30359 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY `
CI'T`Y OF CUPERTINO ' - BUILDING.ELECTRICAL PERMIT NO, 30359 O ^ ��a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL -`,�l J[ NI JI
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI'FI'AL DATE
N - 2F-E-e-PL CUnqG
OWRpER1;S xNSAME: PHONE: CONTRACTOR'S NAME: s� LICpNO,:/y7
• `Mt — u IAS G / Y'(J NIC COMROhp
RCHITECf/ENGIN,fiR: LIC NO: ADDRESS:
1 M vVL
CONTACT: PHONE:
/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL[ PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT E
I hereby affirm then I ant licensed under previsions of Chapter 9(aimmcming JOB DESCRIPTION
G II4C-with'Swlion]000)of Division J ofthe Business.d Pmteadnms Cale.anJ my license is
�00 It, PERMITISSUANCE RESIDENTIAL'
in full forte and effect.in
�UU Lle�se 1 LI0.M •�9� ��' ❑SFDWL ❑KITCHEN REMODEL
PZW Dam - Contras T — APPLIANCES-RP_SIDENTIAL .I OADDITION El PLUMBING RE-PIPE
p'
h0N ARCHITECTS DECLARATION
PANELS - ❑MULTI-UNIT ❑STRUCfURA
Z p M 2 I understand my plans shall be used as public rc<oNs MODII'ICATION
p!-Z--O UPT0200AMPS NfERIOR ❑CHIMNEYREPAIR
r 4I:W Licensed Professional 201-1100AMP5 I ROVEMENT
Q f,- OWNER-BUILDER DECLARATION
�+fY Y�Y11 a 1 hereby affirm that I am'excmpt'fmm the Contractor's License Law for the OVER I"AMPS OR
REMODEIIREPAIR [I DEMOLITION
,�36 U following reason.(Section 7031.5,Business entl Professions Code:Any city or county SIGNS ELECfRICA [I OTHER
41`6 which a quires a permit to construct,alms improve,demolish,or repair any structure
0 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECTALCIRCIT/ 1.
LLJL
Wp
}a2 that he is licensed pursunnOo the previsions ofine Commences License Law(Chapter 9
0 (commencing with Sectien]g07 of Divieinnlnf me Business and Profess inns Code)or TEM P.METER ORLE INST. COMMERCIAL-
6 0.n m that he is exempt therefrom and Bic basis for the illegal exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4411 4,�, sectian]I131.5 by any applicant fora permit subjects the applicant o a civil penaltyof POWER DEVICES ❑TENANT ❑FOODSERVICE
i more than live hundred dollars(85011).
^ Q ❑I,as owner ofthe progeny,or my employees with wages as their sole compensation. SWIMMING POOLELE 1V . IMPROVEMENT
will do the work,and the.amcmre is not intended or offered for still(Sec.]Dl4,Business ❑OTHER
6 3 and Professions Code:The Contractor's Licenu Law does non apply m an owner of OUTLETS-SWITCHES-FIXTUR S
Property who builds or improves Neuron,and who docs such work himself or through
his own employees.provided that such improvements are not intendedit oBercd for NEW RESIDENTIAL ELECTR IT. -
sole.ILhowevcr,nhebuilding orimprmvcmem issold within oneyearofcomplenion,the SQ.PE FLOOR AREA LSQ.PTq
owner builder will have the barren of proving that he did not build or improve for put.
pose os own). +�
❑ has owner of the Seeproperty,am exclusively contracting wine licensed comntors i, TD AL: (� i/
mmWn the project(sur.]M4,Business ane Prmlesalmnv Code:)The Cnnlrocmr's Li-
truselawdoesnotapplytoanownero(property who builds wimproves thecon.and QTY PLUMBINC PERMIT FEE �r 996
who commens for such projects with o commonest licensed pursuant m the Contmeam's
License law. PERMITISSUANCE CUrI1/F
C1Iam exempt under Scc. ;B&PCfmthismason
ALTI7R-DRAIN&VENT-WATER(IIA)
Owner Dam ' VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE J�xr�
Ihereby off under pensltyof perjury one of the following declarations: I .
❑I have and will maintain aCerificate of Consem to self-insure fie-Worker's Compel- DRAINS-FLOOR,ROORAREA,COND. STORIES TYPECONSTRUCf10N
salon,as provided for by Section 37W of the Lubar Calc,for the performance of the
work for which dd,permit is issued. FIXTURES-PER TRAP
LI,T have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofrtthFs,Labor Code,for thhee,Iverrfaomtarnccte ofthe work for which this permit is nomet. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
MYW
It,
Certiu( CoT'._It,)f1Ttl'1 Ts1117 al it Pubey Nay g-nl GAS-EA.SYSTI?M-OVER4(EA)
uno
CERUnCATH OF EXEM"ION 1ROMWORK RS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILl31N MFT:[S
(This senior need not Is,completed ifthe permit a for one hundred dollars IS 100)
m less.) GREASETRAP PLANCHECK FEE
I terrify that in the Nrliirnancc of the work for which this permit N issued,I shall
nw
employ any person in an so to bccomeeu6ect to the Worker:Com m NEWER-SANI'PARY-STORM EA.200 FT.
P Y ) pe ENERGY FEE
z sulion l.�w� (raI fomle.D,e
Z O Applicant IsyT/tI t�'I 0 cr WATER HEATER WIVENf/ELECTR GRADING
tzr y NOTICE TTAPPLICANT,I afteeking this Certificate o Exemption,you should WATER SYSTEMYIREATING
ai become subject to me Worker's Cot ensmlon pru,no is of ane Labor Code,you most SOILS HE
{LT forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
.a7z CONSTRUCTION LENDING AGENCY NEW RE.SIUENTIALPLMB: SQ.FT PAID
V0 I herebywhich this
isaund(See,30 len ding agency for performance mf Date eipt
W.C) L� The work for which this permit is issued(Sec.31197,Co,CJ
Q V Landers Name - TOTAL:
Ixnder' Address TOTAL:
G I certify man 1 have mad this application and stem met me above information is BUILDING FEE
t7o correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V F7 hulldingc...nuction,and hereby mumnxo re,newntmivcs mans city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to cove,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way meme against said City ALTER OR ADD TO MECH.
in consequence of the greeting of this permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITU-01(.100 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX -
Si,muma fAppli.rWComractor Dam EXHAUSTHOOD(W/DUCq - HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous material BEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)? // HEATING UNIT(OVBR 1110.100 BTU)
❑Yes PAID
VENTILATION PAN(SINGLE RESID)
(
Will he applicant orfuture milling wapantuseyAequipmentordevices which Dote Receiptp
haucontaminantsnus air contaminants as moment by the Bay Area Air Quality Management BOILER-COMP(IHPOR 100,000 BTU)
tt? TOTAL:
C:]Yes o BOILER-COMP(OVF.R I00,I100 BTU)
I have read the hmnnleus matmals AIR CONDITIONER ISSUANCE DATE
i5,2553 ems under .1 and r to of the Cali-
forniagdoes&Safery Code,Secninns 255(15,8myresp3.5534.1 understand that:fare NEW RESIDENTIAL MECH. SQ.FT.
`pb'y�Id�yi��eg doesnoncunrecrienc, haveemnan6 mat in is my respmsibiliry to notify me wcupam -
-1r IW1A AOhich 11'1 metpn4'^In iss fo C<nifcatft p
Owneroramhmostr ge �. Data TOTAL: ISSUED BY:
OFFICE