30390 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. (�O
BUILDING DIVISION APPLICATION/PERMIT' PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICA'T'ION
BUILDING A
ADDRESS: SANITARY NO. APPLICATION SUBMITTAL D
• ;7 €, &4A45
OWNER'SNAME: PHONE: sty G C NTRACTO 'S NAME: LIC NCO.
Te-7 4`71 NIC CO,X'TROLN
•kRCHITECT/ENGINEER: LIC NO: ADI/E-/J�/ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Do � '7 .a3 11,2_02 ) ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ N El
QTY ELECTRIC PERMIT FEE
1 hereby affirm ala 13 licensed under and
Professions
ofChapterCode. 9(commencingsis JOB DESCRIPTION
woo with Section 9IXXp of Division 3riche Business and Pmfessions Code.and my license is RF ID NTIA r
F_ in in full forte and SQ t PERMIT ISSUANCE
c"UW I.ianc Class `.G�_-_Lie.. 52e .5-5 9, ❑SFDWL 11 KITCHEN REMOUEI.
yQi Dow Conmacmr' APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
F.pm ARCHITECPS DECLARA'T'ION ❑MULTI-UNIT USTRUCTURAI.
N
O Z�Z I understand my plana shell he used as public record, PANELS
MODIFICATIO
UPl'0200 Ah1P5
FBF--W L¢en¢d Prolewitual El INTERIOR ,CHIMNEY REPAIR
j OWNER BUILDER DECLARATION 2014000AMPS IMPROVEMENT
y W Q 1 hereby affirm that I an exempt from the Contmemr's License Law for the OVER!"AMPS ❑BATH RF.MODEI REPAIR U DEMOLITION
K 36 U following reason.(Section 7031.5.Business and Professions Gale Any city or county SIGNS ELECTRICAL U OTHER
U.y which requires a permit to construct.alter improve,demmll.sh,or repair any structure
.F.,�0g
prior o its issuance also requires the applicant fm such permit to file a signed statement SPECIAL CI RCUI'r/M MSC.
�p. ma he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
I+1�00 (commencing with Section 700B of Division 3 ofthc Business and Pmfcsoion.s Code)m TEMP.METER OR POLE INST COMMERCIAL
c.=.9 Nat he is wimps mertfrom and the tvsis for me alleged exemption.any violation of U NEW BLDG/ADDITION ❑DEMOLITION
Section 11111,1 by any applicant for apemail,adjects the applicant w a civil penalty of POWER DEVICES
nor more than five hundred dollars(851X1). ❑TENANT FOOD SERVICE
< Las owneraf the propeny.m my employees with wages as theicsole compensation. SWIMMING POOL ELECTRICIMPROVEMENT
will do the work,and the structure is not inondedmoffered for sale(Sec.]DW,Business THER
at 3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does.such work himself or through
his own employees,provided that such improvement,art not intended or offered for NEW RESIDENTIAL F.LECTR SQ IT.
sale.IL however.the building or improvement is sold within one year of completion,she S TFLOOR AREA
oS/SQ.PT.
wn
Fuji of stfle.).
er-builder will have me burden of proving that he did nut build or improve far par-
❑1,ru owner of the progeny,,f exclusively contracting Coni licensed commctors i TOTAL:
rostrum the project(See.]M4,Pusinuas and Professions Codep The Cnnaacwr's Lf-
occur Law does not apply to an owner of progeny who builds or improve,chimer,and QTY. PLUMBING PERMIT FEE
woo contracts mr such projects with a contracts(,)heenned punuam w the Contramrs
License Law.
