30394 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - - PERMIT NO. J<^ O
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL J{{JJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
1,6 2D / Al. ha Val
r� ro
O 5 NAME: PHONE. CONTRA OR'S NAME: LIC NO: NIC �� CONTROL a
u d 1(( F tic V11
40, ATE ' I, R' ;olAUI LICN j, ADDRESS: ❑
��ff Y A.
CONTACT. PHONE: BUILDING PERMIT INFO
Uen rg e _ 86_ �� ❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 1-1 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hertby slfinn that 1 am licensed mulct pmvisions o(CM1apmr 9(commencing JOA DESCRIPTION
Q0Z wird Sation]fXXl1n(Divisiun3of the Badness end Profession Code,and my license is - RESIDENTIAL:
0c) w PERMIT ISSUANCE
�.. mPoll(area and eff S 0SFDWL L1 KITCHEN REMODEL
J-Z�; License 1-s Lic.ie APPLIANCES-RESIDENTIAL ❑ADDITION C PLUMBING RE-PIPE
a 6 Date Canteaalpr
Dm ARCHITECPS DECLARATION ❑MULTI-UNIT []STRUCTURAL
,gypv� Iundersand myplans shall heated aspublicarmid. PANELS - MODIFICATION
OZ=dO UPT0200AMP5 [I INTERIOR CCHIMNEY REPAIR
aEnt Licensed Professional 201400OAMPS IMPROVEMENT
gy, OWNER-BUILDER mthe Contractor's
OVER 1000AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
I hereby affirm that I I S exempt from the ContmctCa License Law far
O d U followingreason.a.(Section 703 IS.Business and Pm(asio demolish.
Cale:Any city arrtocounty SIGNS ELECTRICAL ❑OTHER
Hwhich"aits m<n permit m cnnswn,altee improve,h cornit t fi repair any structure
that he sficeuance,MU91 to
he previsions o for sucCommucmittofle.nse signed SPECIALCIRCUIT/MISS.
;!1} (cot he is limned pSesunm to the previsions of the a Busim5a License Law(Chapter 9
apo mane I,engwith 70001 basis
or ol htheeged exemrdon.nyvi Coon or TEMP.METER OR POLE INST. COMMERCIAL:
o y that he ie exempt thcrt(mm and Ne basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLD70N
e, Secdnn]B31.Sb an a licunt fora (mil suM1'ecls then licant toucivil ¢nett of POWER DEVICCS
y y y VP 0 I PP p y []TENANT ❑FOOD SERVICE
Q nm more then five hundred dollars($500). IMPROVEMENT
Lo the work,the property,or myemplended mawagesassit,(Sot,compcmmiess SWIMMING POOL ELECTRIC
will ddathework,and
e:no tureisnm,License La emdfmr salv(Sly oven Business - ❑OTHER.
3 and Professions Cafe:The Suntaneo License Law docs not apply a an owner of OUTLETS-SWITCHPS-FIXTURES
property who builds or improves prereon,and who does such ware himself or Wnmgh
his own employees,provided that such improvements me at intended or oHcreJ for I NEW RESIIIf;NTLAL ELELTR SQ R.
sale.If.huwever.the building or improvement is sold within one yearofcompledon,me Q. I�REA LSQ.fT.
ner-builder will have the burden of proving that he did not build ar improve for per. �1!^
i om.f sale.).
0 1,as owner of the property,am eI.
conclusively contracting with licensed contractors to ,. T - w
construct the pmject(Sec.7044cess
,Bus and Professions Coh.t Tae Convennts Li- �z.
nta 'r
cense Low does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a emitmcmr(s)licensed pursuamuo the Continental SEP' 13
License Law. PERMIT ISSUANCE 1996
C l am exempt under Sec. ,B&P C for prix reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Date ft' 1 L'F L6f Gft I Btu VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby eff rte under penalty of perjury one of the following declarations:
10Ihave enJ will maintainvCertifica¢of Cmnxennn xlGinsure for Warkern Compen- DRAINS-FLOOR,ROOF AREA.COND, STORIES TYPECONSTRUCTION
,arm ,as Provident for by Section 37W of the Laor Corte.fur pre importance of the
work far which this permit is issued. FIXTURES-PER TRAP
'hull,and will maintain Worker's Compensation Insurance,as"tared by Section
3700oflhe Lxdm CCeMpe,tff Ne pedommnceof the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Walk
rlLICbQ{�Tvinay(ance m.rF IdPolicy Y b��./�3?95�7 GAS-RA.SYSTEM-OVER 4(EA)oil _
CERTIF ATE OF EXEMPTION IBOM WORKERS' /1L/6
COMPENSATION INSURANCE ��!! GREASFIINDUSTRL WASTE INTERCEPTOR
BGB.DING DIVISION I1?IS
This section recd not ocompinedl[Wa permit is for one hundreddollam($IIX) GREASETRAP
ser less.) - PLANCHECK FEF.
Loy any that in the perf..be,anninwoh for subch ject 1.me Woo issued CO. all SLW'ER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as ro become subject the Workers'Cnmpcn- ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNI IELECIR
z Applicant GRADING FEE
zy NOTICE TO APPLICANT.If.after making this Certificate of Cemptimn,you should WATER SYSTEMITREATING -
I" become subject to the Worker's Campcnsutom pmvisions of pre Lion Cale,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed invoked. - WATER SERVICE,
.77. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.Fr. PAID Date Receiptp
V,p Ihertby atfrrm thin there is acnnswnion lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.CJ
TOTAL:
0,\ Lendels Name
}K•fl Lcndds Address TOTAL:
Or 1 certify that 1 have mad this application and state that the above information is BUILDING FEE
ti % correct.I agree to comply withall city end county ordinuncesond state laws achamgto QTY. MECHANICAL PERMIT IEE
U ,Z building comarmiion,and hereby amhorice representatives of this city to enter upon the SEISMIC FEE
r move-mentioned property fur inspection puryovee. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cuper iro against ELECTRIC FEF.
liehiliries,judgments,costs and expenses which may in my way altrue ag.lnstsaid City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICAM'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDUINh UNIT(TO 10,(X%1 CFM) MECHANICAL ME
SOURCE REGULATIONS.
�//1(g�� Od Lill
d / AIR HANDLING IINIT(OVER IO,WOCFM) CONSTRUCTION TAX
Sngnamm of Applmac Dain EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEC
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hnzmdous material HEATING UNIT(TO 100.000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2.5532(.)7 HEATING UNIT(OVER IW,"BTU) -[3 ye, CNo VENTILATION FAN(SINGLE RESID) PAID
Date ReceiptM
Willthe applicant to foram building oecupam use equipment m devices which HOILF.R-COMP(JHI'OR 100.000 BTU)
emit Intensities air contaminants as defined by the Bay Arca Air Quality Maneme
agnt'
TOTAL:
Jisvicft
Yes []No BOILER-COMP(OVER 100,000 BTU)
❑
Ihave read the hazmilws matcrwls reyuirements under Chapter CONDITIONERr 6.95 of the Cali- ISSUANCE DAT
famia Health&Safety Cal,Sections 25505,25533.m 25534.1 understand that if the NEW RESIDENTIAL MECH., SQ.FL
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the ox,mo moms which must be met prima,issuance of a Certificate of Occupancy.
Onto,m rimu rind agent Date TOTAL: ISSUED BY:
OFFICE