30278 NYYLIVAIV 1 IV raL IN INrUHMAI IUN WITHIN REDLINES-USE.BALL POINT PEN ONLY I -
• CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
30278
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK L / lYl
BUILDING PROJECT IDENTIFICATION ^ OSS.a^
BUILDING ADDRESS: - SANITARYNO. -, APPLICATIONSUBMITIALDATI
OUGb 6 Ave " -7 ,qty
OWNER'S NAME: PHONE: - CONTRACTORS NA�e� LIC NO: �b
Q.1NA �i2'i-31" (�,�pOgW1 N/C CONTROL.
RCHITECT/ENGINEE - - LICNO: ADDRESS: ❑ '
NTACT: ', rHONe: BUILDING PERMIT INFO
AS K6lIL( TL--318 Z ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB •MECH
LICENSED CONTRACTOR'S DECLARATION EJ ❑ El
with
Q C ZI hereby.tuQTY ELECTRIC PERMIT FEE
rn that I am licensed tinder provisions of Chapter 9(commencing
O Section 7")ofDivisiea 3ofthe Busineasand Professions Cade,and my license is JOB DESCRIPTION
k]U in full force entl effete f PERMIT ISSUANCE RESIDENTIAL:
�ZW License Class Lit.# - ❑SFDWL El KITCHEN REMODEL '
Q,kat Data _ Context., APPLIANCES-RESIDENTIAL EJADDITION El PLUMBING RE-PIPE-
(.,,O WARCHITECT'S DECLARATION
•Z O C 1 understand my plans shall Cut used as public records PANELS El MULTI-UNIT ❑STRUCTURAL
O 4�>0 UP TO 200 AMPS MODIFICATION
ty Lensed Pmfessonal ❑INTERIOR D CHIMNEY REPAIR
"'333 fffXXX !yam-{ OWNER-BUILDER DECLARATION 201-IOW AMPS IMPROVEMENT
yy O W I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 10(1(1 AMPS ❑BATH REMODEUREPAIR ❑DEMOLMON
p(a tw F following reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
{{xxll 0Na which requires a permit m construct,.trot improve,demolish,m repair any s name
prior to its issuance,also requires the applicant for euchpermit m file.signed statement SPECIAL CIRCUIT/MISC. 1
tbut he is licensed pursuant m the provisions of the Contractor's License Law(Chapters' _
(cam he
exempt
Sections andtfbasisror%theeged exe end Professions Cod e)or TEMP,METER OR POLE INST. COMMERCIAL'C
that i is exempt therefrom and the basis far Ne alleged exemption.Any violation of - -- ❑NEW BLDG/ADDITION
{m4 Section than five
anyapplicant farapermit aubjects the upplicam to.civil penalty of POWER DEVICES ❑DEMOLITION
t 1,are then Rvehundred
y,orrsyempl. ❑TENANT
MPROV ❑FOODSERVICE
G ❑willdo owner k,the prepeny,or myemntended With wages astheir(Site compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
and dodue work,and the structure is Out intendedmofferedtarsale(Sec.o an Business E]OTHER
3 m and Professions Code:The Contracture License law dors not apply s if owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or
through
to,
his own employees,s,provided that suchems improvements are not intended or offered fur NEW RESIDENTIAL ELECTR SQ PI'.
sale.obuilder will have th burden of
isoldhe
non Ford or erd
the /�SQ.F!".FLOOR AREA $/SQ.FT
entiatder will have the burden of proving that he did not build or improve for Coot- C AI ((
potentiate.).seley F- 4
❑ 1,as owner of the property;am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor's law Li- JUL
Li-
cense does not apply to an owner of Company who builds or improves QTY, PLUMBING PERMIT FEE ves thereon,and 1996
who contracts fersuch projects with a coutrac[or(s)licensed pursuant to the Commotio'. a�
Law. G� Y
mexcmpt under Sec.' 9ffi Cfor is p PERMIT ISSUANCE . `
Uh (.I.)p'G%II�.
tier ALTER-DRAIN&VENT-WATER(EA) VALUATION
-andORKER'S COMPENSATION DECLAR TI
I hereby affirm under penalty ofperjury one ofthe following declarations: BACK FLOW PROTECT.DEVICE
❑I have and will maintain a Certificate ofConsentto sel4irenre for Workers Campem DRAINS-FLOOR,ROOF AREA,GOND.
soften,as provided for by Section 377 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this parr is issued. FIXTURES-PERTRAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthebor LaCode,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 ING.4 OUTLETS -
MyWorkeis rri
Compensation Instant.caervnd Policy numhefcm: OCC.GROUP - qrN
Caalec Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
' CERTIFICATE OF EXEMPTION FROM WORKERS' r
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
(Thio section need not be completed if the permit is for one hundred dollars($100) BUILDING DIVISION FEES
or less,) - GREASETRAP
Icenify Nat in the perfonoaace ofthe work for which this _ PLANC!4EKFMEE
pee W..lseaCa'm,,all SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become eubjed to the Wnrken'Compen- ENERGZr sermn Lews ofCalifomiu.Date WATER HEATER WNENT/ELECTR•�. Applicem GRADIG fn NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATERSYSTEM/1'REA71NG
abecome subject m the Workers Compensation provisions of Ne Labor Code,you must SOILS forthwith comply with such provisions or this permit shall he deemed revoked.W WATERSERVICE .� CONSTRUCTIONLENDINGAGENCY NEW ft&SIDENTIAL PLMB. SQ.FT. PAIDVI hereby affirm Natthem is a construction lending agency for me performance df
Lks H the work for which this permit is issued(Sec.3097,Civ.C.)
0 U Lender's Name TOTAL:
Lkl Lender's Address TOTAL:
y a 1 certify that I have read this application and state that the above information is - jSETSMIC
G FEE
rr 0 correct.I agree m comply with all city and county ordinances and state laws relating hr QTY. MECHANICAL.PERMIT FEE
V huilding construction,and hereby omhedze representatives of Nis city to entaruprn the FEE
sl s,mentioned property for inspection proposes.(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE C FEEliabilities,judgmenls.costs and expenses which may in any way accrue against said City, pTH OR qDD TO MECH. .,'n consequence of me granting of this permit. - - - G FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTqIR HANDLING UNIT(TO 10,000 CFMSOURCE REGULATIONS. ) ICAL FEE
- AIR HANDLING UNIT COVER 10,000 CFM)
CONSTRUCTION TAX
Srgnema ofApphcaDO Date EXHAUST HOOD(W/DUCT)
HAZARDOUS
t ,HAZARDOUS MATE RIALS DISCLOSURE HOUSING MITIGATION FEE
Will thee Canant danfMuniipal CmOccupant.Chaps,9,12,handle Health us and Safety HEATING UNIT(T0100Af10 BTU)
as defined in fine25 Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety
Code, 7Yta 25532(a)7 HEATING UNIT(OVER IW,g00 BTU)
❑Yes (]No .
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Occupant use equipment or devices which Data Receipt#
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000BTU) `
7buildog
istrict's
❑Yes FIN. BOILER-COME(OVER 100,000 BTU) TOTAL:
f have read the hazardous materials requirements under Chapmr 6.95 of me Cali- AIR CONDITIONER
rom.Health&Safety Code,Sections 25505,25533 and 25534.I understand that if me ISSUANCE DATE
NEWRESIDEMIALMECH. SQ.FT, r
he1rices not currency have a tenet as o is my res Of.C mpea notify me occupantf the requirments which mum be mm portnissuvnce tits Certificate of Occupancy. '-wner or aumonzed.gem Dme TOTAL: • ISSUED BY:
OFFICE