30068 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y^�f}'S(
CITY OF CUPERTINO I BUILDING-ELECTRICAL - PERMITNO 30068
� O O V N/
BUILDING DIVISION -APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
!A AL
OJ1'NER_S[J AMI?; r �D PHONE: CONTRACTOJi$NAME: LICNO:
11IY/�G/us EX . S.,-Ka+r� J+U �Oni 3C* NIC CO/ R LO
ARCHITECtoo"JNEF ICNOG122ya AD F.55: ^ ❑ /'./
CONTACT: T p}IONET l� BUILDING PERMIT INFO
Consultant Fces Paid by Applicant(Initial) B ELECT. PLUMB
RI e14 5 m�T
LICENSED CONTRACTDR'S DECLARATION QTY ELECTRIC PERMIT FF.E ❑
I hereby affirm that 1 am licensed under provisions of(]mpter 9(commencing 1 B DESCRIPTION
�a'Z with Section 7000.fDivision dry the Business end Professions Cale,and my license is RESIDENTIAL
�- in full force und,ffece PERMIT ISSUANCE I �F
F�U[U License Class Lica ❑SPDWL [I KITCHEN REMODEL
N< Dale Convector APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
p.7rn ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
y O Z� I understwd my plans shall lensed.,public recoNPANELS s MODIFICATIONOZ O UPT0200AMPS ❑INTERIOR C2 CHIMNEY REPAIR
24 Licensed Professional 201.]WOAMPS IMPROVEMENT
CCC OWNER-BUILDER DECe Contractors
ON OVER 1000AMPS ❑BATH REMODELI EPAIR ❑DEMOLITION
y Q 1 hereby affirm shut I um exempt from the COmraelCo License Law for the
x 3 a U following i soa(Seaton 903L5, t,Business and Professions Calc:Any city nr amnty SIGNS ELECTRIC []OTHER
which requires a permit oi construct,aline improve,sn demolish,or repair any slrvnure
Chit he its is p,alsorcquire theepplieum softhe Contraeh ctor's
icensle ae aw(Cl plargeserval SPECIAL CIRCUI
QQthat he is licensed pursuant to the of Division 3 the Cnmencos tLicense Law lChopmr9
thke
at he
exempt therefrom
IIlnd du basis for of Business and Professions Code)or TEMP.METER POLE IN COMMERCIAL:
Sll he is exempt therefrom end Ne basis for alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC Seclion]OJLS by eny applicam farupemlit subjcels the upplicam loacivil Penalty of POWER DCVICE.S
W-'y NANT ❑FOOD SERVICE
I,- y not more than fivehundredeprope dollars
yempl IMPROVEMENT
❑ I,,the owner ofNe pr.peny,amyemployeeswith wages vs0ei(Sec.compensation, SWIMMING POOL ELECTRICwill •QOTHER
and dnlhe work.Code
no,mmis not intendist,La doedi es ton apply I.
Business
m and Professions Indiction
The improve.
Contractors License Law Jas not apply roll owner of OUTLETS-SWITCHES
his)o ny who builds or improves tbsuch i and who docs such work deed or m Ilwugb
his own employees,provided that such improvemems are not intended.,.(fere)for NEW RESIDENTIAL EL R SQ
sale.IL howevegth,building.,improvemem is sold within one yawn(completion,the SQ-FT�LOOR'AREA 5/SQ.FT.
owner-builder will have the motion of proving that he did not build or improve for put-
pose us owner
wne of T p 9199
❑L uct the rujut property,am,Business ely
Professions
Code:)The
eConntracross m
connect the project(Sec.]B4a,Business end Pmfeasions CoJeD The Convectors Li.
cerve Law does not apply to an owner of propeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE ri, VV
whocommos forsuch pmjcns wulaacontmmndti
s)licensed pursuant the Contractor's VV r—
`cense lam exempt under Sec ,B&PCfsr lhisreason PERMIT ISSUANCE C,1� OF
Owner Dam ALTER-DRAIN&VENT-WATERHIA) V 2 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE G Ar—h
I hereby affiml under Penalty of perjury one of the following declinations: 3 ✓ ov-
•(]IhaveenJ will maimain aCertificmeofCohsenuoself-Insure for Worker's Compen- DRAINS-FLOOR,BOOR AREA,GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 7]00 of the Labor Cale,for the performeae of the
work for which this pc.it is issued. FIXTURES-PIR TRAP
❑E have and will maintain Workers Compensation Iamnev,as required by Section
3700ofthefa1ho1CotR.for theperformanccof the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
M omen !+T'Mrkers Compensation
Ic rend Policy numbe�s)�e�
apensee tion`Insurance Policy No: 3— —jam GAS-EA.SYSUM-OVER4(EA)
CERTIFICATE OF EXEMM10N FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR _
lTfiis section need nee becine leted if Ne pentyl is fur one hundred dollars El 100) BUILDING DIVISION FEES
GREASETRAP
or less) PLANCHECK FEE -12 At
I cmify diet in the perlbrmencem'he work(or which this permit is issued,E shall SEWER-SANITARY-S'PDRM EA.200 FT.
not employ any p amen in b
in any manner so as em
coe subject I.the Wmkers'Compen- ENERGY FEE
,z cation Laws of California.Duro WATER HEATER WNENT/F.LECTR
y�O Applieant GRADING FEE
tiNOTICE TO APPLICANT,If,after making oris Cendimm of Exemption,you should WATER SYSTEM/TREATING
'became subject to die Worker's Compensation pmvioco s of the labor Cale,you must SOILS FEE
W� finovith comply with such Provisions or this permit shall b,deemed revoked. WATER SERVICE
Q Q LL//''..
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID i
V I hereby affirm that them is.constriction lending agency for the performance of --- __Da Receipt ,
LTs 'Ne work for which this permit is issued(Sec.3097,Civ.C.)
Lenders NameTOTAL:
{U Lenders Address TOTAL:
1 ccnify that I have read this application and same Nat the above information is BUILDING FEE �•
corat.Ieg.,.,.mply withull city and county oNinarcesand state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction.and hereby authorize representatives ofthis city to enerupon the SEISMIC FEE
above-mentioned property for inspection ptlrpo es. PERMIT ISSUANCE ELECTRIC
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way aecmengainn said City ALTER OR ADDTO MUCH.
in consequence of the granting of Nis permit. PLUMBI -
APPLICANTUNDERSTANDSANDWILL,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANI LFCE
S EGO 'DNS.
.iC,, AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signattmo'Applien Contractor Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will the ii,diemilor forum building cecuparo,ons or handle hazardous mmedal HEATING UNITTO 1W,fd)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12 and the Health and Safety
Cada,Section 25532fay HEATING UNIT(OVER 100.000 BTU)
❑Yes C]No VENTILATION FAN(SINGLC RESIDE PAID
Will the applicant or future building occupant use equipment or devices which Dom H
ace pt
W
n hazardous air comaminan¢a defined by the Bay Aro Air Quality Management BOILER-COMP QHP OR 100,000 BTU)
TOTAL:•Distdct4
[I Yes [:1 No BOILER=COMP(OVER 100,000 BTU)
'
I have read the hazaNauxmaterials requirements under Chapter 6.95 of de Cali. AIR CONDITIONER ISSUANCETE
fond.Health&Safety Cade,Sections 25505,25533 and 25574.1 understand Lha if the NEW RESIDENTIAL Ni SQ.FT.
building docs not currently have a mane that it is my responsibility to notify the occopern
of the requiremrnm which most be met prior to issuance of a Certificate of Oceupvoey.
Owner or suthomed'em Data ISSUED BY:
OFFICE