30280 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES;USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICAL PERM11 NO, 30280 0 ��O
BUILDING DIVISION I APPLICATION/PERMIT PLUMBING-MECHANICAL. '
'1 BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - • - SANITARY NO. APPLICATION SUNMITI'A I.DATE
075 "- Hde�el �� A�� � ,: •�_2`�-Q,6
OWNER'S NAME: PHONE: CD�IHACTOR'SNAME: - LIC NO
TS4 N y'9 6.-7 85� /TT--✓i-5 (?,4 4 �4 •I N� N/C CONTROL.p
NEER:, LIC LIC NO: ADDRES�,s:
r .12 1 C-roLaLrgq'AJ ✓!y S, T.
CONTACT:„ - PHONE:
BUILDING PERMIT INFO
t
El Consultant Fees Paid By Applicant(Initial) BLDG EIEC PLID413 MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PIi12M1'I' FEE
bh rcny emrmN tl . dud p i.am ofenanter9(connencmg JOB DESCRIPTION
{OWa2 lh5 i ]011o)ef Dl 0 3 fth B si dPr fessmns Cude unJm Icenams
F+0 0 full( d ffe�B yt PERMIT ISSUANCE RESIDENTIAL'
Urr fvense Class u Lcp !;�094540 ❑SFDWI. [3 KITCHEN REMODEL
Za aCS Dam Cont ATa�RS / �a7e pf�: APPLIANCES-RESIDENTIAL �j�/`�'EDITION El PLUMBING RFmPIPE
an ARCHITECPS DECLARATION - - LIMULTI-I1NIT ❑STRUCTURAL
PANF,LS
2 p(/1 ZL 1 understand my plans shall be used as public records, MODIFICATION '
02:1 - _ �. - UP T02011AMP5
4 ED INTERIOR E]CHIMNEY REPAIR
[-,�1"'W Licensed PoAtosi...I , 201-IfXX1AMP5 IMPROVEMENT "
bd a�j OWNER-BUILDER DECLARATION OVER 10fX1AMPS
py,R'W sc 1 hereby afEnn that'1 am exempt from oz'
the Cmans s License Law for the C]BATH REMODEUREPAIR 0 DEMOLITION
Se a d U following Munn.(Section 0031.5,Business and PmRssions Code:Any city or county SIGNS ELECTRICAL. []OTHER
-
LLLL1l O I. which requires a permit to t orswc6 alter,improve,demolish,or repair any stmcmm -
"7f prior to its issuance,also requires the applicant for such permit to file.signed statement SPECIAL CIRCUIT/MISC.
} Nat he is licensed pursuant o the previsions of the Contractor's LhmseLaw(Chapter 9-
,Erp��jj (commencing with Section 7001 Division 3 of One Business and Professions Codelor TEMP.METER OR POLE INST. - COMMERCIAL:
6 e that he is exempt therefrom and the basis for the alleged exemption.Any violation of - El NEW BLD(/ADDITION [D DEMOLITION
y Section 711315 by any m,hannt fora pemtit subjects the mplicam to a civil pcnahy of POW13R C
�E•..2Y not more than five hundred dollars(S500).
❑TENANT - ❑FOODSERVICE
q Q ❑ 1,as owner of the propeny.m my employees with wages as their sole compensation, SWIMMI ELECTRIC IMPROVEMENT -
C2C2 will do the work,and the mucmre is not intended or offered for sale(Sec.7044,Business `ZZ ❑OTHER
6 3 m and Professions Cede:The Communes License Law does not apply m an owner of OUTL a fS-S W IT -FIXTURES '
property who builds or improves thereon,and whe does such work himself or through -
his awn employees,provided that such improvements ate not imeadul or offered far NEW RESIDENTIAL E SQ ET.
