30786 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 3 0 7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J{ }l„1({V�
BUILDING PROJECT IDENTIFICKFION
BUILDIN ADDRESS ,r —� SANITARY NO. APPLICATION SUBMITTAL PAIL
12 -2�t7
OW .R:SN E: COKIROLp
NE: CQN'1'RACTORR NA LIC NO:
ARC /EN N 'ft: EIC NO'. ❑
CONTACT: PHONE: BUILUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P B MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION N TY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRI 'ION
O0Z with Section 7000 Drvwi 3 fthe Businex,a dN -s ons Cole, nit my licenscis RESIDENTIAL
DENTIAL
in 00 w� yIy PERMIT ISSUANCIi
full force un f �{ ❑SFDWL ❑KITCHEN RF.MOUEI.
aF.UV Lieenxe Class C/ Lic.p IANCFS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N<i Dmc Comractor
FOy ARCHITECTS DECLARATION PANEL. (3 MULTI-UNIT [I STRUCTURAL
Z O o�z 1 meemi it my plana shall be used as public records MODIFICATION
DPTo ,, 1 dp5
OZ—� ❑INTERIOR ❑CHIMNIiY REPAIR
FSI Lal Licensed P-fessi.,ul 201-10gp AMP IMPROVEMENT
9Yf; OWNER-BUTLD17R DECLARATION OVER IIMMIAMPS ❑BATH REMODELrREPAIR C3 DEMOLITION
P:W Q 1 hereby affirm that 1 um exempt from,M1e Contractor's License Law for the
�yyx(O y U following reason(Sce,fun 701I.S,Bu,incx,and PnJcaslon,Code:An,voy or county SIGNS ELECfRICAI. ❑OTH k
LLl'31a.y which requires a permit to construct.alter,improve,demolish of repair any structure J-
E"u'O� prior to its isauonce,also real the applicant for such permit to file a signed staromem SPECIAL CIRCUIT'/MISC. —I
!{} that he is livened pursuanuo the provisions of the Contractor's License Law(Chapter 9
—GO (commencing with Section 7000)of Division 3 ofthe Buvine,s and Professions Code)or TEMH METER OR POLE INST. COMMERCIAL'
a y y that he is exempt therefrom and the basin for the alleged enemptinn.Any vinlmion of - ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TF.UANT FOODSERVICE
t more than five hundred dollars(5500).
F y} IMPROVEMENT
QwiLas a orofths,,mal process menarinemployees dmoffeges asaltheir(Set.compenso,ion, SWIMMING POOL ELECTRIC
will Jothe work,ande:The Contractors
Law do for sale(Set.o an Business C1 OTHER
—w and Pmy wh b Code:The Contractor's Live m,Law Jnex not apply t. f owner of OUTLETS-SWITCIIIS-FD('1'URES
6 3— pmpeny who builds or improves thereon,and who doessuch work himulf of through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold withinoneyar afcompletinn.the SQ.FT FLOOR AREA 5/SQ.Ff.
n-builder will havems burden of pmvag that he did not he",nr improve lin pur-
pvemTode.)_ w
1, owner of the property.am exclusively contracting with licensed mmeme,1. OTAL:
C] 1. r
ca
M A ' D
construct the project(Sec.70W,Business and Professions Code:)the Contractor's Li-
ems Law does not apply to on.wact d property who bui Ids or i arproves thereon.and QTY. PLUM B[NO PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor x MAR 25p��1
License Law. PERMIT ISSUANCE IICIi
I am exempt under Sec. ,B&P C for this reason
Owner Date �t LL 1
ALTER-DRAIN&VENT-WATER IEA) j- VVIUATnTINU
WORKER nderPCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hertwillo underpenaltyof ofCmury one ofthe fnsure for declaraWorker v Co
I ❑ Ihave and will maintains Certificate of Conxmmxelf-insure for N'orkuGs Compcn- DRAINS-FLOOR.ROOE AREA COND. STORIES TYPE CONSTRUCTION
Bsal it,as pe-Aided for by Simon 37MI of the Labor Code,for the performance of the
k lich this rmit is ismod, FIXTURES-PER TRAP
ave and will maintain Workers Compensation Insurvrce,as required by Section
3700 of Labor Care,fomhPATTON
f the work for which this permit is iaued. GAS-EA.SYSTEM-1 INC.a OUTLETS OCC.GROUP APN
M W a C l it 1 hPnlic h r v
y GAS-PA.SYSTEM-OVER a(EA)
cam : f ewwsfNa . ` .
