30119 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO • , I BUILDING.ELECTRICAL . . PERMITNO, ••
BUILDING DIVISION APPLICATION/PERMIT r PLUMIHNG-MECHANICAL- O 0 9 '1 C�
BUILDING PROJECT IDEM'IF'ICATION J 1 1 J
BUILDING ADDRESS ^ - ^ SANITARY NO. APPLICATION SUBMITTALDATI
OWNER' NAME:, - 7.7 P�NJ CONTRAis
R'S NAA1EPill- Q LI NO: /
NIC CONTROL#
• 00 L
ARCHITEC!`:N NELjR: LIC NO: ADD RISS: - ❑
CONTACT; PHONE: BUILDINGPERMITINFO
�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMMUCHB
❑ ❑ ❑ ,o
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aftitm that In.licensed rude......isions of Chapter 9(euro acing JOB DESCRIPTION
O al %tin Section 7")ofDaviona 3 afore Business and Professions Crap,and my en at, RFSIDENTIAL
W— in fidsdoCcc and ' PERMIT ISSUANCE
❑SFDWL 1-1 KITCHEN REMODELlt Leas APPLIANCPRESIDEIA.Zw
FZ ❑ADDITION E)PLUMBING RE-PIPE
A CHU lS DECLAR ' ON 'I"s ❑MULTI-UNIT ❑STRUCTURAL
PANF:1.5
ZO yZ IunderntanA niy plans shall he used as publle ncnNs MODIFICATION,
OZ�O _ UP'I'02IXIAMPS ❑IMF.RIOR t , ❑CHIMNEY REPAIR
f:s W,� Licensed Professional - 201-1000AMPS IMPROVEMENT
0pia, OWNER-BUILDER.DECLARATION +
j
pia, 1 hatch,off rm hill 1 am exempt From the Commclnr's License haw fnr'ihe OVER If1U(IAMPS ❑BATH REMODF.IIRF,PAIIt (]DEMOLITION
K 3 L V fallowing mason.(Section 71131.5,Business and pmPo,fi ns Code:Any ci iy or cuunly SIGNS ELECTRICAL. (]O'fI IER
Yl F'y{La which requires a pe l l to commucgalml,improve,demolish,ar repair any structure Oy.] priono as is...mr,also requires tneapplirmifurauah pmmiuo Bleasignedatatemenl SPECIAL CIRCUIT/MISC. "
E y Nat he in licensed pan.anmothe,onskinn Ne Contractor's License Law(Chapter 9 _
CC (cntimencia COMMERCIAL:
gwish$atinn]Bhtq of Division o(Ihe Businell anJ l'rafeninna Cnde)nr ,IMP.ME OR POLE Sl'.
Q. c C that he is exempt thenfront and the basis Far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION;
4• Sedinn 7831.5 by any appliance far a permit zabjecu the applicant to a civil penally of POWER DEVICES
�m ❑TENANT [I FOOD SERVICE-
Oryno,morc than Bre hundred dollars(SSW)., - - IMPROVEMENT' -
=6 F� hos owner aline property.or my employees with wages as their side compensation, SWTMMINGP l,PLEC'1'R
will do the work,and the swctum is not intended cur 4
offered finsale(See. 44,Business ❑OTHF,R,
W 3 uaJ Rnfcssions Code: Contractors License Lawdoes sat apply in ua owner,of OUTLET: SWITCHES- URP
fA' property who b.ilds'or improves thereon,and Illi does such work himself or through
his own employees,provided that such improvements are not intended or offered for NE 'SLDF,NTIAL ELECTR
sal,.If,however,the buillingerimprovememis sold virtual ,year of rnmplelion.the SQ.Fr.FLOOR AREA SISQ;FT.`
owner-builder will have the burden of proving that he did not nnild nr Improve far par- -
pose ol'sall -
❑ 1,a owner cf the prefect,,am exclusively coolurmmg wird li<ensJ enmmcnsrs m TO L:
rmmmatdmmrjecl(Sea.]0,4,Breancws.nd Pmrestins Culdep The Gma...... Li- nn nn
ase Law docs not applyto an owner of property he build,orinn,ovcs o„m....and QTY PLUMBING PERMIT FEE
whoeontmets lorsuch projectswhh acontnnods)licensed Pronalut to the C(nttaitor's
License Law. PERMIT ISSUANCE
I um e6nm code,Site le
c. ,B&P C fnflnisnson' .f
Owner Date - ALTER-DRAIN&VENT-WATER(EA) VALIIAT'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE - /�
I hereby affirm under pauabG
y ofpequry one of the fennel declarations: Itl lv
Ur WiYr IIINQ
❑ Ihaveandwill nmintainaCenilicme of ConununsdGi...mfc,WorkcrsComl'rn- DRAINS_FLOOR.ROORAREA,COND. STORFES 'rYPECONSTRUCION
cation,as provided far by Section 371Y)of the Labor Code,for the perfan etarc of the
work for which this larval is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as occurred by Section
3700oflhe LaborCede.forthe performance of the work for which this permit isissued ,GAS-EA, SYSTEM I INC.4 OUTLETS' OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number ate:
Cartier: - Policy No.; GAS-EA.SYSTEM OVER 4(HAL.
