30079 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30079
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.Cf1ANICAL
BUILDING PROJECT IDENTIFICATION
4e'O�AC
PRISS: SANITARY NO. APPLICATION SUBMITTAL DAD
D t O
PH 1c 'S LI
NIC CONT LN
EARCH )DR /� ❑ Q
FI N ' - `w11 BUILDINGPERMITINFO
(44 ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB ME
LICENSED CONTRACTOR'S DECLARATI ERMIT FEE
QTY ELECTRIC P
1 hereby affirm that I am licensed under provisions of chapter 9(commencing B DESCRIPTION
G00 with Smli.m70(XpofDisi,ma3.ftha Bminessand Professions Code,and mylicense is - RESIDENTIAL,
{ys�l O O PERMIT ISSUANCE
F�� in full Tome and ellen. 9 b ''❑SFDWL ❑KITCHEN REMODEL
�UZ LicenseC 1.ic.p APPLIANCES-RESIDENTIAL
y6 Orae Comranur ❑ADDITION El PLUMBING L PIPE
ARCHITECII'S UECL A El MULTI-UNIT El STRUCTURAL
'ZOyZ mpq yT�an code PANELS
�I�vp�� MODIFICATION
oy_- T7Im 10 UP'10200AMPS ❑INTERIOR ❑CHIMNEYREPAIR
Fri Lice., ssranal 201-1000AMPS IMPROVEMENT
OWNER-c.emp,iRD Cm TION OVER 1000 AMPS ❑BATH RIEMODEUREPAIR ❑DEMOLITION
C I hereby affirm the 1 am exempt neuritic Cssiona o i Any c Law for the
�dxd06U
which requires
permit to
703L5,Buslomampowc.dmoli Codi Any city or county SIGNS ELECTRICAL ❑OTHER
W a W FNe which requires n permit,e crmsthe alter,imprr se,demolish,m repair any swemm
that
the is liensed!Incrar Te quina txrwi,a scant forme Counseen lors Licensn.e
signed statement SPECIAL CIRCUIT/MISC. -
� p. Ihrtheislicenced Increasing 7 the provhisio 3the eBusinessa Lit ems Isio(s Codmr9
p�•�p (commencing with Senion]fp0)of Division3of Ne Business and Professions Code)or ]EMP.METER OR POLE(NST. COMMERCIAL:
0. m p that he is exonpt themfrom and the basis froths alleged eaemptloa Any violation of ❑ BLDG/ADDITION ElDEMOLITION
�,N Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES TEN NT ❑FOOD SERVICE
z>. mre not othan five hundred dollars($500). OVEMENT
T6 ❑ has owner of the properly,ur my employees with wagesmtheir sole compcnsmion, SWIMMING POOL ELECTRIC
Fq will do the work,and the structure,is not intended or offered for sale(See.7N4,Business OTHER
W and Professions Cale:The Contractors License Law does oat apply te an owner of OUTLETS-SWITCHES
-�IXTURFS
fl'3•' properly who builds or improves thereon,and who does such work himself or through
his own employee,,provided that such Improvemmots arc non intended or offered for NEW RESIDENTIAL ELE);�R SQ FT.
sale.If,however the building or improvement is sold within one year ofcompletion,the SQ.IT,FLOOR AREA $/SQ.FT.
mer-builder will have the burden of proving that he did not build or improve for put- -
poeofsal..) qq p
❑I,as owner of the properly,nm exclusively com...fiqg with licensed emnwcmrs to T L' k•J, '/ �,,1
construct the project(Sx.'70WEL Business and Professions CMc)The Conuncon,Li-
cane law does not apply to an owner of pmpwy who builds or improves thereon,and QTYY PLUMBING PER FEE 41JIG,19
who er muncfs for such project,with.r.rl.t mU licttned pursuant the Cconaeo is
License Law. PERMIT ISSUANCE Vt 9AL1
❑I am exempt under Sec. ,B&P C for this reason 9
Owner Dee ALTT:R-DRAIN&VENT-WATER(EA7 -v/-c //IV, VALE
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: Vn'' V
•�I have and will maintain a Certificate of Consentto sd8inaure for Woskers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cellon,as provided for by Section 3700of the Labor Code,I the performance of the
rk fry°hick this permit is issued. FIXTURES-PER TRAP
;?leve turd will maintain Workers Compensation Insurance,as requited by Section
37W ofthe Labor Care,for the performance of the work far which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Ch rter,W.Jp �+s�a�a9 umnm carritt and Policy.31W � GAS-EA.SYSTEM-OVER Carrier. o \ai . Policy No W
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUIfAING
(This secn need not he comiEthicplete) e perom is friars,hundred drift., -
tioDIVISION I>BES
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person n any manner sons 1.become subject ,,the Workers Compen- ENERGY PEE
Z sation laws of California.Dam WATER HEATER WNENT/ELEC R
OO Applicant GRADING FEE
y NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should WATER SYSTEMITREATING
F" become subject to the Workers Comp,nsatlon provisions of the Ichor Code,you must SOILS FEE
forthwith comply wish such previsions or this permit shall be deemed revoked. WATER SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESED17NTIAL PLMB. SQ.ET. PAID t ccs tM
V 0 (hereby affimt that them is a construction lending agency for the performance of p
the work for which this Fjr/It lis gyred(Sec.3097.Civ.C.)
QI'•" Lender's Name •_dJV
V Lenders Address - - TOTAL:
0. 1 0. certify,that I have mad this application and Stam(het be about information is BUILDING FE
ILII correct.l agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby authorim oTm,enmtivesnflhis city to enter upon the SEISMI
`w above-mentioned property her inspection purposes. PERMIT ISSUANCE
(We)agree to save,imm
lendy and keep hamdess the City of Cupertino against ELECTBI FEE
liabilities.judgmcros,costs and expenses which cony in any way eceme against said City ACTBRORADDTO MECH.
PLUMBING FE
in consequence ofthe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICA FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0J00 CFM) CONSTRUCT ONTAX
Signatercof Applicam/Conlmcmr Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thevp,li,em.,future building xcupuniamrcor handle hcoushmsntal,oal HEATING UNIT(TO IM."BTU)
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade, tion 25532(.)7 HEATING UNIT(OVER 100,00)BTU)
es ❑No VIENTILA]'ION FAN(SINGLE RESID7 PAID
Will the applicant or future building accupaut use equipment or devices which - Date Receipt N
mil hazardous air eonmmin.ms as definedA.by the Bay AAir Quality Management BOILER-COMP DMP OR 100.000 BTU) T L:
• District? BOILER-COMP(OVER'1 01,000 BTU)
❑Yes []No ?'
ejld�,
Wthe adaus materials ratimmm,nts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
tolm& afe "Ae.S.ti..,25505.25533 cad 25534.1 mWe.d That if the NEW RESIDENTIAL MECH. SQ.FT.
at c ntly have atenant,that it is my responsibility m notify the cocupant
ire a must be mat poor m issuance n v cm cupancy.
thoriud agent Date - TOTAL: ISSUED BY:
OFFICE <