30436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY It
CITY OF CUPERTINO BUILDING-ELECTRICAL _ PERMIT NO. ^ O /! a�/N
BUIL6
DING DIVISION 'APPLICATION/PERMIT -I PLUMBING•MECHANICAL � � s 4 3
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �(�1 ^ I V /Y�O ' SANITARY NO. APPLICATION SUBMITTAL DATE
OWN NAME: III/_' ` ,IL//7.tk'PHONIi: — NOI'NACIO 'S AM(?: I, Ye fyCy(y '
1X1 ( LII'4 N/C CONTROL#
I \RCHI'PE /ENGINE R: L N 1 OR S. - I
CONTACT', '" PHONE I5 BUILDING PERMIT INFO
Consultant Fees Iaald by Applicant(Initial) BLDG CLEC' PLUMB MECH
EDLICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm for I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�'r with Section]tXla)nl Division3 of the Businos JI' dneians Cale,unJ mylicenxc iv - RESIDENTIAL,
00 in full tome and effU PERMIT ISSUANCE
IVU Linenss lass Licp '❑SFDWL 0 KITCHEN REMODEL
��Iy Dwe_kq••JZ�ContmcwEta APPLIANCf•_S-RESIDENTIAL ❑ADDITION (D PLUMBING R&PIPE
y A CHITECTS DECI. O C MULTI-UNIT ❑STRUCTURAL
F I PANELS
lunderstand n0y plane shall he used as public recnNs- 1 ,MODIFICATION .}
OZ—_ UI'TO 2W AMPS ❑INTERIOR ❑CHIMNEYREPAIR
LLj Licensed Professional 201.10]OAMPS - IMPROVEMENT
Qy 3 OWNER-exempt frDECLARATION OVER 101X1 AMPS
-y+��6 1 hereby affirm that 1 ran exempt from the Commdbr's License Law for the F1 BATH RLMODEUREPAIR ❑DEMOLITION
N
3 L U following reason.(So lam 7031.5,Business and Professions Code:Any city racially SIGNS ELEC'1121CAL ❑OTHER
W LL 0 which¢quires a permit m consume,alter,improve,demolish,or repair any strunure
cv-
I:�0 ,mrso its bmanm,alsn requires theapplican,for such Permit o file asigard statement SPECIAL CIRCUIT/MISC.
} dauml.hostsed punuanno the provisions of the Comma's License Lsw(Chapter 9
GAO (crmmcncing with Section]0a0)af Division Sri l{u,inessavd Professions Cakdm TEMP.ME'T'ER OR POLE INST. COMMERCIAL: -
0.y^y than he is exempt therefrom and the basis for the alleged exemption,Any viii of 1 ❑NEW BLDGIADDITION ❑DEMOLITION
i4E7 Lay,
Section 7031.5 by any applicant for ajwnnil suhjects the applicant to a civil penalty of POWER DEVICES " ❑TENANT - ❑FOOD SERVICE. `
t mom than five handed dollars(35030).
�z'6 I,as ownerof the ro norm to ems wish wa es as their rale coat tion, SWIMMING PDOCELECTRIC ^� IMPROVEMENT
❑ F a Y YemP Y B pensu
will dothcwork,andthextrecture isnot iatendedornRcreJ forsule(Sec.]04,Basin ss COTHER
and Prnfassious Cole:The Contractor's License law dawn not apply to on owner of OUTLETS-SWITCHES+FIXTURES I
6'3^ property who builds or improves thereon,and who Joe,such work himself or through
his-own employees,provided than such improvements are not marnded or offered for NEW RESIDENTIAL ELECI'R SQ P-n
sale.IL however.the building dr improvement issold withmone yearnfrompletion,to Q.FT.O. AfIEA $/SQ.FE
caner-builder will have the burden of proving that he did not build or insprove for par' 'O
pmcnfsele.). pep_' i
C 1,as owner of she prifti am exclusively commoing with Iicori contractors m TOTAL:
construct the portico,(Sol.704,L Business and Pmm,,kow Coraf The Contranors Li-
cense Law does nor apply to an owner of property who burlap be improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a commemr(s)bccnscJ pursuant n the Contractor's
Liceme Law. • ' PERMIT ISSUANCE
❑lam exempt order Sce. -,In&P C for,his mason
ALTER-DRAIN&VENT-WATER(EA) VALVA N
Owner Uate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm tinder penalty of NrmU one of the following declarations:
❑ I have and will maintain a Certificate ofCommalin self-insure for Worker's Croupier- - DRAINS-Izl.00R:ROOF,AREA,COND' STORIES '' TYPE.CONSTRUCTION
cation,m provided for by Section 37M of the Lehr Cale.for the performance of the
work f n which this pcsmit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section _
of the labor Cale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC 4OUTLETS YOCC,GROUP 'APN
My Wn pent dPnllcy rn ����T�p��jjpppp
Came, Policy No. JJrl[SQLL GAS-FA.SYSTEM OVER 4 LEA)
CERUITCATEOF XEMPTION FROM ivORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This genion need not he completed if the porrof is for hundred Joll:aa(s IW) BUILDING DIVISION FE S
or less.) GREASETRAP - I'LANCHECK PI3P.
