30215 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
CT'
BUILDING PROJEIDENTIFICATION
215
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
SG on AIez PHw zN� s3s3v 4 fcAC
NyR'S
OWNAME ONE: CON'rR OR'S NAME: LIQ NO I
NIC CONT'ROLa
�MICHITECf/ENGINEER: LIC NO', ADDRESS: �- -V/7 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRAC'IDR;S DECLARATION QTY ELECTRIC PERMIT FEE arsLyl�
I hereby mR That I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Seen 17000).f Div,,ion3offhcBosior,andp fessions C andmylicenscis
�1O ` PERMIT ISSUANCE 6 RESIDENTIAL:
F-_ nfull fd If iorce ane �J
Q
ZU License_- Loc.p ❑ L SFDWroYJCITCHEN REMODEL.
a_U Dam Contmc —71/V APPLIANCES-RESIDENTIAL []ADDITION //LJ,P�LUMRING RE-PIPE
Duei
ARC]IIIFCI"S DIiCLARA'110N ❑MULTI-UNIT ❑STRUCTURAL
Z p v�Z PANELS
I undemwnd my Clem shall be used as public remNs MODIFICATION
pZ—� - UPI O2INIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
I-�F'LL1 Licerted Pmfesimul 201-1000AMPS IMPROVEMENT
OWNER-BUILDER I am
m the CATION OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Q I hereby affirm Thr 1 am exempt from the Contractors License law for the
k 3 L F fallowinguires a (Semi t construct,
Business and improve.
d moll Gxle:Any city as county SIGNS ELECTRICAL ❑OTHER
ul u.y which requires o pem,il m ronswet,ulleq improve,demoli.vh,or repair any aWC1urC
co; priono its issuance,also acquires the applicant fm.mch Permit Tnlileosignedstatemeut SPECIAL CIRCUITIMISC.
y 'hat he is licensed pursuant to me Provisions ofthe Contmnor's License law(Chapmr9
WC�� ]commencing wish$amours]lMp)ol Uivisiannof the Business and Professinnx Cude)ar TEMP,METER OR POLE INST. COMMERCIAL:
ac
ta m That he is exempt Therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES
fin not..man five hundred dollars($50g)). ❑TENANT 13 FOOD SIiRVICE
1-=6 Las nwnerot the norm toacs war waesos lheirsulecom nation, SWIMMINGPOOLELECTRIC 1PROVEMENT
D (] the sh c Yemp Y 6 R
F
will do the work,and the nnnureisnot intended naoffered for
sale ofa(ply 704/.Business OTHER
G3 m and Professions Cale:The Ci mmdnra License law does nm apply to an owner of G OUTLETS-SWITCHES-Fl%TURF'S
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not imended or offered for NEW RESIDENTIAL ELECfR SQ LT.
sale.If.however the building or improvement is sold within one year ofcompletion,the SO.IT.FLOOR AREA $/SQ.PT.
iter-builder will have the burden of proving mal he did not build or improve for pur-
pose of sale.).
EJ 1.as owner of the Property,am exclusively contracting with licensed contractors to IN
o ranict the project(Sec.II11y Rninns and Prefessinn Cole)The Contmcev's li-
censeLaw does not apply to an owner of propcdy who builds or improves thereon.and QTY, PLUMBING PERMIT FEE T n
whocommcLs forsuch projectswith acnntmcmr(s)licensed pursuant)the Cumrnnnr's ' l
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner Dine ALTER-DRAIN&VENT-WATER(EA) J. V/////ggqAA777000QQ77��aa1Q���AA��TLON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICEr�ly
I hereby affirm under Penally of perjury one of the following declarations: Ut LI1�
❑ Lhasa anJwillmaimaimCenifieam of CunwnuOself-insure fm Waders Campers- DRAINS-FLOOR,ROOF.AREA.GOND. STORIES .s II JV TYPE CONSTRUCTION
saam,us provided fur by Section 3700 Of the labor Code,for the perfnrninncc of the
work for which This permit is issued. FTXTURES-PER TRAP
]have and will maintain Worlers Compensation Innrance,n required by Section
37W ofthe labor Cad,for me performance Of the work for which This permit is issued. GAS-EA.SYSTEM-1 INC.S OUTLETS OCC.GROUP APN
My Workthio' fy e-,trier and Polic
Carrier: - / r^' � Policy No. hw CAS-EA.SYSTEM-OVER 6(FAT
CERTIFICATE OP EXEMPTION FROM...K '
COMPENSATION INSURANCE GREASSINDLIML WASTE INTERCEPTOR
(Thi,oclion need mol la,coin,],,td if the Per...if is fonmc hundred dol lam IS I W) VISION FEES
or heed GRIiASE'TRAP PLANCHECKF ;
1 certify Ihm in the peUi,rmarev ollhe wtt
work for which this pmil isueJ
ixa .I shall I
not employ SEWER-SANITARY-STORM EA.200 HT.
