30377 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUI LDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECI]AN ICA L 30377
BUILDING PROJECT IDENTIFICATIOY
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDAI
-L 2V;6 Herptej-eq-lo RD Cueve-caN•v CR gSo(q Qi21
OWNER'S NAM F:: P NE: CONTRACTOR
`S1NAME: LIC NOi
iL1E�! 00 ► 33x4 x LLNIi C V R-966-71 NIC CONTROLW
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
4-79 E,.Ra.A.k, ual.� 0231(- S'TwE��rF S(IZ
CONTACT. PHONE: BUILDING PERMIT INFO
-Cum f�17n gqq 8S ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS IJDEC``L�IA�RATIION 6 QTY ELECTRIC PERMIT FEE � ❑ ❑
I hereby affirm mar 1 am licensed under provisions of Chap.,9(commencing JOB DESCRIPTION
WOO with Scene.700 fDivision 3ofthc Business and Professions Cade,tied my license is - RESIDENTIAL:
F O in full force and effect PERMIT ISSUANCE,
a-J License Cl _. Lic.# DSFDWL D KITCHEN REMODEL
ti Q W Date Comre• rr APPLIANCES-RESIDENTIAL ❑ADDITION D PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS
p.Oyi J� El MULTI-UNIT El STRUCTURAL
Z O H Z I understand my plans shell be uuJ as public rands y 1`T( — MODIFICATION
OZ�n UP TO 200 AMPS
F F tic Licensed Professional D INTERIOR D CHIMNEY REPAIR
F.'1OWNER-BUILDER DECLARATION 201-1 WUAMPS IMPROVEMENT
C W Q I hereby affirm that 1 am exempt fmm the Cummcmr's License Law for the OVER Hit)AMPS - D BATH REMODELREPAIR D DEMOLITION
3 LL U following reason,(Section 7031.5,Business and 11 fesiunn Cade:Any city or county SIGNS ELECTRICAL. D OTHER
O m which requires a permit to cataract.altar,improve.Janollxh,or repair any structure
a!, cion.is,vatruwa,tiko racturo,thea,qui,amf I ponni,tople a,i,msd,mmrwm SPECIAL CIRCUITAITSC.
y that her,lc . d]Itialmort fitlife poliliomol th Cam t License L (Chapter9
HMO (eommuw
enng lh Seed 17000)or DiAnot3 of life 11 aln,ness and Pr fessioCode)or TEMP.METER OR POLE INST. COMMERCIAL'
c.q a y that he is exempt throlmin and the basin ll alleged exemption.Any violation or D NEW BLDG/ADDITION D DEMOLITION
Section 7031.5 by any applicant for a permit xuhjects the applicant to a civil penalty of POWER DEVICES TENANT El FOOD SERVICE
not morethin five hundred dollars SSW).
FSG D 1.as owncrofma pmpcny,army employees with III asthcir,.Ia compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p., will do the work,unJ Ne strvcmnix not inrenJcJ nr nlTcrcJ 4rrsale(Sec.]LW4,Business :1 ❑OTHER
3 ro and Pfom,xi ns Code:no Gnnrmurts Llano Lnw.dms not apply m na owner of T OUTLETS-SWI'rcHtis-FIXTURES
property who builds ar improves thereon,and who does such work himself or through
his own employees,provided that.such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however the building or improvement is sold within one year ofcompletion,the SQ.FT FLOOR AREA S/SQ.FE
owner-builder will have the burden of proving that he did not build or improve for pur-
pove of sale.).
E]1,as owner of the property,am exclusively contracting with licensed contractors to IOTA 50d S� ,
construct the project(Sec.]0.k4,Rumness and Professions Code:)The Contractor's Li-
meLaw does not apply toanowner ofproperty who builds orimproves themon.said QTY. PLUMBING PERMIT
-he contracts bonsai projects with a,mametor(s)licensed pormse m the Contractor's
License law.
❑Itim exempt under Sec. ,B&PCfmthismaron PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA) s
Owner Dam U VALUATION
WORKERS COMPENSATION on DECLARATION BACK FLOW PROTECT.DEVICE giYl [/1�y
I hereby affirm mica Certificate perjury one of the following dceker'x o ^' / iOnaa
Dlhave and will rtminby Secti37Certificate of he Labor Cooent to k,for forarmormFCompche DRAINS-FLOOR,ROOF.AREA.CND.
