30286 SI` APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES I USE BALL POINT'PEN ONLY e '
f CITY OF,CUPERTINO - .- - MIBUILDING-ELECTRICAL • PERMIT NO.� 3 0 2 8 6
"' BUILDING DIVISION a APPLICATIONIPERT - PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARYNO.` APPLICATION SUBMITTAL DATE
d 19'-lrS t .
. OWN S AME: 1 • PI{ONF,: CONTRACTOR'S NAME: LIC NO',
\ �aG'•_ N/C ,I CONTROL#
ARCHITECDENGINEER: LIC NO: ADDRE n rie .l, '
• CONTACT: ,I _ : PHONE:- - '" _ - BUILDING PERMIT INFO-'
❑ Consultant Pe¢s Paid by Applicant Qn11BID BLDG ' ELECT PLUMB . MECH
r '❑ El �ElB.. ❑
LICENSED CONTRACTORS DECLARATION" QTY ELECTRIC PERMIT FEE -
I hereby affirm that I am licensed'a de provisions of Chapter 9(om e ting JOB DESCRIPTION,
QRZ with section 7H00)irD " 9 fthe Busi dP f ,ion Cad d toy hcenaols
OO In full fomeand effcaL PERMIT ISSUANCE RESIDENTIAL:.
�UV Lwa...Clan. 'Lic.If ❑SFDWL C1KITCHEN REMODEL
rnGL Da¢ ""Coatmcmr APPLIANCES-RESIDENTIAL • [1ADDITI6N UMBING RE-PIPE
ARCHITECT'S DECLARATION, _ 'PANELS•
p,7m ' I ❑MULTI-UNIT '.OSTRUCTURAL
Z O n 7, 1 understand my,plana shed be used publ c records - MODIFICATION
OZ-, UPT02MAMPS - [IINTERIOR ❑CHIMNEY REPAIR
r4u) Licensed Professional ' 201 IMOAMPS IMPROVEMENT
QrY •�.l OWNCRBUTLDER DECLARATION
L[4 1 hereby B' that I r m pt Ithe Contract.,',L L f d ' OVER 1000 [IAMPS' BATH REMODEUREPAIR [I DEMOLITION
0 4 U
following (Section 5 Business Professions Code; anyorcomily SIGNS ELECTRICAL OOTHER
)
' '3OvFI which rated.,.penult 1Instruct alt,,improve,demolish, l any structure -
prior to its1.so rqures the pplt for suchpermit to filargued tT ent SPECIAL CIRCUIT/MISC
a,
that he licensed paramour to the previsions offific Contractor's License La (Chapin 9
� QD (tom enicng with Section 7000).f Dmviso J rul Business and Pnfos ,Cod)or - TEMP.METER OR POLE INST, COMMERCIAL,
Y c that he is exempt Therefrom and the bass for the alleged examption.Ary violation of
Sect 70315b [I NEW BLDG/ADDITION El DEMOLITION
y hundred
permit subjects the applicant a civil f POWER DEVICES
p„ act..,a th f h areal II yempl []TENANT C:1 FOOD SERVICE
Q ❑I lith p petty y ply th g lb v. let mise t' SWIMMING POOL ELECTRIC IMPROVEMENT
Fa wJld rh kand The.t t t t dd B df .ale(Sec 744
,0R ss - - .. ❑OTHER
a
�m and P f ns CooleT.The Commerce License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who huilds or imp over thereon and who doe,such work himself or through, -
his own employees,provided than such Improvements are not intended or offered for NEW RESIDEbi BLECTR SQ Fp.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.'
mcna,litulder will have the band,band,en of proving that he did not build or improve for pur- -
posa taale) p A �. .
E]1,as owner of the property,um exclusively contracting withlicensed contractors to %N, TOTAL: ,.
construct the project(Sao 7044 Business and'Proorec mos Code)The Gmtractors Li
nae Law des not apply to caner of property who builds or improves Whereon,a ad QTY PLUMBIN IT FEE i�ff . 3,o '1(1(1C
whocot tsforsuchp j t ooh a conuuchum)licensed pur,...I to the canvacmrs �/{f1a �7�7U
License Law ,' 'PERMIT ISMJA§1Z .
❑I um exempt under Sec. B&P C for his reason - - CITY Ot- ULD-c r1 i mo,
ALTER-DRAIN&VE WATER(.
