30774 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY I.
CITY OF CUP ERTINO BUILDING•ELECTRICAL ' PERMIT NO.
BUILDING DIVISION APPLICKPION/PERMITPLUMBING-MECHANICAL - 3077
.4
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSS: - SANITARY NO. APPLICATION SUBMITTAL DATE
10351 r41 ��, �_ iy - S7
OW RS NAME1 PHONE: COryJRACfOR'S NyN LIC NO:
J - 6
µ —II //1 - o NIC CONTROLN
ARCHIT17=IENGINEL'R:; LICNO; ADDRE.S: - ❑ '
9 7S, /J> a 15.1( .
CONTACT: PHONE: BUILDING PERMIT INFO
/�(�(� --.Z('.5� ❑ Consultant Fees Paid by Applicant(Initial) - BLDG - ELECT PLUMB MECH
I,ICINSLDCONTRACfORSDICIARA110N ' QTY ELECTRIC PERMIT FEF:
z I hereby Bit. that 1 am I tensed u d p v n nl Chuptvr l mmnmencm8 JOB DESCRIPTION
Wwith Semmn]gMpof Dmv.' Sof theBmi IP f Bions Cude,und my license is RESIDENTIAL•
� in full forccund eflecl PERMITISSUANCH
�UE Lima.Class Lic.if ❑SFDWL ❑KITCHEN REMODEL
F�W Dam Contract., APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
II_pdr( ARCHITECTS DECLARATION - PANELS ❑MULTI-UNIT rSTRUCfURAL
z Oyz l understand my plans shall be used as public records MODIFICATION
Oz�O UI'T0200 AMPS -' ❑INTERIOR C1 CHIMNEY REPAIR
1= U; Licensed Profeoi...I 201.1000AMPS IMPROVEMENT
sit :1 OWNER-BUILDER DECLARATION
ON OVER 1000 AMPS - El BATH REMODEUREPAIR ❑DEMOLITION
6 1 hereby affirm that am exempt from thee Conlmctnrs License Law for the
WLLW,U followingrcnycm (Section 7031.5,Businessand Prolession,Cited Any city or county SIGNS ELECTRICAL []OTHER
�I- which nol s permit .wtalmr,mpr Iml,h,ma,pi,cay,amemoo
........ilii
prior to it uice,alrequires the applicantf hp n t 11 n gn d n t mem _ SMCI,LC,RCIII'f/SH,
E.
but heal a Ip tt th Precision, m of theC t r.lt encl w(Chapter 9 COMMERCIAL:
. LZ (commencing- BSc( Divisionn 7000) fDivision 9orthu Rus ncss II :Cal )., TPM( METER OR POLE INST.
6 o e' that M1 aria II nfr d th b 's for the dlleged exe (I A y 'obmm�of - [1 NEW BLDG/ADDITION ❑DEM01,1910N
o, Sttl n 7031.5 by y uppl t f pe mit subjects IM1c appl t I 1 penalty of POWER DEVICES
t y not more than live hundred doll.,($500). El TENANT ❑FOOD SERVICE
3C C1 Losownernfthe pmpeny,or my employees with wage ar their note cmnpensatinn, SWIMMING POOL ELECTRICIMPROVEMENT
will do the work,and the structure,is not immvdednroffend forwle(Sm.7014,Business OTHER
iand Professions Code:The Commodo's License Law Wws not apply of on owner of OUTLETS-SWITCHES-FIXTURES.
property who builds or improves Hewn,and who does such work himself or through
his own employees,provided that such improve n m s me not Intended or offered for NEW RESIDENTIAL ELECTR SQ FT. �RG�.
aide.If.however,thc building or improvement is sold within one yearof cnmplttion,the SU. OQRf ✓- SISQ,PT.
