30800 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - rry ' BUILDING•F,I,F.CI'RICAI. . PERMIT NO. 30800
� O O O O
'NUILDING DIVISION �' APPLICATION/PERMIT PLUMBING-MECHANICAL f 'I J o
BUILDING PRDJFAT'IDENTIFICATION
' ' TY
_ n r SANITARY NO.. APPLICATION SUBMITTAL DATE
�r��`L4 VTQOOrr
In 14913 .
O E SN ME ' PHONE: C NTRAC OR'S AMEN LIC NO'.
Wo�dr .NC, .( r "s 'i 5 .' I'T'S 5 /c -c ot»
,RITC sNGINBLR , LIC NO: �pDDR 5y, 'I�, 44 5I /'aQ
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CONTACT: - PHONE: - ,0 1. BUILDING PERMIT INFO
f no
O Q Consultant Fees Paid by Applicant(Initial) . - BLLDD�G. ELECT ,PLUMB ;�e MITC�H
LICENSFOC 1' ACTURS DECLARATION QTY ELECTRIC PERMIT FEE.
I he by affirm m t 1 d under pr f Ch pie 9(commencing JOB DESCRIPTION = _'
{O{A�C) with 5 I ]OOO)of D, n3 ultra Basin s Professions Cod d -1
Fw0 fall f and effect yicense is PERMIT ISSUANCE Q "
of Lcet. la. Lc.» 5 001 ❑KITCHEN REMODEL
APPLIANCES—RESIDENTIAL
� W Dam Contractor ADDITION PLUMBING R&PIPE
Fly ' ARCHITECT'SDECLARAT N ❑MULTI-UNIT "^ ,OSTRUCTURAL `
PANELS'
'Z O 7,. ,"^ I d island my pl s sM1all he uiW as puhlie recs+Ns '• s. - MODIFICATION
'
vv�
,OZ:f � - I' UPT0200 AMPS �
O -F� +C] [I CHIMNEY REPAIR`FW 'L tensed Profeseuanal. INTERIOR, .,Ii I, 2nl;In00AMP5^ "" IMPROVEMENT `pts;,!
�$G -r
OWNER tlxempER DECLARATION. OYER I(gOAMPS , - ❑BATH REMODEUREPAIR [I DEMOLITION
a 1 hereby affrm on I con exemptfire.s an the Cessions C d L 1 far the
iq5 O U follow ng reason (Section 7031.59 Business end Professions Code:Any city r c poly -SIGNS ELECTRICAL ❑OTHER
W a.O F" which requires a permit to construct,alter,improve,demolish. repair any s0uuure -- r.
rn p,ort ituance I o 4 're the f h permit t Flux statement grad r" SPECIAL CIRCUI'UN ISC 'y - ✓
Ihth ll red pusttanuo theprovisions fth Commodes uL (Chpter9 4 62
DO (oat enc g 1hS t 9001E fD' .ia 3 Dhe Bumessdnd Profs! nscde)ar TEMP.M2TER OR POLE INS T. ACp1 A'
d p,e C Ihut he s exempt therefrom and the basis for the alleged exempt Any violation of -, - ❑N �M/Arb� ❑DEMOLITION
m les, Section 7031.5 by any appl a f p I s lh t Ih old t t Penalty f POWER DEVICES W"7�j, �»»�
rn lIC1LIYODD SERVICE
yyuCC�l,�dse ❑hmis Lmowren th T h d Pdrady Marym(y5e5m110p)l e agefe th let m fn,
- SWIMMING POOL E(.CLTRIC , r IFLN
Tnthe work,
ands t I t intended r offered alpBusiness 1-1 OTHER
m and f n Code:The Cont L Low does t apply to
an woe of OUTLETS—SWITCHES FIXTURES
Property who huilJs nrwitnesses ffioaaanJand wb.does khinsdfothrough
employees, irovidentified,
uitiipements a aot imtonJeJ nroffere"ur
y
NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however the buildingor unarwerwint is sold within one year ofeampletio the t, „'SQ.FT.FLOOR AREA y $/SQ,FT.
owner coulderwillh the human f provingthth dA not build or improve for par,
0'
- pose f s
ae).
territorial
L f the property,am exclusively c ri g"w
licensed contractors la ' T O �,s
onst tilopio)eeSex.30,14 Business Pofes. ns Coda)The Confidences
Lt.
-nseL d snot apply to en woe fprpny fi huilAe, p th reun,anJ QTY. IPLUMBINGPERMIT I FEE S a
w1memeardardifernwirprojechwalt mhr t r(s)licensedpum pursuant Contractors
-
Lia use L r PERMITISSUANCE{' r
1 ur exempt under S_ac. - ,B&PCforthisnarom - •" '+
ALTER-0RAIN&VENT—W (E UAT
Owner hate VALUATION
WORKER'S COMPENSATION DECLARATION BA CK PLOW PROTECT.DEVICE
I hereby affirm under penalty ofperjury one of the following declarations 'lq� rte,•
I Inve and will maintain a Cardinale cf Consent in self-mance for Worker's Comped- DRAINS-FLOOR,ROOt,AREA,GOND.
