30416 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIRICAL PERMIT NO. O n
4
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL,
16
BUILDING PROJECT IDENTIFICATION
JWILDINGADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
LIC e„P�TtN� . S.ZrLq
O NEIi'S NAME: PHONE: CU
RA OR NAME: LIC NO:
-T-KO
T u F/y Ikcv\-k` 1 ` O 1, y J NIC CONTROL#
4RCHUECTIENGINEER: LIC NO: DRESS: �I ❑
Sr S
CO1NTAcc - PHONE: - BUILDING PERMIT INFO
f ywl AyN(N..1 Ir1-D�yy (J I{ q 4.L P{ ❑ Consultant Fees Paid by Applicant(Initial) HIM LECT PLUMB MECH
LICENSED CONT CTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby orrirtm that 1 am licensed amen provisions ar Chapter 9(cnmmenang JOB DESCRIPTION
O0Z with Section 7000)of Division 3 of the Bminesaand Pntfessians Cale,and my licenses RESIDENTIAL:
O PERMIT ISSUANCE
W m full force end eRect. ❑SFDWL ❑KITCHEN REMODEL
tU Date License Class C.. APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RGPIPE
IL Date Cammcmr
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O n Z 1 understand my plans shall be used as public twoNPANELS MODIFICATION
'OZ� ` UP10200 AMPS
1= sensed Professional [I INTERIOR ❑CHIMNEY REPAIR
�X OWNER-EUILDM DECLARATION 201-1000 AMPS GIPROVEMENT
1 hereby affirm into I an,exempt from the Con racm(s'Liveno,Law for the OVER 10100 AMPS ❑BATH REMODEIJREPAIR (D DEMOLITION
O a U following reason,(Section 7031.5,Business and Professions CMC:Any city or county SIGNS ELECTRICAL ❑OTHER
OI••' which res,mo s's permit w comtmct,alien improve,demoliah,or repair any structute -
pdormilsisamence.alsona,mors theapplicent fornuch permit o rile o signed statement SPECIALCLRCUIT/MISC. '
} that he is licensed pursuant to the provisions ofthe Contractor's license Law(Cuipter9
0)o '
<C, (commencing with Section700fDiv;sion 3 ofthe Business and Professions Code). TEMP,METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of C3NEW BLDG/ADDITION [IDEMOLITION
%�LL Section 7031.5 by any applicant for a pannitsubjects the applicant m a civil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICE
L1... �' not mote roan five hundred dollars($501E.'
C Q ❑ I,as ownerof the property,or my employees with wages as their sole compcnsafio., SWIMMING POOL ELECTRIC IMPROVEMENT
22y.' will do the work,and the structure ❑
is not intended oroffered facials(Sex.7044,Business OTHER
la and Professions Cale:The Contractors License Law does not apply to an owner of OIITI.ETS-SWITCHES-FIXTURES
4' propmy who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If.however,the building or improvement is sold within one year ofc.mpletion,the SQ.FT.FLOOR AREA $/SQ.ET.
owner-builder will have the burden of peeving that he did not build or improve for par- 141,
M '
Pass of sale.). I .,
❑1,as owner of the property.am exclusively contacting with licensed contractors to 41
construct the project(Sec.7044,Business and Professions Code)The Contactors Li- AUG9,1 ��9
times law does not applyman..nerof property who builds onmprovea memo.,send QTY. PLUMBING PERMIT FEE TIC
whocontmcts forsuchpmjmtswimaconimctor(s)licensed pursminto the Contactors �I'
License law. PERMIT ISSUANCE 1�1- (,U
❑IamexemptuoderSec. ,B&PCImdd,n.n [(11b
ALTER-DRAIN&VENT-WADER(EAJ VALUATION
Owner Date
s WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
J hereby affirm under penalty of perjury one of the following declarations:
Cj I have and will maintain a Certificate of Consent t.self-insure far Workers Compton. DRAINS-FLODR.ROOF.AREA,CONE STORIES TYPE CONSTRUCTION
cation.as provided for by Section 37M of me Labor Gyle,for the performance of the
work for which this pe,.I is issued, FIXTURES-PER']RAP
❑ 1 have and will maintain Workers Compensation Imumnce,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN.
My W. Cm nsationlnsum ecartieram Policy rJtS
/ Cartier. �_F�'j`t�
Pubic, No.:� n 6S3-9b GAS-EA.SYSTEM-OVER4(EA)
/J CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASBnNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FI!FS
(This section recd not be complesdif the permit isfmune hundred dollars($ItN) GREASETRAP or less.) ECK FFE
(certify 0.1 faint any verfiar
sh obeor kmewubject 1.thepeaW is;m,'Compiml SEWER-SANITARY-STORM EA.200 FT.
not employ any penton in any manner eco atm become subject t.the Wrirkers'Cnmpen- ENERGY FEE
z cation Laws o(Celifomia.Date WATER HEATER W/VENT/ELELTR
O Applicant GRADING FEE
N NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM?TREATING
become subject m the Worker's Compensation provisions of are Labor Code,you must SOILS FEE
I3�sl [ forthwith comply with such provisions or this pcmtit shall he deemcdovoked! WATER SERVICE
tCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.per. PAID
U O Date Rueiptp
I hereby arfirm tha0here is nn
ction lending agency for the wrfoance of
U. E. the work for which thispermit is issued
W(Se(S<cJ097,Civ.CJ
O U Lenders Name TOTAL:
W Lenders Addrnss - TOTAL:
,HI,,astt
C1 cerify that I have read this application and state that the above information is BUILDING FEE
i-t CA corned.l agree to comply with all city and county ordinances and state laws telafingso QTY. MECHANICAL PERMIT FEE -
U building construction,and hereby authorizereprecentatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
PERMIT ISSUANCE.
(We)agree to save,indemnify end kap harmless the City of Cupertino against ELECTRIC FE[
Babilkies,judgmems,costs and expenses which may in any way accmeagalnst said City ALTERORADDTOMECIL
in consequence of the granting ofthis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Right CFM)
MECHANICAL FEE
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTIONTAX
ignature of ApplitenVCommctor Data EXHAUST HOOD OVMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the epplianmrfuwm building wcupam score or handle hazallous materiel HEATINGUNITfTO I0A00BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
❑Yes (3 No VENTILATION FAN(SINGLE RPSID) PAID'
Date Receipt#
Will the applicant or future building weapons use equipment or devices which
t hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
isvict? BOILER-COMP(OVER 100,000 BTU)
E3 Yes ❑Nn '
I have tend the hazardous..,ads requirements under,Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATES
tomo Health&Safety Code,Sectors 8505,25533 and 25534.1 understand that if she NEW RESIDENTIAL MECIL SQ.PT.
building does nn,conendy have a tenant,that it is my reepmeibility in notify the wcr,urt
of the co,mmtrtents which mast be met prior t.issuenm of a lead icate of[k<upency V V
Owner or authorized agent Date TOTAL: ISSUEDDY:
OFFICE