caner-builder will have the burden of proving that he did not buil dor improve for par- Fl f {1
lose of sale.). - TOTAL:
1,m owntt of Ice am exclusively c.nwaing with licensed commttors U. -
construct the , at (Sm...n c Business and Pmfeoinns ds o, The Commttors Li , - JAN
1 4 11CItsD
cense Luwdoesnmapplyman with
whosedporimpmves thereon.and QTY. PLUMBING PERMIT FEE J/S ISLII
who contracts for such projects with econwcmr(s)linmscd purnuunuothe Connector's
/�•TI��// �^ ,. ,
License Luw. PERMIT ISSUANCEUt•,t,V.et,ItI,�NU
❑I nonexempt under Sea ,If&PC for this odo.n
ALTER-DRAIN&,VENT-WATER BOO VALUATION
Owner - Ilam
WORKER'S COMPENSATION DECLARAHON BACK FLOW PROTECT.DEVICE -
f� Iherehy and.under peruay of perjury nuc of the 1.11.oing declarations
1mmi :
Y ❑ I haveand will u .0 Cen0B.11uf Consem m self-m,mxim Walkers Cwd1.- DRAINS-FLOOR ROOF AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Salion 37M of the Labor Code,for the Performance of the
we&tin which Nis permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700.fda,Labor Code,forthe perfoaumv.f the work far which this permit is issued. GAS-EA.SYS'GE -I INC.40UTLETS OCC.GROUP APN
My Wor r.Compenwtir�t l mace carrier and Policy nu{nbetJ{3�� GAS-PA.SYSTEM-OVER 4(EA)
Cameo �- Policy Ne, Sl L
Cf: TIMCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
This sectimm nerd not becnmplelW if the pewit is for one hundred dollars(gl W) GREASETRAP-
orless) PIdNCHECK HE
Joy;ry that in the Performance any
fsthe wakfa which his perthe W icissued,
,,'Citatin- SEWER-SANITARY-STORM EA.200 FT.
nmc ply 1C y st hent nc sunrtdt the W krs'Compe- - - - ENERGY FEF. .• 1 .
Z' Apps Ir I C lin rniu Dare "
O 0
Applicant t - - I" - WATER III'iATBIt WNBN9'IP.LECTR' � GRADING FF.P.
G TA NOTICE TO APPLICANT If,site,mukmg Ih.Cert Ycaleof LxenlpWn youshould WATER S Y STHMRR BATING
a^" become subject o the Worker's Compensation provisions of the Luor Code.you most SOILS FEE
W Iti fnMwith comply with such provisions his permit shall MJtt,IneJ revoked. WATER S[RVICE
0 -
5z CONST RUCTION LENDING AGENCY NEWRMIDENf1ALP1.MB, SQ.FT. PAID
C.) 0 1berchyufOw that here is a construction lending agency for the perf.wanceof Data ReceiptM
U. Fthe wink fur which this pewit is issued(Sce.3097.Ci,C.)
Fader,Name - - TOTAL:
Lenders Address TOTAL: 0
f+ 6, I cenify that I have mad this application and state that the above information is BUILDING HE
TA correct l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 71 building conswction,and hereby authorize mposemuatives of this city m enter upon the SEISMICFEE '
above-mentioned prnpeny for inspection p.,,ws. PI?RMIT ISSUANCE�
(We)agree mo saand ve,indemnify keep hawless the City of Cupeu rt.against HLF,CTR IC FEE
liabilities,jud,on,o%cans and expenses which may in any wsytmeme again,,said City AUI'E:RORADU'TOMECH.
in amseyucnce nr the grunting of this pemdt PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR IIANULING UNIT(TO 10.000CFM)
SOURCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) , CONSTRUCTION TAX
Signature of Applicant/Contractor Dme EXHAUST GOOD(WMUCTI
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store m handle hamtdmasnaterial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Cale.Section 25532(0)7 HEl'ING UNIT(OVER 100.000 BTU) „
❑Yes FEB. VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or fumre'building occupant use equipment or devices which Date Receipt If
:mit Efficacious air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(34OR 1017,000 BTU) ,
OouictP - TOTAL:
E]Yes r7 No' - BOILER-COMP(OVER 00,00)BTU)
I have rind the hazardous mammals requirements under Chapter 6.95 of the Cali- AIR CONDI'I']ONE k - ISSUANCE DATE e '
fomin Health&Safety Gde.Sedions 25505,25533 and 25534,1 understand that if the NEW RHgIDIiNI'IAI.MECH. 'SQPI'.
building doss oat cutmmly have a weant,thut it is my uspunsibilitya notify the occupant .
of the requirements which must b,met pfiono issuance.1 a Cenifloam of Me6puncy. _
Owner nr uuthrnzcd agent Date TOTAL: ISSUED BY:,
OFFICE