'STORIES TYPE CONSTRUCTION
cation,os provided for by Section 3900of the Labor Code,for the performance of the "
work for which thisperm,ti- s issued, FIXTURES-PER TRAP ' .
1have
` andwill mnWorkerseInspma. esped by Section
om-Ce,for thaincofthew fier,whichth permit is issued, SYSTEM-
GA-S—EAi.SYSTEM-I INC.4OUTLETS
-Itr
OCC.GROt4Ly APN
My Workers Compensation lusurance carrier Policy number ae
Currier: -
Policy No. GAS—EA.SYSTEM-OVER 4(P.A)
CERTIPICATROFP.XEMPTION FROM WORKERS' ^ -
COMPFNSAIION INSURANCE ^ GREASIIINDUSTI2L WASTE INTERCEPTOR' s
IL1 NGDIVISIONFEE.S
(Th' t peed theca opiated fthep tic t':f - neh Ired dall.ry($100) i - {. _ -
of en Y. YP t rhe an m ace ofthe work SEWER—SAMTARY STORM PLANE E �,
- Icer!try that the performance ' wh ch ilii.Tenn u. vs el lshull RM EA.20017 -
ENE
iter es b c m 5µb)e',i- the Woo,y,m should WATER SYSTP.M(fREATING GRA Y lE
Z anionL Cvhfnmi Yte "'11 pen
C)Q
Applicant nk this a WATER HEATER W/VENT/ELECTR - GRADING FEE
tF�—l• NOTICE. ICA i I( rutj Ie of Exton u n
hcc.ina.uh/ct In the ke sComp Y previsions of the labor Code you must _ - SOILS FEE i
fain Ili comply with suhp ' urlv`.th Permit shall he dee red revoked
W,Q WATER SERVICE -
"� CONSTRUCTION LENDING AGENCY '.1,NEW RRSIDEMfIAL PLMB. SQ.FT PAID a
, UO Ib reby offirm that there sa convtrectio,i lend ng agency forlheperforman of Ume tpt»
W the work f u.which pe rat i d Pi e.3097,Civ.C.) •
L ddcrs N TOTAL.
Lende Add - - I .. ,TO'14L O e..
1k...,r, a, 1 certify th t I h read thisppb ndnn and slate that th ho f d '
� is BUILDING �.�
1ft, V) corredl g- i comply with allc'ty d county ordinances and site law telaungm QTY. MECHANICAL'PERMIT FEE '
U'� hulldingim slocoan,andh by authorize representatives of the city to enter upon the S&SMICP %+ O
above-madboned prupery for inspection punposes. s. p
(We)agree to save,indemnify and keep hannlc{s the City of Cupertino spend PERMIT ISSUANCE ELECTRIC FEE t Awl O
habilities,judginents,costs and expenses which may in anyway accrue against said City` ALTER OR ADO TO SUCH. /+'
in asequence ofine granting of this permit. - PLUMBING FEE
PPLiCANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT '
I`s AIR HANDLING ON[I(TO 10,000 CFM)Oft A. - -
OURCER/G) ATIONS' - T _ - MF,CHANICAL EE17
'
���..x AIR HANDLING UNIT(OVER 10,000 CPM,
F_ CONSTRUCTATAX
nature fApplican t r - Dat. EXHAUSTHOOD,(W/DUCI') -
// HAZ R OUS MATERIALS DISCLOSURE. - - HOUSING MITIGATI FEF
Wi 7henpplic"I lure building occupant score or handle hazardous material HEATING UNIT(TO 100.000 BTU)
' as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(a)9 _ - HEATING UNIT(OVER 100,003 BTU) _ o .
[1yx No ..
r. r -it - VENTILATION PAN(SINGLE RESID), PAID, ,
Will the plicurn I orfuture hurldtng occupant use equipment or devices which - , - • e Date - FReceip
li
I liberation,air comerairearins as decided by the Bay Area Air Quality Mdnagem tot BOILER' COMP(3HP OR 100,0110 BTU).
.aiatOYae No BOILER yCOMP(OVER 100,000 BTU) d,
O
(have read the huzardousmnureis rcgmreanents under Chapter 6. of the Colt- AIR CONDITIONER r�1' ISSUANCE DATEY
forma Health&Safety Cole,Sections 25505 25533 and 25534 16 dlevand diol If the NEW RESIDENTIAL MP.CH. SQ.FT'
matching rh t modually have.tenant,that isou pmarbtlty m norry theoccupant .
of the req 'em�t hich mustMmet pr or to ac fo Cerft caa of Occupancy ,.
I
Owner of amhrazed agent"' DateTO LOL ISSUED BY
s 'OFFICE,