30653 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PI.UNIBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AP
- - PLICATI NSUBMITTALDATE
�d36g Go .�v� �a�c, ls� .
O ER'S NAME: PHONE?: - CONTRA�1'OR'S bl E C 1YM S LIC NO:
�J l S (i ps 0 I/V C V J r NIC CONTROL p
1RCHITECTIENGINEER: LIC NO: ADDRESS: F-1
38HY ter
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONOZZ QTY ELECTRIC PERMIT FEE
I hereby affirm that I sm licensed under provisions of Chapter 9(commencing 1 OB DESCRIPTION
PIC0 with Section 7030)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL
0p full once and effect. PERMIT ISSUANCE
WU ❑SFT)WL ❑ rrCHEN REMODEL
�V�j License Close Coria APPLIANCES-RESIDENTIAL CD ADDITION RPL IMBING RE-PIPE.
Date TS DECLARATION
GG ARCHITECT'S DECLARATION [I MULTI-UNIT []STRUCTURAL
F�Z 1 undersand my pins shall be useJ ate public records PANELS MODIFICATION
OZ-0 UPTO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[- III Licensed Professional 201-I000AMPS IMPROVEMENT
,9 OWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
FF.i GOCC Q I hereby affirm that 1 am exempt from the Common's License Law for the
O y V following reason(Section 7031.5,Business and Professions Codc:Any city or county SIGNS ELECTRICAL []OTHER
a LL NFa' which requires a permit in construct,otter,improve,demolish,or repair any strucere
prior to its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
yy that he is licesm<d pursuant he provisions of the Conwcons License Law(Chapter 9
8Q0 (commencing with Section 7001)of Division 3 ofthe Business and Professions Cover or TEMP.METER OR PO LE INST. COMMERCIAL,
a q a K that he is exempt tberefmm and he basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
PC LSH, Seen.7031.5 by any applicant fora Permit subj<as he applicant too civil penalty of POWER DEVICES
} t more than five hundred dollars(8500). MNRO IMPROVEMENT [I FOOD SERVICE,
6 ❑ 1,as owner of the prop<ny,or my employees with wages as heir sole compensation, SWIMMING POOL ELECTRIC
will do he work,and he structure is not intended mi ffesed for sale(See 7044,Business []OTHER
and Professions Code:The Committees License Law does nm apply to on owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves hereon,and who does such work himself or through
his own employees,provided that such improvements are rot intended or oRercd for NEW RESIDENTIAL ELEM SQ ET
safe.If,however,the building or Improvement is sold within one year of completion,the SQ.FT.FLOOR AREA ESQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of mleJ.
❑1,as owner of the property,am exclusively contracting with licensed contractors sit
TOTAL:
onsuuct the project(Sec.7044,Business and Professions Code)The Contractor's Li-
cense Liw docs not apply to an owner of property who builds or improves themon,and QTY. PLUMBING PERMIT FEE
who contacts for such projects with a commons)licensed pursuant o the Contractor's _
License law. PERMIT ISSUANCE .6O
❑I con exempt under Sec. ,B&P C for his conn
Owner Dam ALTER DRAIN&VENT-WATER(EAG VALUATION
^
I hereby ul�m�nder penalty fperury neKERSCOM DofhefRlwogdeclaatlonx: BACK FLOW PROTECT.DEVICE //'rI.l j '., `
❑ I have and will maintains CenificeteofConwntioself-insumfor Workes Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,ss provided for by Section 37M of the labor Code,for he performance of he
work for which his permit is issued. FIXTURES-PER TRAP (p- Q
❑I have cad will maintain Workees Compensation Inc..,m required by Section
37M of the Labor Cade,for he performance of he work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker'Cy�Cnq�pcnsaI n lnsunpce cno read Policy u@ ryry,� n
CarricT: Sta-W +JKU Puhcy NO.:- S §27--'l� GAS-Eh SYSTEM-OVER 4(iA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASGINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This when need not be completed if he pemdr is for one hundred dollars IS 100) GREASETRAP
or It(This
FEE ,
I certify that in the perfommnce of the work for which this parmit is issued.I shotl SEWER-SANITARY-STORM EA.200 FT.
notempI yny person many Hoer soa to subject m he Workers'Compen- ENERGY FEE
,Z satiric Laws of Cnl'ri /3In% WATER HEATER WNENT/ELE=
z� O Applicom � _ GRADING FEE
NOTICE TO APPLICANT:If,after making thi Certificate of P.xemprian,you should WATER SYSTEM?HEATING
W become subject the Workers Cmmpenmtion provisions of the labor Code,you must •�O SOILS FEE
forthwith sh
fowith comply with such provisions or this peall be deemed revokod. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,FT. PAID
V ti Iherebyaffirmhmthere iso emsuunion lendiagagency lattice permtranc<of Date Receipt
she work for which his permit is issued(Sec.3097,Civ.C.)
l" F" Lender's Name TOTAL: '
Lender's Address TOTAL: -
1 cenify that I have sessions application rid some that the above information is BUILDING HE
10.p correct.l agate to comply wish all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
V z buildingcansauoim,and hereby authorize repremntativesa(,his citym onto,.,.ted SEISMIC FEE
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)as.m save,indemnify and keep harmless the City of Cupertino against
liahilities,judgmenns,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence ofihe grontingofthis permit. PLUMBING FEE �Q. Q-Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NDN-POINT AIR HANDLING UNIT(TO IBM)CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
ATR HANDLING UNIT(OVER 10,001)CFM) CONSTRUCTION TAX
Signaere of ApplicanVContracter Dam EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.0(()BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety.
Code,Section 25532(u)4 HEATING UNIT(OVER 103,000 BTU)
E]Yes FIN. VENTILATION FAN(SINGLE RESID) PAID
Dam Tk'
Will air contaminants
a building by the occupant Air Qualitnt or y
Manages ement
ant BOILER-COMP CHP OR 100.000 BTU) -TO
mit hazardous air conmminnts as defined by the Bay Area Air Quality Management TOTAL: Qt0
District? BOILER-COMP(OVER 100,003 BTU)
71 Ye" - ❑No _ DEC 11996
I have reed the hazmdeus materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
TaeWHealm& Cade.Sai rix 25503.25533 rid 25534.1 undersand hat if she NEW RESIDENTIAL MECH. SQ.FT. CNS Ur V UI"[hI INV
ndy hav eventthatinismyresponsibilitytondifytlxoccupant Vleb s con ssunmofaC<ni0cmeofOccu `/ lygent Dase TOTAL ISSUED
OFFICE