30154 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 3Oq H /1
1 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL EAT
D2
&J0 Coo LCL ^ A
OWNEQ:S NAME Pf1 —(���' CO T ACTOR'SNAME: LIC NO:
62A —II J�.1/ N/C CON'IROLM
.ARCHITECDENGINEER: LIC NO: ADORES
CONTACT. PHONE: S J< BUILDING PERMIT INFO
44Y
/Y1 g�2 v )730 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT MECH
0 0 a 0
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRtm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OF cd in full force
it effec wlei^n the ConuactordProlessiona Crule,and my license is PERMITISSUANCE R IDF.NTIA '
Z with tion 7000).1 Dr,kion O ears `"
G V nt. ❑SFDWL ❑KITCHENREMODEL
APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
ARCHITECT'S DECLARAII N �OIIAb PANELS
Fly ❑MULTI-UNIT ❑MFIC
Z O y Z 1 understand my plans shall focused as public rtm
cds MODIFICATION
O Z^ UI'TO 200 AMPS
1-wf ttnsed R
Laofersinml ❑INTERIOR ❑GHLMNEY REPAIR
OWNER-BUILDER DECLARATION 2011-IfMNI AMPS IMPROVEMENT
C W G 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 11100AMPS ❑BATH REMODEUREPAIR D DEMOLITION
�3aF fallow ng reason.(Section 703 LS,Business and Professions Code:Any city or county S IGNS ELECTRICAL ❑OTHER
YF-W O n which¢quirts a permit in construe,alter,improse,demolish,or repair any drume
prior it)its issuance,also requires the applicant for such Front to file a signed statement SPECIAL Cl RCUIT/MISC.
y that he is licensed pursmm to the provisions of the Contractors License Law(Chapter 9
CCOC) (commencing with Section 7")of Division 3 of the Businew not Professions Cade)or TEMP METER OR POLE INST. COMMERCIAL
a.d ey that he is escmpt themfrom and the basis for the alleged exemption.Any violation of
LL Section 9031.5b an applicant for ❑NEW BLDG/ADDITION ❑DEMOLITION
�y y y pp 00), subjects the applicant to aeivil penalty of POWER DEVICES
F2P [more than five hundred dollars(b5fNf1. ❑Ii:NANT ❑FOOL)SERVICE
F9C ❑ Lus concoct the propcny.ormy employees with wages as theirwAr compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p,L will do the work,and the structure is not intended or offered forsale ger,9144,Business OTHER
W 3$ and Professions Cade:The Contractor's License law it.,not apply to an owner,of OUTLETS-S WITCHES-FIXTURES
property who builds or improves thereon,and who Joos such work hi¢.elf or Through
his can employees,provided thio such improvements am not intended arc offered for NEW RESIDENTIAL ELECTR SQ RT.
sale.IL however,the building or improvement is snld within one year of completion,the SQ.ET.FLOOR AREA 5lSty FE
owner-latfilder will have the burden of proving that he did nm build or improve for puts
faceof side).
01,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
antrum the project(Sec 9044.Business and Professions Cade:)The Contract...hi-
centtLawdoes nos apply toanowner ofpropert who build%or improves thereon.and QTY. PLUMBING PERMIT FEE
who commens nonsuch projects with a crmlractor(.)licensed parsuont to the Contractors
Licence law' ` PERMIT ISSUANCE❑I ane exempt under Scc. .B&P C for this,reason Al19
Owner Uam ALTER-DRAIN&VENT-WATER(EA) VALUATIONlO
WORKERS COMPENSATION
DECLARATION
CLAhIOJedarmions: BACK FLOW PROTECT.DEVICE 1-JI / L/I' LUfL.O,Ib.
Iherchy uffima under pennh [ V
❑I have and will maintain aCenificate,of Convent to ml6insum for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TVPE CONSTRUCfIOF
smima,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
ABB of he labor Code,nor the performance of the work far whichthix pomata is iswcd GAS-EA.SYSTEM.I INC.4 OUTLETS
My Worker's Comlunsatlon Insurance carrier and Polk number am. OCCGROUP qPN
Cartier: Policy No: GAS-EA.SYSTEM-DVIiR 4(EA)
CERT119C O OF COMPENSATION INSURANCE,
WORKERS'
COMPENSATION INSURANCE GRF,gSFIINDUSTRL WASTE INTERCEPTOR
IThiv aeatian need oat he campined if the permit is for one hundred J.Ilars(S IOU) BUILDING DIVISION FEES
or less) GREASE'IRAP PLANCHECK PER
Toy any thminthe perfearrany
of the work fur which this pee Womis is'Comhall SEWER-SANITARY-STORM EA.200 FT
not employ any parson in any mannCLy w ea to the Wnrkcn'Compcn- ENERGY FEE
,� cation Laws of Cab Uac s�lla� lYl
�O Applicant 2. WATER HEATER WNENT/ELECI'R
GRADING FIiF.
z y becomeNOTICs bj AP LIe A NTW..k B,afar making this Ccnificnm of F[..bar o d you should WATER SYSTEM/fRGATING
become subject,.the Worker's Compenmmn provisions of the Labor Crile,you most SELLS FEE
� Emhwith comply with such provisions or this permit sM1atl be Jttmed invoked WgTER SERV ICE
a
7'z CONSTRUCTION LENDING AGENCY NEW kBSIDEYI'IAI.PCMB. PAID
V k for
thi thvuhemiscalud m.30lending agency forthe perl'mmmev of Dem RectiptN
� F the work for which this permit is issued(Sec.JU99,Civ.C.)
Lender.,Name V Landers Address TOTAL:
} d 1 certify thio 1 have mud this application and zmtc that tls ahwe information is
[-^ I` BUILDING FEE
h mnect.l ague to comply with all city and county ordinances and state laws relating f^ QTY, MECHANICAL PERMIT FEE
L)2 building contortion,and hereby ushorim rcpremmmives ofthia city to vale.upon the F
E
above-mentioned propcny for inspection purposes. PIikMIT ISSUANCE
(We)agree to save,Indemnify and keep harndess the City of Cupertino against EEincilisequence of the axband eathispewhich may in any way acerae against sail Ciry ALTERORADDTOMECII. ILnsvgnencc of the granting of this permit. FEE `APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'F(TO 10,000 CFM)SOURCI:REGUI �NS. zna � ^/ L FEESUR tt//66LL////L/L///LL////// ��,/t`?R/�, AIR HANDLING UNIT(OVER 10,000 CFM7DONTAX
Silt a mo pplsanVComranor Date EX HA UST 11001)(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or from building Occupant store or handle hazardous material HEATING UNIT(TO 100,M)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cody Section 25532(a)? HEATING UNIT(OVER 14,000 BTU)
❑Yes ❑No
VENTILATION FAN IS INGLE RESID) PAIL)
Will the applieant or future building Owcupem um equlpmem.,desire,which =CONDITIONER
Dam Receipt N
emit hamNouv air contaminants as defined by the Bay Arca Air Quality Managnnem I'OR 100,0 0 BTU)
District'
❑Yes ❑Na ER 100.000 BTU) TOTAL:
I have read the hazardous materials lcgairemema under Chapter dN5 of the Cali-fomiu Health&Safety Code,Sedans 25505,25533 and 255]4.I aMerxtand That if theISSUANCE DATE
building docs not cutrtndylmvcu tracd.thatais r,mSPoOhFbyu.ami lydmmcuNnt MECH. SQ.FT.of the rppoine.nrs which must be ton prior to ounmtt of s Cenificam of 0.cupancy.Owner or authoriud age^t DocTOTAL: ISSUED BY:
OFFICE