CERTIFICATE OF EXEMPTION FROM WORKERS" r
COMPENSATION INSURANCE GRF.ASFIINDUSTRh WASTE INTERCEPTOR
ION PEES
(This section need not rte completed;olio remit is barium,ban BUILDING DIVIS
or less.) OREASE'(RAY PLANCHECK FEE- - -
z
Toy any that in the tinyman aoft ewnrk Bo whichihis siss'Cuumadial SEWER-SANITARY-STORM EA.200FT
not L w any personstati. y mm�n` n Ignn the orkeri Cnmpem ENI?kGY FEE
.cation Lows of CWifomie.Dam'
7� Applicant WATER HEATER W/VIiNT/F.LF:CI'R GRADING FEE -
�7 N ,NOTICE TO APPLICANT:If,aftar stn as nplioa,yod should WATER SYSTIiMn BEATING` ' -
a � N mocsnhjerIu,he Worker's Corupematiants vva nrt fvf lbm Crdc.You.1111 SOILS FEE
„W gremlin damply with such provisions or this ithallrte deemed revoked. WATIik SERVICE
CONSTRUCHON LENDING AGBNCY NEW RESIDENTIAL PLMB. SQ.Fi'. PAID
V Q Ihereby affmnhm them isaninaruction lending agency for the performance of Dale Receipt#
Fthe work fm whichihis permit is issued(See 309].Cie CJ
lenders Naine TOTAL:
WIxmder's Address .. TOTAL: U
1 rectify that 1 have read this application mad stale that the above information is, BUILDING FEE Tac correct.I.,me to comply vsklrall city add coucry ordlnancesind.Imerows relating.. QTY. MECHANICAL PERMIT FEti
rU Z buildingmmstrumion,and hereby vat node repie.sentatives ofthis ciryloenter upon the SEISMIC FEE
aum c-im ntionerl property for inspection purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the Cityof Cupertino lit ELECTRIC FEE
liabll iritis,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO M ECF,.
in nw,rry.a of ilia granting at this permit PLUMBING FEW
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CPM) ..
SOURCE REGULATIONS. �MECHANICAI.FCG
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCfIONTAX
Signature of Applicant/Cantmcmr Date EXHAUST HOOD(WMUCD - HOUSING MITIGATION TEF.
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicnnt or future Buildingocaupam store or handle haeardous material HEATING UNIT(10100.100 BTU) - -
as defined by the Cupertino Municipal Code,Chapter 9.12,olid the Health and Safety
Code,Section 25532BB! HEATING UNIT(OVER lma U)
❑Yes ❑Nor PAID
_ VBNTILAI'IONFAN(SIN . RESID)
Is Dom Rccuipt#
Will the applicantha or future building bycheat.use ea Air
or devices which
emit hamrdous air conmminants as AefinN by elle Bay Arca Air Quality Management BOILER—GGMP UHV,6R 100,000 B'IU)
biadm] TOTAL: .
❑YIN ❑Nn� BOILER-COMP VER 100.000 BTU)
d thWenceslaus
I have mad!are requirements under Chapter 6..95 of the Cali- AIR C(]NDI NCR ISSUANCE DATE
forma Heenan&Safety Code,Sections 25505,25533 and 25534,1 understand ohm if the NF.W IDENHAL MECH. SQ.IT,
building dotes ani cunendy have a¢•natal Wm i1 is my msponsiniliry m notify the necul all
ofth,retluirunena which moa be mel porn In issuance nfn Cenifrmm ofOmupency. -
Owner.,anthoriied.,,at Date TOTAL: ISSUED BY:
,OFFICE .