30947 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES:USE BALL POINT PEN ONLY `
CITY OF CUPERTINO. • BUILDING.ELECTRICALPERMITNO.
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL' 30947
` BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARY NO.. APPUCATIONSUBMITTAL DATE
'11 33 - L,bNc GUzuZzLO'
OWNER'S NAME: - PHONE: F CONTRACTOR'S NAME: ,LICpNO:
LyJWl.l1A.) r '40$ ZSZ-�33 5Ca2U . .N/C - CONTROLN "
A_RCHITECf/ENGINEER: - - LIC NO: ADDRESS: • ❑ '
1. l WMuuT Ike• 1 4SGd6
CONTACT. PHONE: -
• BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 heresy affirm that I nm If the Bal undo provisions of Chapter 9(commenting is IDB DESCRIPTION
ErDat with Section Division3of the Business and Professions Cade, it any license is
00 y PERMIT ISSUANCE RESIDENTIAL'.
a Licene Cl...and cR n. p
6VU License Cla ' �''�Ice Lic.M u - - ❑SFDWL ' [I KITCHEN REMODEL
F�W Date BCuntmc.,- YtlLkC APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
to s, ARCHITECT'S DECLARATION PANELS. ❑MULTI-UNIT' EISTRUCTURAL
z�N e
I understand my plans shall be uud as public r cords MODIFICATION
C Z 4 UPTO 200 AMPS "
[I INTERIOR n [I CHIMNEY REPAIR,
F,� Licensed Professiunol 201-IOOOAMPS ON IMPROVEMENT
2q$aV OWNE&BUILDERm the Com oto
I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1P90 AMPS ❑BATH RECl DEMOLI=N
PWWWS O y U .hitch ng reason.(Section]onstru Business and Professions Code:Any city or county SIGNS ELECTRICAL OTRER
F O F which,:quires a permit re construct,alter,Improve.for su demolish, fi repair any imucte
yy prim tainscense ptoomm to he p..War,o for suchmune toicensle.e aw(htemem SPECIAL CIRCULUMISC.
pr It
that he is licensed pursuant to the provisions of the Contmemre License Low(Chapter9
00 (commencing with Section 7000)of Division 3 of the Business and Prefessions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
pi o oC that he is exempt immfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION: ❑DEMOLITION
JWC.fir 0.� Section 9031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
p. not more than five hundred dollars($500). ❑TENANT [I FOOD SERVICE
[I I,asowneroftheptupeny,m any employees with Ingests theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Fo wilidethe work,andthe awmure is am intended oroffned for sale(See.9044,Business []OTHER
R and Professions Cade:The Contortive,License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves damon,and who does such work himself or through - -
his own employees,provided thatsuch improvements are nrn intended or offered for NEW RESIDENTIAL ELECTR ZS
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT FLOOR AREA $/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for parr-
Pass of,ma).
❑1,ax owner of the property,em exclusively contracting with licensed contractors to TOTAL: S .
common,the project(Sea WTI,Business and Professions Code:)The Connector's Ll- Ja /�w
cerise Law does not apply to an owner of Property who builds to improves thereon,and QTY, PLUMBING PERMIT FEE AJ0,
who Imarect, su
foreh pu
rojects with a contractonin licensed pursnano Ne Contractor's
License Law. 1 PERMIT ISSUANCE C�
❑'Iamexemptunder Sec. ,B&P C for this reason
Owner • - Date - ALTER'=DRAIN&VENT-WATER(EA) w }y}I,ATION
WORKER'S COMPENSATION DECLARATION
I herebyaffirm under BACK PLOW PROTECT DEVICE V
penalty of ofCon enc of the m mr-declarations oar.
❑ Ibave and will forty eCion 37 to ofConsent Code,for the
Workersce of the
DRAINS-FLOOR,ROOT,AREA,GDND. STORIES TYPE CONSTRUCTION
work for cation,as provided for by Section 3]00 of the Labor Code,for the performance of the - -
[RIhaveand will maintain
issued. FIXTURES-PER TRAP -
®I have and will main win Worker's Compensation Insurance,as required by Section +
•
3700.f the Labor Code,for performance of the work far
�nwhicyh this permi[is issued. GAS-EA.SYSTEM-]INC.4OUTLETS OCC GROUP- '� APN '•
Ca Workrier: er's�Common satipp`nihs, came poley No.� �3.I YI�I�96 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' Ibr
COMPENSATION INSURANCE GREASETNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe permit is foram hundred dollars DUsa GREASE TRAP
or less.) PL_ANCHECK FEE '
I ccnify that in the performance ounce work for which this permit is issued,Inhale SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner so as to subject m the Workers'Cmmpen- ENERGY FEE
Z ...mu Lawsof Califronm Date
O Applieran - sectors, WATER HEATER WNENTMLECTR' GRADING FEE
ti NOTICE TO APPLICANT mkin
If,after ag this Certificate of Exemption,you should WATER SYSTEM/TREATING
F become subject the Worker's Compensutimi pmvicions of the Labor Code,you must SOILS FEF.
.W ti fonhwiN comply with such pmvicions or thie
Q 'peour shall be deemed revoked, WATER SERVICE ,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V G l hereby affirm that there is a construction lending agency for the performanceof Data Receipt It
the work for wboth this permit is issued(Sce.3099,Civ.C.)
(L H
U Lender's Name - -
I21 Lenders Address TOTAL:
"" ^
(y 1 carry that 1 have read this application and state that the above information is BUILDING FEE
Iij correct,l agree or comply with all city and county ordinances andstate laws relating to QTY MECHANICAL PERMIT - FEE
V Z building construction,ad hereby authorize rep rse rmaives of this city to enter upun the SEISMIC FEE
above-mentioned properly far inspection puryuses. -
(We)agree to save,indemnify and keep hatmlesa the Cit M of Cu nine against PERMITdSSUANCE ELECTRIC HE
in
granting villas Isparta,which may in any way accrue against said City ALTER OR ADD TO MECH.
- onsequence of the granting villas permit.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ' AIR HANDLING UNIT(TO 10,000 CFM)SOURCE REGULATIONS. MECHANICAL FEE
r�p• AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signet a fAppli UCon[racter Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamm future building vaupor stone.,handle hazardous material HEATING UNIT(TO 100,000 BTU) i a
as defined by the Cupertino Municipal Code,Chapter 9d 2,and the Health and Safety
Cade.Section 25532(a)7 + HEATING UNI'r(OVER UXLM BTU)
❑Yes "'Q Nn ' VENTILATION FAN(SINGLE R851D) PAID r
Date r Receipt M
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR IW,g10 BTU) t •.
Lit hafine
hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Disnint9 ' BOILER-COMP(OVER 160,000 BTU),
my. No
AIR CONDITIONER
1 have read the h Mz ,S s,i..., is requirements under Chapter 6 t. of the if OI - ISSUANCEDATE
fomia Health&Safety Cala Sealant 25505,255JJ and 25534.1 understand that if Nd NEW RESIDENTIAL MECH. SQ.FT.
buildingfthdoes not etnemlyhave
dloa rnant,that itismy responsibility tononif0c occupant
n
of Ne requirements which muvt he con priormissuance tufa Cenlficaie of Occupmcy.
Owner m authmized agent Date TOTAL: ISSUED BY:
OFFICE