LIC NO:
2 1Z
NIC CONTROLp,
ICHI'E '/E GINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: BUILDING PIiRMI'E INFO
❑ Consultant Fees Paid by Applicant(Initial) L-Ec PLUMB MEal
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB
I hereby affirm that I nm licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�Z with Section 7")of Division 3 of the Business and Professions Gale,and my license is RESIDENTIAL:
ty� in full force and effort. PERMIT ISSUANCE
�V License Class Licp ❑SEDWL ❑KITCHEN REMODEL
f.Z Dam Contractor APPLIANCES-RF3IDENTIAL **DDITION ❑PLUMBING REPIPE
yaA' ARCHITECTS DECLARATION LE MULTI-UNrE []STRUCTURALF y H 1 understand m PANELS
ZOy� my shall be used ux public records MODIFICATION
CZ-0 UPT02MAMN ❑INTERIOR ❑CHIMNEY REPAIR.
g-: Licensed Professional 201-1000AMRS IMPROVEMENT
MO OWNER-BUILDERDECLARATIONCLARATION OVER 1000AMPS ❑BATA REM(�j(IEOVIR IT -
I hereby affirm that I ao exempt from the Comonors License law for the Ij.Zi ftTT77 �:
aCGV following Mason,(Section 7031.5,Busincssand Pmfcssions Code:Anycdyor county SIGNS ELECTRICAL ❑OTHER Y
W which requires n permit to cnnswct,elmr,improve,demolish,ar repair any stnicwre
FSO pdormiucensed aahoalto he theappllcont fur suchpcmtit Livens La.(ataa mem SPF,CIAI.CIRWIT/MISC.
0Oy Rmhc ixlia,with'Whan'0the provisision 3fthef the Buiness and ProLaw TCede)pter 9
(commencing wird Section](Ng))of OEvisionlofNc Business and Pmfcssions Code)or TfiMP.MGIER DR POLE INST. � COMMERCIAL:
T�c C ohm he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
M Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
^m ❑TENANT [I FOOD SERVICE
F Z i net more than Use hundred dollars 15500). IM ROVEMENT
Q ❑Lo Me
,the pe tuactor myemntended withweges rSalei(Sm. 044,8 sines, SWIMMING POOL ELECTRIC
and do fie work,and the he Con m not intended o Law do for ole ppcc.7044,Business HER
3 and Professions Code:The CeS themrs License Lew doer not apply to if owner of OLITLLTS-SWITCH ES-FIX'T'URES
hpunparlyis own who builds or improves thereon,and who does such work himself or through
his own employees,pmvidW that such improvements thin on intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhowever willthe have me
of hmentinmlhewithinitbuild or improve for
PS Pl. ORAREA SISQ.FC
nwner-huilder will hove Ne burden of proving that he did not buil)or improve for put-
E] 1,USsowua of the properly,am exclusively comments with licensed contractors to TOTAL:
construct the project(Sec.2044.Business and Professions Code:)The Contractors Li- (sg YV \\\TTaT sr
cense Law does not apply to on owner ofpmperty who builds or improves Extent,and QTY. PLUMBING PERMIT FEE ecJ��1NQ
who contracts for such pmjects with a comraean(s)licensed pursuant to the Cusumano's
License law. PERMIT ISSUANCE 011�TSf Ur
❑Inmexe def Sea ,B&P C for this reason
(Owner pmt ATTER-DRAIN&VENT-WATER(EA)
VALUATION
+R:SCOMI'l?NSA'I'TO DECLARATION HACK PLOW PROTECT.DEVICE
I hereby affimt under penalty of perjury one of Ne following declarations:
•E]]haves d will maintain a Certificate ofComem to self-insure for Workers Compcn- DRAINS-FLOOR.ROOF,AREA,COND.
sation,ux provided lin by Section 32110 of the labor Code,for the pedonn Lure of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,ass required by Section
3200 of the Labor Code for the Performance of rhe work for which this permit is issued. GAS-FIA.SYSTEM-I INC.4 OUTLETS
My Workers Compensation Insurance carrier and Policy number am: OCC.GROUP APN
Carder: pulley No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSPJINDUS'pRL WASTP,INTERCEProR
COMPENSATION INSURANCE
(This sation need nut hecompleted if the permit is for rum hundred J AE.S100) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
renify that in the shborcomofthe work for which this permit issued,Is hall SEWER-SANI'1'AkY-STORM EA.200 FT
not employ any person in any manner so as to u
become subjeco the Worker:Compen- . ENERGY IEE
Z station laws ofCalifornia.Dale
70 O Appha nt WATER HEATER WNRN'f/ELECTR GRADING FEE
F7 N NOTICE TO APPLICANT:if,after making Nis Caribbean n of Exemption,you Should WATER SYSTEM/TREATING
1; become subject to Ne Worker's Compensation provisions of the Labor Code,you most SOILS FEE
Lfiyl forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE:
a �
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PINE. SQ.Fr. PAID
V O l hereby aftionthis pe More is sued(Sm.30[ending agency for per(nrrriartce of Data Receipt p
Lks F the work for which this permit is issued lgec.3092,Civ.C.)
U Lenders Name TOTAL:
fill I<nders Address TOTAL:
0. I renify that 1 have read this application and some that the have information ie BUILDING FEE
V) correct.l agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
V 4 building construction.and hereby authmise repmonmtives ofthis city to enter upon the SEISMIC PER
ahnve-mentioned properly for inspection purgises. PERMIT ISSUANCE(We)agree m save,indemnify and keep handle.Ne Chy of Cuperom,aa..ast ELECTRIC FEE
Imbilitit,,judgmems,costs and expenses which may in any way accrucagaim,,md City ALT ER OR ADD T'O NIECE,
consequencein of Ne granting of this Permit. PLUMBING IEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10.070 CFM)
SOU ULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,010 CFM? CONSTRUCTION TAX
M/C'Eauracuo EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA-LARDOU$MATERIALS DISCLOSURE
Will the applicant or future building mmPant store or handle hmallous nmmrial HEATING UNIT Q O 100.00 B'TID
tis def red by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532pi? - HEATING UNIT(OVER 100,000 BTU)
❑Yes El No VENTILATION PAN(SINGLE RESID) PAID
WillNe applicant or furore builJing occupant use equipment nr devices which Date Receipt N
emit hasa Boas air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP DHP OR 100,000 BTIH
TOTAL:
D so-
C Yes 1`1 No BOILER-COME(OVER 100,000 BTU)
I have real the hoordous n tarmis pier AIR CONDITIONER ISSUANCE DATE
try 25533 a v under Cha 695 of hhe Celi-
bumii HcoesIIIE&t curieufall Cala e a tinaner 25505.is my
and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
buildingdoesnotta whicyhave Istenant,Nat it ismyrexponsCarlyto emnotifyam Gamper, Q
of the rnyvircmemx which mustMmet prinnoisxuance afe Cedifcam of Occupancy.
Owner or authorised.,not Dam TOTAL: ISSUED BY:
OFFICE `.