30247 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C[TV OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI,
BNI.DING PROJECT'IDENTIFICATION
I UILDINGADDRUSS. SANITARY NO. APPLICA9'ION SUBMITTAL DXIT
104-7-7 gfWE-1 CREFX PLAC-E. CUPERMO
OV{EER'S NAME: PHONE: \COON`TRRAAC{TOOR',S NAME: ') LIC 400:
Y. '+ ar—Reda 'Oon-K 'J'8[�? NIC � CONTRO
RCHITECr/ENGINBER: LIC NO: ADDRESS:SD 2`', , L O
,✓{ !NV V
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) DLnR6LIZ. . PVISI ME
PH
LICENSEDCONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of m
Chapter 9(comencing JOB DESCRIPTION
moz wihs tion9RW)ofDivision3ofthe�usinessendProfessionsC e,andmylicc tis RESIDENTIAL:
O in full force and efret. PERMIT ISSUANCE CS L C KITCHEN REMODEL
�U�j
License Class _ Lic.x APPLIANCES-RESIDENTIAL ITION C PLUMBING REPIPE
Date Camrmemr
F-Dtn ARCHITECTS DECLARATION �r MULTI-UNIT CSTRUCfURAL
z O 7J- 1 understand my plans shall be used as public seconds, `�� PANELS MODIFICATION
O z UP TO 200 AMPS
Licensed Prnficoa al [IINTERIOR [ICHIMNEY REPAIR
..1 OWNER-BUILDER DECLARATION 20LI000AMPS IMPROVEMENT
c I hereby affirm that I an exempt from the Contractors License I[.as, far the OVER 1000AMPS C BATH REMODEUREPAIR C DEMOLITION
,
ny ; following mason.(Section 9031.5,Business and Professions CadCe:Any city at county SIGNS ELECTRICAL
OTHER
iL ya which requires a permit m concoct,alter,improve.demolish,or repair any structure
N.l prim to its i,soanm,also requires the updinvan install perming file tripled statement SPECIAL CIRCUITIMISC.
y that he is limited pursuant to the provisions of the Commences Licence Law(Chapter9
all (commencing with Section 9000)of Division 3 tithe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
'L d e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of -. ❑NEW BLDG/ADDITION C DEMOLITION
Section 9031.5 by any applicant for a permit subjects the Vdicanno a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
zp. not mom than five hundred data. 150n. IMPROVEMENT
Q ❑ Lmowner of Ne pnspeny,or my employees with wages us their sole cnmpensmion, SWIMMING POOL ELECTRIC
f� will do the work,and thewrocmre is nut isamdedornffend for call,(S..704d,Rosiness COTHER
and Professions Cole:The Coasts is License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
reopen,who holds ar improves thereon,and who does such work hi all or through
his own employees,provided that such improvements are not imendeJ or offered for NEW RMhQ&bT'IAl.ELECTR SQ FI'.
sale.If.however,the building or improvement is sold within one year ofcomplc'min, in SQ.FT.FL AREA ESQ.FT.
owner-buildersaa.) will hove the burden of proving that he did not build or improve for par- �^
posse
0 1 as owner of the Fropeny,em exclusively contracting with licensed contractors to - L:a
construct the proien(Sec.nlaa.Business and ProfessionsCode:)TheComuctorsLi-
cse Law does not apply to an owner of property who builds or improves LU ves themon,and QTY, PG PERMIT tFEE
who comrr ns fnr such Projects with a comrmmrMpursomnth
l licensed uu e Contmcmis ss,
License Law. Ill. PERMI UAN -
❑ I am exempt under Seo. ,B K P C fnr this reason
ALTER- A ENT-WA 'R EA)
Owner Date r, V L ATION
WORKER:,COMPENSATION DECLARATION BACK FLOW PR EVICE ..��1 �41 ae/+\�
Ihereby ofarm under penalty of perjury one of the following declarations: L/
I have and will maintain a Certificate of Consent to self-insure for Worker's Compere DRAINS-FLOOR.RO ,COND.
STORIES`,`; TYPE CONSTRUCT ION
soon,u provide)for by Section 3](NI of the Luton Gds,for the ierfnrmancc al the
work for which this permit is issued. FIXTURES-PER TRAP r
C 1 have out will maimmim Workch Conferral Insurance,as reyuirW by Section J
3900 of yth�e�Labor Code.l or tlheeypeerrffoo'rmaanncee oofythe work for whhichy this perntitisissued. GAS-EA.SYSTEM.I INC.J OUTLETS OCC.GROUP 1 APN
My
Polar
Cam`er. L\Y `w tFl Is111ltl pogo y NoytZp ��l GAS-EA.SYSTEM-OVER 4(Ill
CERTIFICATE OFF.XEMPTION FROM WORKERS' GREASUINDUSTRL WASTE IN'TERCEPT'OR
COMPENSATION INSURANCE BUILDING DIV O FEC,
(This section need not becomple¢dif the permit is Torula hundred dollars GREASE TRAP
m less.) [GRADING
NCH[CK FEE
I certify that in the performance of the work forwhich this permit is issued,I shall
At
not employ an SEWF,R-SANITARY-STORM FA.200 FT.
p y y person in any manner xn a,m h vats subject to the Workers'Compel- ERGY FEE
z artium L al main.[Am
z O A Iieen WATER HEATER WNENT/I:LECfR
PP •.�{{�� FEE
NOTICE TO P Ll A :I, er m i tisCcni icalco !xemptiom ashould WATER SYSTEMRREATING
become suhject to the Wmkels Co nTer tion provisions of the Labor Cade,you must LS FEE
fordwith comply with such provisions or Nis pc.it shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. D
V D I hereby affirm that hem is a construction lending agency for the performance of D Reociptx
D. the work lin which this pemtit is issued(Sec,3097,Civ.C)
0 dentists Name TOTAL:
L) Lenders,Addressq `
LL I certify that 1 have mad this application and state that she shave mountains is BUILDIN FEE 2 y f
to correct.l agree to comply with all city and county otdinansm and state laws relating to QTY, MECHANICAL PERMIT FEC
V Z building emenruclim.and hereby amarum representatives(if this city to eater upon the SEISMIC sE14
above-mentioned property far inspection purposes. \ t
(WO agree m save,indemnify said keep harmis the City of Cupertino against b PERMIT ISSUANCE. ELECTRICVE
Iiubilities,judgmems,costs and expemus which may in any way accom against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLl1MBING I' '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FTi.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Commmnr Dote EXHAUST HOOD(WIDUCq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicator or future building occupant erre or handle haiallous material HEATING UNI'r(To 100.01)BT'U)
as defined by the Cupertino Municipal ode,Chapter 9.12,and the Health and Safety
Cade,Smarr,25532W 25532HEATING UNIT(OVER IN),"BI U)
❑Yer VENTILATION FAN(SINGLE RESID) PAID
Will the applicant ar(arum building accupm ame equipment or devices which Date eipt
.mit hxrnrdous air contain.antvJef by the Bay Area Air Qualily Management BOILER-COMPCHPOR 10y"BaD
�UlstricCC Yes ✓ BOILER-COMP(OVER 100,000 BTU)
I have read the haardous materials AIR CONDITIONER - ISSUANCE DATE
re,25533 tn,under Chapter.M 6,a 0(the Cali
forma Heald n Safny Cede,Secant 255115.73533 and 25530.I understand that if ate NF FSIDENT .MECH. FT.
building does not currently ave nom, al it isany rcspsnsibilitymnotify the occupam
quimtnentwsvhich est he nto's rte mCelificat Oc
Owner or amount agent IF ISSUED RY,
OFFICE