P y any person in any manner m¢s'o haome suhjccnn the Workers'Cmmpcm ENERGY F i
Zsatins haws of Calif ornia.Date
ZO Applicant WATERHEATER W/VENT/EL[CB GRAD] , It
NOTICE TO APPLICAN'LIf,afiermoking this CcriEcme of Exemption,you should WATER SYSTEMOREATING
become subject to the Workers Compensation provision of The Labor Code,you must SOILS FEE
fonhwim comply with such pooi.,am,m,his Permit shall be deemed revoked. WATER SERVICE
0
0 CONSTRUCTroNLENDINOAGENCY NEW RESIDENTIALYLMtl. SQ.FT. PAID
U
U I forwhichinnlhatlhcre isanal Sec.3097.
len Jing agency for the perfatmance of oro Rcccipla
WLR me work for which thispmniit is isnot)(Sw.3f197,Civ.C.)
0 U Lendera Name TOTAL:
W Lenders Address TOTAL:
4 1 certify That I have read thia application and anile that the above information is BUILD] G FEE
V) comm.l agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
U building construction.and hereby authorize representatives of this city to enter urym The SETS CPEG
above meminned property for inspection purposes.
We g yon P yo pe gainst PERMIT ISSUANCE /ws
( )e recto cast,ts indemnify it hay in anthe Cit of novai F.LE RIC FEE V
inconsequenc of the
craning of thisfofwreawhich mayinany way occmangains'saidCity ALTER OR ADDTO MECH.
in consequence of'he gmming of this Pennil, PLO ��G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO'-POINT AIR HANDLING UNIT(TO 10,000CFM)
'RCE REGULATIONS. MECHANICAL FE
I —7AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUC ION TA%\
gnature of ApplicantUmmanor ( D e EXHAUST HOD IW/DUCT) HOUSING MITIGATION FGF.
HA9-ARDOUS MATERIALS DISCLOSURE
Will me applicant or future building cecupam stem or banJlehazallous mammal HEATING UNIT(TO 110,0100 BTU) �\
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
CWe.Section 25532001 HEATING UNIT(OVER 100,000 BTU) �
rYes ❑No PAID —\
VENTILATION FAN(SINGLE RFSIU) Dom Ruxiptp
Will the air comm m fm.,a building by the B use ea Air u or devices which
emrrier?rdouv air wmamimntx as dcfinN by the Bay Area Air Quality Menagcmcnl BOILER-COMP(3HP OR 100.100 BTU)
Tl TAI:
DisvimT
[3y. ONO ROLLER-COMP(OVER]00.000 BTU)
I have read the hazardous materials re ulromeuts under Chapter 6.95 of The Cali- AIR CONDITIONER
9 ISSUANCE LyC1'1F
G,mia Healthes no Safety Cafe,Sochave
255115,255)3 and rdbii 1 to notifym That if the NEW RESIDENTIAL MECH. SQ.FT. IOC/
building Jcea nor currently have a levant.Thal o k my tesponsi erifi'o notify The Occupancy,n'
of the requirements which must M1a mai prior m i.vawnce of u Cenilicme of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY
OFFICE