Owner Data -VALUATION '
WORKERS COMPENSATION DECLARATION - BACK FLOW PROTECT.DEV
In by affirm de p It) fperjury one fone following declarations •. '
❑ I have and will maintain a Crtiticam ofCousentto lf' sure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,CON STORIES - TYPE CONSTRULTfON3
ation,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which Nis permit is issued. PIXTURPS-PER TRAP '
_]I have ad will maintain Work Compensation Insurance a.required by Section '
3701 ofthe Lab r-Corb for the perf rmancis ofthe workfor whicliffbi,penfib.s issued. GAS EA.SYSTEMLI INC.4 OUTLETS - -
My W k p ss t I In tics Carrie d P l y-num
OCC.GROUP APN
CarriPIicY Ni..� GAS-EA.SYSTEM-OVER4(EA) �' ...
„ •• CLRTIFICCO OP EXEMPTION FROMW KERS GREASE/INDUSTRL WASTE INTERCEPTOR '
COMPENSATION INSURANCE
(This water.need nal be completed rf[he permit is for onehundrul dollars($1(q) � BUILDING DIVISION BEES
j � -,
' or lee J � GRF.ASE'1'RAP, •r-; 4 - � .
I comfyth t' the Performance oRbe work forwhrh thi p l' .suul,fshall PLANCHECK FEE ,
non amply any person in say manners.as to become snbjecrto the Workers Compen-, 'iSEWER-SANITARY STORM EA.200 FT. .
7. sunup Lowe of California.Date ENERGY FI3E
O - - WATER HEATER WNENTMLECfR
O
NOTIAppliCE
"Y/ GRADING FEE
ti NOTICETOr,mmAPPLICANT.If,after Compensation
thiswikina caf the
Exemption,youshould
most
WATER SYSTEMRREATINO
become k C on,.,ti p ''ons of the an d pale you most SOILS PEB
forthwith..Ply w'th sv h p '.'ons or his permit shall be deemed revoked WATER SERVICE
Q
U z _ ' CONSTRUCTION LENDING A NEW RESIDENTIAL PLMB. SQ.W. PATO 'r
U O' Thereby affirm that heri isaconsmuctlagency lending agency Porthe perPormance of Data R Ips#
o tbeworkf.r which'this pesmir is issued(Sec.3M7.Civ.CJ I • _
O Lender's Name 'TOTAL:
FU Lenders Add 5 - i TOTAL:
In 'I cert that I h a llapplication J t that Th mf rel ti nt is BUILDING FEE '
wry correct.1 ag e t ply m n city and'county ordinances and stn lelrelating m QTY. MECHANICAL PERMIT ;•FEE
UZ building construction,and herebymtharizerepresentatives ofths city to enter upon the - SEISMIC HE y
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE '
(We)agree m save,indemnify and keep hamrti
lless the City of Cupeno against ELECTRIC FF..
liabilities,judgments,costs and expensesw 'h may in anywayaccrue againit said City ALTER OR ADD TO MECH.
in consequence of the granting of this - - PLUMBING PEE t _
APPLICANT•UN ANDS ILLC)MPLY WITH ALL NON-POINT AIR HANDLING UNIT G70
S RCER NS. • MECHANICAL FEE
7-3vr 9 AIRHANDLINGUNIT(OVER10,Oo0CFM)i CONSTRUCTION'TAX
,t Sig Appl cant/Co Date ,EXHAUST HOOD(W/DUCT) ' HOUSING MITIGATION FEE.
HAZARDOUS MATERIALS DISCLOSURE - _
Will theapplicant or future building occhpantsmre orhandle huaeNoue material HEATING UNIT(TO 100,000 BTU)"•
res defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - _ "
Code,Section 25532LU? '" ' HEATING UNIT(OVER 100,0100 BTU) -
❑Yes „ " 7 N '
VENTILATION FAN(SINGLE RESID) PAID
Will thea fcant or future building - Date Receipt# -
pp gby the my Area
Air Quality
Mme Braced BOILER-COMP 3HP OR 100,000 BTU
mit hazardous air wnntmivanN as defined by the Bay Area Alr Qunlity'Mvnagement ( ) -
District? y"TOTAL:
❑Yet' t 7Nd• BOILER-COMP(OVER IW,000 BTU)
I have read the hearid material7 AIR CONDITIONER - ISSUANCE DATE
e4 re t de Chapte 695 litheCali-
forma Health&Safety Code Sectors 25505o 25533 and 25534 1 understand that if the• - NEW RESIDENTIAL MECH. SQ.FT.
- building does not,muctly have a report.that it my re.ponsibdity m notify the occupant '
I of the requirements which must be met prior to issuance of a Certificate of Occupancy. _
Owner or authorized agent s, TOTAL:
ISSUED BY
OFFICE*