.shoe,as pmviJhi for by Section 3]W of tM1e LeMm CMe,for Ne performance of the 1://r'STORIES }TYPE CONSTRULTIO
work for which this .it issued. Vf'
VI panni 2 FI%TURES-PER TRAP LL-
Ly 1 have and will maintain Worker's ante ofuni w Insurance,h required by Section f�fl Oil /
37W of the laMsr Crula,fonM1c Cerformance nfthe work for which this Permit isisued, GAS-EA.SYSTF,M-1 INC.40I1TLETS OCC CROUP APN
My Workcr'yCpOl c�'tie Insurance comer and Pulicyt �p 4(µ-i1 6
Comma_S e/F\E F:JWD Policyrmm Wyk' P D GAS-EA.SYSTEM OVF.R4(EAT
CERTIFICATE OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDU$'BL WASTE,INTERCEPTOR
(Thisuction need not M nnnplemA if the pennil is forona M1undmd dollas(SI(fl) BUILDING DIVISION FEES
or Iris.) GREASE TRAP
I certify that in the perfbrnwnec of the work for which this permit is issued,I shall PLANCHECK FEE
not employ any person in any mntmeno an to hocunm subject to the Workers'Coiter- SEWER-SANITARY-S'I ORM EA.20017.
Z amine lows ul Celifnmia.Dem
ENERGY FEF.
zO Applicant WATER THEATER WNENI]ELLCTR GRADING FBF.
NOTICE TO APPLICANT.If,after necking thin Cenilicnte of Escape.,you should WATER SVST'EM?RF,A'1'ING
become sub cct to The Worker's Com
a ' ] Ps or this provisions of the Labor coke,you most SOILS FEB
Ft7 forthwith comply with such provisions or rifts permit shall be deemed revoked. WATER SERVICE.
G Q
'J z CONhem is TIONacon%t LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
C.J work
by which
that issuedgrcti097.leading agency for the performance of Data Receipt#
Hthe work for which this permit is issued(Sec.JW],Cu,CC.)
Lender's Name
W famde,,Address TOTAL: TTIOTIAI.
F' 0. 1 cenify that 1 have read this application and nae that the above information is BUILDING FEE
pa correct.l agree to comply with all city and county ordinances and state laws relaingto QTy, MECHANICAL PERMIT FEE
V Z building coencrox icon,and hercbyauthoriu repessumboesoe Nis cityto enmrupom the SEISMIC FEE
.boot,-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save.indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,cosaend eapcnsu which may in any wayaccmeaIam.,I said City ALTER OR ADD TO MECH.
in consequence claim granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB.IXq CFM)
S URCE REGUL TIONS, MECHANICAL FEE
s AIR HANDLING UNIT(OVER IOA(p CFbD
CONSTRUCTION TAX
Srgmamre of Apphomon7 mu<m, Data EXHAUZMT
MUCO
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicamor fumrc building oecupout time nr handle haurdous material EA TOW.010 BTU)
as defined by the CuNr iso Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255)2m)'! R 1 00.000 BTU)❑Yes �NnSINGLF,RESID) PAIDWill Ne applicant or lawre building mcupam use equipment ar devices which Dam Receipt#emit hvmdatus air cnntuminuntn ax defined by the Bay Arca Air Quality Management OR I00,f(X)BTU).1rid7❑Yes DNo ER I OP(Taq BTU) TOTAL.
1 have read the halanlatm mnmomix reynirements i do,Chapter 695 of the Cali- AIR CONDITIONER -
fomia Health&Safety Cook.SWlions 2.5505,25533 and 25534.1 understand that Cthe ISSUANCE DATE
buildingJots notcuremly hooses¢•nunt.thet'ulsm mihilit meati, the mccu nm NEW RESIDENT IAL MECH. SQ.lel'.
p°
of the requirements which I'mxt ho-ow,prior n,Issuance ora Cenilause or Occupancy.
Owner or aahonlad agent Date TOTAL:
ISSUED BY.Cle
OFFICE