30725 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING PROJECT IDENDPICrI ION
725
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA.
Z l 92 S H�IA N►J I S�oR'r 2 I Z 3o�q(,
WNER'SNAMEi
MA Z4- I 3N TytNTR Cp�1�RN ER� 6ILICNO'
-I✓4G�TIl� 1 NIC CONTHOLq
\RCHITF.CT/ENGINEER: DURESS:
"o Sox 10441 SAID TOSC q C e
CONTACT. PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑ ❑
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
1A1y 30izz with Scction700n)u1'Dlv:don3 nfthe Rusincas and Professlans Codc,undm Icnnseln RESIDENTIAL:
FO- in full fo.ue u.W eBM. GCM y ' PERMIT ISSUANCE
<F.UZ�j License s l.• �� Q ❑SFDWL ❑KITCHEN REMODEL
NQS Dwa�Cantrucwr APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
1„py ARCHITECTS DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAL
Z p y Z 1 understand my plans shall he used as public records MODIFICATION
O Z 4— UPT0 200AMP5
F �W Licensed Profosional El INTERIOR ❑CHIMNEY REPAIR
.j 201-1000AMPS IMPROVEMENT
SIyC QOWNF.nBUILexemDERCLARATION OVER I(XOAMPS El BATH REMODE EPAIR (]DEMOLITION s
I hereby affirm that 1 ran exempt fromm the Contractors License[nun for the
3 a F following reason.(Section]OJLS.Business and Yrnfessions Cade:Any city or countySIGNS ELECTRICAL ❑OTHHk
which regmre,a perm ,it to e......na alta,in.Pro ,demolish,or repair any'fracture
prior to as issumnce.also muddies the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M1fl$C.
that be is licensed pursuant to provisions of the Contractors License Law(Chaptr9
1+1 00 (commencing with Section 70(ion Visas 3,;
fDivision3 ofthe Busincsvand Pro[esslnns Cale)or ]PMP.METER OR POLE.INST. I COMMERCIAL' -
L 6 o yy that he is exempl therefrom and the 6vsis for the alleged exemption.Any violation of
iCml+� Section]031.5 by any applicant fora permit subjects the applicant [I NEW BLDG/ADDITION ❑DEMOLITION
W.,y 1 PP penalty n[ PUWER DEVICES ❑TENANT ❑FOOD SERVICE
F Z Y not more than five hundred dollars($500).
�Sp ❑Las owner of the property,or my employees with wages avtheirmle nsmpenza.ioq SWIMMING POOLELEC I IMPROVEMENT
will Ao.he work,and 1healn.cYurc in nm mmndud uroffered fortune(Sec 7044,Bu.vincss ❑OTHER
mand Professions Cale:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
pmpeny who builds art improves thcreoa,and wha dyes such work himself or shmugh
his own anployee.v,pnovidid tlmt such impmvemcna arc not intended or offered for N17W RESIDENTIAL ELECTR SQ It . -
sale.If,however.the building mimpmvenant issoW withiamse year ofcomplesos.the SQ.FT.FLOOR AREA ESQ.FT.
paaer-buildcr will have the burden of proving that he did not build or improve for pur-
ofsafe.)."
❑1,as owner of the property am exclusively contracting with licensed contractors to TOTAL:
construct the project(See 7(i44,Business and Professions Code:)Me Contractor v L,
cenke,law does not apply to an owner or property who builds or improves merear,and QTY. PLUMBING PERMIT FEE
who contracts focwch projects with o contrecmtis)licenced pursuam m she Contractors /s
License Law. 8O,
C] I am exempt under Seo. ,B&P C far this..a PERMIT ISSUANCE
Owner DateALTER-DRAIN&VENT-WATER(EAI 'yVPT10N
WORKER'S COMPENSATION DECLARATION
1 hereby (firm ander BACK FLOW PROTECT.DEVICE �(J
v pene0y of perjury one of the following declarations
❑lhaveunJ will nminmina Cerificae of Consennosdf-insure for Workerx Compem DRAINS-FLUOR,ROOF,AREA,COND.
salon,as provided for by Section 37M of the Labor Cede,for the performance of the STORIES TYPE,CONSTRUCTIO
work for which this permit is issued. FIXTURES-PER'IVAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700oftheLabor Code,for the peformanceof the work far which this post is)tuned, GAS-EA.SYSTEM-1 INC.S OUTLETS ,OCC.GROUP APN
My Workerns
s C...npewion Imamnce carrier..it Policy another am:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This—'inn need not becomPleted Bthe permit is for one hundred dollars(9100) BUILDING DIVISION FEES
or lc,,.) GREASE TRAP
1 verily that in the performance of Ne work for which this permit is issued.L shot) PLANCHECK FEE
not employ any person in any manner1paprpe"JI ro the Workers Camper- SEWER-SANITARY-STORM EA.2(X1 FL
Z vision Law it l.fi� SV 7l� ENERGY FEE
O Applicata i WATER HEATER WNENT/ELECTR
O
GRADING FEE
ti
NOTICE conesubject
APPLICANT.IL after making this Certificate of Fsemptio d you should WATER SYSTEM/TREATING
ficth it mbjcet r the Workers Con.pens this pc mit hal of the Labor Gds,you must SOILS FEE
forthwith comply with such provisions nr this permit shall be Jammed revoked. WATER SERVICE
Qs 0
.72 CONS'1'RUCTION L ENDING AGENCY NEW RESIUFMIAL PLM EL SQ.FC PAID
V Thereby affirm than them isncunswction lending agency for the performance of Dae Receiptk
{✓ti F the work for which this peril is issoed(Sec.3097,Civ.C.) -
Lenders Name
U Lenders Addrss TOTAL: TOTAL:
H I verify that i have read this applicaion and stove that the above informations is BUILDING FEE
to correct.[agmc to comply withal[city and county ordinances and state laws missing to QTY MECHANICAL PERMIT FEE
Ll Z building constmctinn,anJ hereby amhodze rcpresemativex ofthis city menmr upon the SEISMIC FEE
ahave-omadoned pn.perty lir inspection pmFoxvc PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless die City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said Ci.y ALTER OR ADD'fO MECH.in imstst enecof the grunting of this perir - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTqIR HANDLING UNIT(TO IQ(XO CFM)
SOUR( GULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature ofAppliaaa/Comraor Date F.XHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will she applicant or future building«cupantsmreor handle hazardous material HEATING UNIT(10100,1X%1 BTU)
as defined by the Cupertino Municipal Civic.Chapter 9.12,and the Health and Safety
Code.Smdnn 25532(x)^ HEATING UNIT(OVER 100.000 BTU)
❑Yes o
VENTILATION FAN(SINGLE 0.ESID) PAID
Will the applicant or infuture building by
Htuse yAequipmentordeviceswhich Date Receipt%
emit hazardous air contaminants as defined M1y the Hay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Diwriet) TOTAL:
❑Yes �No BOILER-COMP(OVER[W.0I1(IBTU)
1 have mad the hazaNnus materials requitementa under Chapter 6.95 of she Cali- AIR CONDITIONER
forma Health&Safety Cede.Sections 25505.25533 and 25533.1 unduntand Lhal if the ISSUANCE DATE
building does no.currently base a tenant that it is my respersibility to notify the occupant NEW RESIDENTIAL MECIL SQ.Er
-I cots which run 'w to isswmce ofa Cenificam of Occuparay.
1Z-S D.,
Owner or authnriud agent Dare TOTAL:
ISSUED BY:
OFFICE