sale.If however,the building or improvement is sold within oreym,of completionthe' SQ.FT.FLOOR A$EA S/SQ.FL
owner-builder will have the barren of proving that he did not build or improve for par-
pose of
❑howner owner ej the property,.B exclusively contracting with licensed umw zona m >
ceps La the project Sacapply
Loan Business and property
who but Cede:)The e,domma,
cense Lawdoes
x,tab plymts with
a cafpreperty whored ptorimpro am Cmatragaod QTY, I'LUMBINCI!E IT FEE
who contacts for such projects with a mntractorts)licensed pursuanno NC Cnmmctnr's
License Law. PERMIT ISSUANCE p11n
C] lam exempt under Sec. ,B&PCfor Nis reaann - nVu O
Owner Date ALTER-DRAIN& T-
VENWATER(FA) - O VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LIiYUY '�,IC;7
L hereby affirm under penalty of pejury one of the following declarations: ""� �J �
❑ I have and will maintain a Cernficate of Consent to self-insure for Worker's Cramped. DRAINS-FLOOR,ROOP,AREA,COND.
gotten,as provided for by Section 3700 of the Labor Cattle,for she performance of the STORIE9 TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
X1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code.for the performance of the work for which Nis permit is issued. GAS-EA.SYST❑ht-I INC.4 OUTLETS
My Worker's Compensation) ' ier and Policy�j'yJQ�j' ¢, f OCC.GROUP APN
Carrier: STA TB 4Nn Policy No. GAS-EA.SYSTEM-OVER 4(FA) _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI%INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEGS
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.) GRPASE TRAP
PLANCHECK FEE
Loy any thminthe p my
of thework becomewhich this One Wisiss'Compn- SEWER-SANITARY-STORM EA.2g1 Ff.
not employ any Califon in any manner so as to become subject One Work<ri Compen- ENERGY PEC b ZQ
z Z Armon laws of California.Data WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
y NOTICE TO APPLICANT:If,Co making this Cisions of of Exemption,you should WATER SYSTLMRREATINO
P
; became subject m the Worker's Compensation provisions of the Labor Code;you moat SOILS
t
forthwith comply with such previsions onhis permit shall ne deemed revoked. WATER SERVICE
0 CONSTRUCOONLENDINGACIgeCY NEW kFSIDENTIALPLMB. SQ.FT. PAID
U
U 0 I hereby affirm thatpit i is sued(Sea:
ending agency for the performance of keceipt p
� F Ne work for which Nis permit is issued(Sec.3097,Civ.C.1
U Lender's Name TOTAL:
HJ Lender's Address TOTAL: -
0. I certify that I have read Nis application mW state that the above information is - BU . NG HE st,
h comae legrte to comply with all city and county ordinances anJ ante laws reletingm QTY, MECHANICALPERMIT FEE
U z building..... uctim.and he rmya flumnerepresentatives of this city to arannpon the SEI. I'FFh -
'� above-mentioned property for inspection purposes. '
PERMIT ISSUANCE
- (s,judm e m save,indemnifyexpenses
which harmless the City of against s against ELECTRIC FEF
liabilities,judgmentsecoarsandor his eawhich may inany way accme.gainst said City ALTER OR ADD T'O MECH.
in conuquence of the graining or permit. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TD 10.(100 CPM)
SOURCE REGULATIONS. MECHANIC 1.ME
AIR HANDLING UNIT(OVER 10.01)0 CFM) CONSTRUCD A%
Signedure of Applicant/Coneractor Dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATE 'FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant stomorhandlehuWons material HEATING UNIT(TO HX,01Xd BTU)
as defined by the Cupertino Municipal Cede.Ch,oar 9.12,and the Health end Safer,
Cede,Section 25532(a)? HEATING ONIT(OVER 100,000BTU) -
❑Yes soo VENTILATION FAN(SINGLE RMID) PAID
Date R Il
will the applicantta furore building by Bt use equipment ordeviceswhich
mitict? us air comamitunts as defined by Bethe Bay Area Air Quality Management BOILER-COMP(IHPOR 100,000 BTUj
District? - BOILER-COMP(OVER 100,000 BTU) TO
IL
❑Yes �Nn ,
I have read the hazardous materials AIR CONDITIONER
t5,B53 mat V 534.I and 6 tend that
Cali- ISSUANCE DATE
forma HeaIN&Safety Code,Sections25505,25533end25334.1 todcrsyrth Natmthe NEW RESIDENTIALMECH. SQ.Etr
building dos not currently have atenane that it is my resporasibilirymnotify theoccupant
of there mm�0 whiSl p t be met prior to issuance of a Car ificam o Ouu N -
O
Owner m authonred agent Date TOTAL:
ISSUED BY.
OFFICE