CERTIFICAIION FROM WORKERS' GRGSFANDUSTRL WASTE INTERCEPTOR COINSURANCE BUILDINGDIVISION FEES
(Thixxecdon need not he complmed lOh,pori,;,fnrom hundred delta,,(SIM) GREASE TRAP
or less.) PLANCIIHCK FEE
Icmifythminth,per 1mrameeoflnswork forwhich,hispennitis issued,Ishall SEWER-SANITARY-STORM EA.200 Fn
not employ any peraon in any manner so a,to become subject to the WorkersCamper- ENERGY FEE
,7, Bari,,.tax's of California.Date WATER HEATER WNENT E[LECfR
O0 Applicant GRADING FEE
'Zr V) NOTICE TO APPLICANT':If,after making this Cmifcme of F.cort don,you should WATER SYSTEM/TREATING
f" ? become subj.,to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such p-visions or this permit shall be deemed revoked. WATER SERVICE
Q
�Z CONSem isaRUCTION LENDING AGENCY NEW RESIDENT Al.YLMB. SQ,FT PAID Date Recciptis
VQ weak
reby which tur IN,hat peritrixal(Sitecommotion30[ending agencyfor the performance of
the work for which this permit is ismcd(Sec.3097,Ci,CJ
U Lender's Name TOTAL:
p
>" WLenders Address TOTAL'.
y 1 certify that I have read this application and state that
the attune information ix BUILDING FEE
F (A coram.l agree to comply with all city and county ordhmnces and state laws mlating to QTY. MECHANICAL PERMIT FEE
7
I V R building construction.and hereby authorize reprewitatives of this city to enter upon the SEISMIC FEE
above-mantloned property far inspection purposes, PERMIT'ISSUANCE
(We)agree'.s v,,indemnify and keep brood...,he City of Cupertino against ELECTRIC FEE
liabi es,judgmen¢.c tx end expenus which yinaayw'ayammeagaiwt mdCity TER OR AUU TO MECH.
inc So ties IV
n(the ming o"I'm permit. PLUMBING FEF.
AI' ACANT UNDE TANDS AND W .COMPLY WITH ALL NON-POINT pIR I ULING UNIT(TO 1(1,11(10 CFM)
SO CE kL0U1,AT NS. //`- MECHANICAL ME
v 4J- AIR HAND G UNIT(OVER 10,00(1 CFM) CONSTRUCTION TAX
Si mare of Applies HAZARDOUS
111!!!✓✓✓���J ate EXHAUST HUO NUCTI HOUSING MITIGATION FEE
HALANUOUS MATERIALS DISCLOSURIi
Will the applicant orfumre building mcupum.anrc or handle hazardous material HEATING UNIT(TOL MI PTU)
an defined by the Caperton Municipal Code,Chapter 9.12,and the Health mal Safety
Coda Section 2553201" I HEATING UNIT(OVER 1011. BTU)
❑Yes 0N VLNI'l1.AT10N FAN SINGLE RENSPAID
Will thea licant or future buildin ,use a ent or dc'ccs which Dmc Receipt M
pp building then Area
BOILER-COMP LINT OR 100.1X10 BTU)
emit hararJoua air contaminants as defined by the Nay Area Air Quality Management
TOTAL'.
Drs,mmP BOILER-COMP(OVER 1100,000 BTU)
O Ycx 0N
I have the lacerationslacerationsat
ons merlalire
x od
m uer Chaper6.95.17th,Cali- AIR CONDITIONER
rem lacerations DATE
,qu
famia Health&Safety Code,e.dons 25505.25531 and 25534,1 undentatul Na,if Jac NEW RESIDENTIAL MECH. SQ.FT.
huilJing.imnetcurhich h:aina mete that.i,myecofa Ceni tonmifythc.ecup.m
ul'the reyuir,m,nts which must be tact prior to issuance.fiat Cenilicum of(keupancy. .I
Owner or authorize)agent Date TOTAL: ISSUED BY:
OFFICE