30702 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELELTRICAI, PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDR S: SANITARY NO. APPLICATION SUBMITTAL DATE
toggI otinL - y I — 9�
OW;QS S A '1RACTOR'SN NAME,
a Ia. / LO
NIC
CONTROL N
AKCHUEUVENGINEER: LIC NO: ADIMES ❑
CONT CT: PHONE: BUILDING PERMIT INFO
a't. / 215-3 0 ^ ❑ Consultant Fees Paid by Applicant(Initial) LUG ELER PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
�Z
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DE$ PTION
with Sectio.7WE.fDivision3Ofthe Rwimessandprofamions Codgandmy license is R RID
ly" to full force and effect. PERMIT ISSUANCE 3 'r NTIA
�UIpp" License Class
Lc
in
ElSFDWL - ❑KITCHEN REMODEL
kc..Zu] Dam Com=lor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
EI
INI..ju, ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
,ZOv2 4 I understand my plans shall beused.a publiencnrds MODIFICATION
'OZ=10 UP'1'02WAMPS ❑INTERIOR El CHIMNEY REPAIR
eri4i` t.7 Licensed Professional 201-1000AMPS MPR
NY "a{ OWNER-BUILDER DECLARATION
y❑y Y 1 hereby affirm that 1 um exempt from the Contractors License Law for at OVER IOWAMP5 ATH REMODEUREPAIR 0 DEMOLITION
to a Oi FUF following reason.Section 7031.5,Business and Profosslor,Cndc:Anycity or county SIGNS ELECTRICAL 0 OTHER,
4F=O ye which requires u Permit to consmsm,uller,improve,demolish,or repair ,eny strctam
%..1 Printouts issuance,a iso requites theapplicent forsuch permino file.A,nadsamentem SPECIAL CIRCUIT/MISC.
that he islicamad Wrsuam..the provisionsofthe Contractors License Law IChiptcr9
aCO (commencing with Section](100)of Division 3 Ofthe Businessnnd Profasio^s Code)or TEMP.METER OR POLE INST. COMMERCIAL:
D.p,M e' that he is exempt Nerefmm oad Ue basis for the alleged exempliu^.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES OTENgNT OFOOD SERVICE.
I-Zi not mom Bass five hundred dollars(SSW),
pO 01.as owner of the property,or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
GCGC will do the work,and thesta,mr,isnotinundedmaffcredfuraule(Sec.TWIBusiness DOTHER
63 m snit profession.Code:The Cmumara rs License law does not OIXT
apply to an wner of OUTLETS 4 J
pmpany who builds or improves Nemo^,and who does such work himself or through s
his own employees,provided that such improvements are not intended or offered for. NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,however,the building or improvement is sold within one year ofrompletio^,the SQ.FP.FLOOR EA $/SQ.F..
mer-builder will have the burden of proving Net he did not build or improve for put- -
pose of sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to T /
construct the project(Sec.7W,Business and Professions Code:)The Contractors Li.
cense Low does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such pmjats with acontmcmAs)licensed pursuant to the Contractors
License Lew' PERMIT ISSUANCE t So
0 1 am exempt under Sec. ,B&P C for this reason
Owner
ALTER-DRAIN&VENT-WATER
(PA) VALUATI
• Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE � C QEn O
1 hereby affirm under penalty of perjury one of the following declazetinna: J
I have and will maintain u Certificate of Consent nr self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. $TURIE9 TYPE CONSTRUCf10N
union,as provided for by Section 37M of Ne Leber Code,for the performance of the - O
work for which this permit is isemi FIXTURES-PER TRAP
0 1 have and will maintin Workers Compansmion heaman.,as required by Section
3]011 of laharCode,fnrJheperformun of the work lOr which this pemtit is i.esucd. GAS-EA.SYSTEM-I INCA OUTLET'S
I OCC.GROUP APN
Co MY aur kCnt ..tint^t�w"Pce tO dPnlicy ny d ac: GAS-EA.SYSTEM-OVER a(EA)
Cartier. uY alley No
CER IFIC OMPE SATI ON FROM W RK S'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(this section need not be completed if the permit is far one hundred doll...($100) BUILDING DIVISION FEES
or less.) GRGASE TRAP
I verify that in the performances(the work for which Nis PLANCHECK FEE
nut eaald., ny person inanmanner so as to lecom iubjecnOne Workers''Camper- SEWER-SANITARY-STORM EA.20B FT.
Y a^- ENERGY FEE
�.
Applicant
nt of California Dom
O A livor WATCR HEATER WNENTIIiLECTR
PP GRADING FEE
Vi NOTICE TO APPLICANT.IL alter raking itis Certificate of Exemption,you should
become subject m the Work ds Compensation provisions of the LabWATER SYSTENU TREATING or Cake,you must SOILS FE
Lit
forthwith comply with such provisions or permit shall be deemed revoke,. WATER SERVICE.
a �
UO CONSem is ac ONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FR PAID
I hereby which
pauhere isaco (See.3N7,
lending agency for the performance Of D Receipt If
W the Under'k for which Nis permit is issued(Seo.309],Civ.C.)'
ULender's Name TOTAL:
{11 Landers Address
p„ 1 canify that I have mad this application and stem Nat Ne above information is BUILDIN FEE
Z] correct.1 agree to comply with all city and county Ordinances and state laws elating to QTY, M 1 AL PERMIT FEE
U ,�7a. buildingco.nrunion,ad hereby amhariae reprssenmtives of Nixcitymenmrupsm the SEISM FEB
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and kap hmmle,¢Ne City of Cupertino against PE TISSUANCE ELECfRi E
liabllities,judgmentu,costs and expenses which may in anyway accrue against said City A ORAD,TOMECH.
inronsequenec oftha granting of Its permit. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. - AI CFM) MECHANICAL FEE
AIR HANDLING ON[I(OVER 10,000 CFM) CONSTRUCTIONTAX s
Signatueof ApphrardCortracmr Data EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in future building occupant store Or handle haysNous materiel HEATING UNIT Gro I W."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end he Health and Safety
Cale,Section 25532ho? HEATING UNIT(OVER 100.000 BTU)
❑Yes Otho VENTILATION FAN(SINGLE RESID) PAID
Date Ra M
Will the applicant or future building ed by the Bt use equipment or devices which BOILER-COMP(3HP OR 100,900 BTU)
emit hazaNnus air contaminants as defined by the Puy Area Air Quality Management T6TA1.
District?
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
1 have read the hae.rdsus matedis requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
9 p ISSUANCE DATE
fomia Health&Sofey Cade.Sections 255115,8531 and 25531.1 understand the if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a roan tient in is my responsibility to notify the acupat {�1
of the requirements which must be met prior m issuance of a Cenificate of Occupancy.
Owner oramhon.,agent - Dutc TOTAL: ISSUED BY: �- Is c:;,
OFFICE