I cerify[hit in,heperfotmance of the work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA300 FT
not employ any permn in any manner xo us to berme whject m the Workers'Compcn . .- ENERGY FEE J
O z rasion laws of Cmifmpa.Date Wp'IEN HEATER WNEM'/IiLECfR
O Applicant - : GRADING M
y No ricE TO APPLICANT:If,uRer making this Cmilicate ofExemption,you s000ld WATER SYS'IT:MCRI BATING
at;^ becmnesubjee,to the Worker's Comperviaon provisions of th,e LeMn Code.you mos, SOILS FEE '
fonhwi,h comply with such provisiom or permitshall be deemed revoked. WATER SERVICP.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
I herehy affirm that there i,awnstmc,ion lending ngeney limbo pcofdm0nnw of Data Receipt#,
r F the work for which this permit is issued(Sec.3097,Civ.C.)
OLenders Name TOTAL:
4VLI Lenders Address TOTAL-
,
OTAL-I ccnify that 1 have read this application and slate that the above information is BUILDING FBM.
y ,correct.I agree to comply with all city and courtly.,,Iacocca andswm laws relating to QTY, MIECHANICAl,PERMIT FEE '
'• V buildingconswction,and herebyautherise representatives of,his city rammer upon the SEISMIC FEI7 '
above-mentioned property for inspection purposes. -
(We).9. yrs a g PERMIT ISSUANCE g yard keep harmless the Cis fCu ninon Dion ELECTRIC FE:E
lishilities,judgments,mens and expenses which may in anyway accrue against aid Ciry ALTERORADDTOMECH.
in o0ncrumble of the treating of this j conit... - PLUMING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'P AIR HANDLING UNIT C 010.000 CFM)
S>URCP,REGULATIO 5. AIR MECHANICAL.FEE
HANDLINGUNIT(OVER10000CFM)
� CONSTRUCTION TAX '
ignat ran,App moot/Comrndor Date 17XHAUST HOOD(W/DUCI) a
' HAZARDOUS MATERIALS DISCLOSURE: HOUSING MITIGATION FEE
Will the applicant or future building occupant nrrc orhandle hared..'material HEATING UNIT fro 100,000 BTU)
as defined by the Cupertino Municipal Code,CTsp ll 9,12,and Ne Heath and Safety
Code.Section 25532mr? - HEATING UNIT(OVER 00,000BTU)
ElYex I-'.7 CIN. PAID
VENTILATION PAN(SINGLE RRSID). Date Receipt N
Will the applicam or future building occupant use equipment or devices which -
mithtecohmsail conmmieantsres defined by the Bay Arca Air Quality Manigcment BOILER-COMP QHPOR 100,000,BTU) _
'1 Dismot? TOTAL:
Ill CYa- CNo BOILER-COMP OVER 100,000 RTU)
I have mad the hornrdous materials re iiremenm under Chapter 6.95 of the Cali AIR CONDITIONER o f
9 P ISSUANCE DATE
forma Health&Safety tly ha Sauna,23505.atitis 3)andns5J4.I to notify the oc if the NEW RESIDENTIAL hfECH. SQ.FL
building pure not currently have a meant,thane is my msponsCenifim notify the oocupam
'
of the requirtmems which mon be met prior m issuance rf.a Cenif¢me rl Occupancy.
Owner or authortred agentDate TOTAL: ISSUED BY:
Zoe
OFFICE