C1 am exempt under SeeH&PCfor chis reason PERMIT ISSUANCE
ALTER-DRAIN&VR NH WATER(EA)Owner Dom VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
/ I hereby affirm under Penalty ofpepury one of the following declarations: O EP 4q(S
❑ Have and will maintain u Cerdlicrc ofConsent w insure
self for Workers Camper- DRAINS-FLOOR,RODE AREA,COND. J
saran,as pmvidal for by Section 3910 of me Luton Gude.for me pccrorm ace of tan STORIES I`7 TYPE CONSTRUCTIOD
tort for which Bir permit is issued. FIXTURES-PER'1 RAP
U 1 have and will maintain Workers Compensation Insurance,is,required by Section
3900ofthc Labor Code,fill the gerfnmwnce of the work l'orechich Nis permit i,issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Work Comppp r 1 pp 'rand Policy nuJnf'� a6 [, OCC.GROUP APN
CamieeLyO�A/id n���//r Policy Net . aia9Gr?'I7CnF57 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASESNDUSTRL WASTE INTERCEPTOR
(This section rad nm be completed if me permit is fmtwe hundred dollars Ig 1018 BUILDING DIVISION FEES
tar less,) GREASE TRAP
PLANCHECK FEE
Ioy any matinthe anyperformance o as t becomork e which this perthe it Wisissued,I shall'Comper- SEWER-SANITARY-STORM EA.201)FT.
mol employ oily Pecan in any manner so as ns become subject m the Wmkcn'Cnmpen- ENERGY FEE
,C) Anion Laws of Glilornia.Dee -
�
,Z C) ApplicApplicantWATER IIEATER W/VENT/ELECfR
�+ GRADING 12EE
.N. NOTICE TO APPLICANT:If,dor making this swi reaof of L Labor
Code
you should - WATER SYSTEMO'REATING
a , become subject the Worker's Compensation provisions of she tactor Cade,you must SOILS FEE
forthwith comply with Hoch pwvnions monis permit shall be deemed revoked. WATER SERVICE
aQ
UO CONSTRUCf1ONLEN,IN'GAGENCY NEW RF_SIUIiYI'IALPhMB. SQ,FT PAID
I hareby.1hich nn chat there.iti isconstructionede30 lending agency for cueperformance of e s � Date RaeiplM
W U thework for which this permit is issued Sec.3099,Civ.C.) 1
0 U Lenders Nance
TtyrnL:
W Ixnder's AJdress TOTAL:
p, 1 cert ify that I have read this application and state that the atmos,information is BUILDING FEE
tq correct 1 agree cocomply with all city and county ordinances and stem laws miring m QTY. MECHANICAL PERMIT FEE
IJ z building construction,and hereby authorize representatives of this city m enter upon the SEISMIC FEE
uMrvcmentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree w save,indemnify and keep harmless the City,,(Cupertino ugaimt ELECTRIC ME
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER Ok ADD TO MECH.
m nmsegnence of me grating nI this permit PLUMBING PEE.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,000 CFM)
SOURCE REG t TIONS. MECHANICAL FEE
C7, tI - AIR HANDLING UNIT(OVER 111,000 CFM) CONSTRUCTION TAX
Signature of Apgiblie Ammucwr l Dam EXHAUS'THOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle ha>ardons material HEATING UNIT(T0100,000 RTU)
re defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section 25532bd? HEATING UNIT(OVER I(fggO BTU)
❑Y. C1No
VENTILATION FAN(SINGLE RESUH PAID
r Will me applicant or future building occupant use equipment or devices which Dae Receipt a
emit hmardous air contaminants a%defined by the Bay Area Air Quality ManagementF79T,"',
COME OR 100,000 BTU)
District? TOTAL:
OYes UNo COMP I B0,0N)BTU)
I have madlne hmardolnmturials cpurerrems under Chapter 6,95 of the Cilli-
forma Health&Safety Cede,Sections 25505,25533 and 25534.1 urdenwrd net if the ISSUANCE DATE
biiWingdosnmcu rely have a tenant.that is is my osrymsmilityw notify me occugamMECH. SQ.FT.ofthere u' ewhieh nest • prior to iswd a Ceni fleate of Orcup"IOwr or authorized agent D:te `� TOTAL:
ISSUE,BY:
OFFICE