30445 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30445_
BUILDING PROJECT'IDENTIFICATION
BUILDINGADDRESS: SANITARY NO APPLICATION SUBMITTAL DATE
o -' � i7n f gi l3 6
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
Ltd N/C CONTROL a
\RCIII'TE'T/ENGINF.ER: I,IC NO: ADIIi55: W" O ❑ ��
fnl'
COMfACf: r71HONE: �(' r/ BUILDING PERMIT INFO
C244I \IQ's q4t2?j�/l I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MBCH
LICENSED CONnsed under
nd r DECLARATION QTY ELECTRIC PERMIT FEE
I hereby sf0em that I am licensed ines, pmvisiow of Chapter 9(commencing JOB DESCRIPTION
Wa'Z such Scctisn]WO)of Diaision 3ofthe Business aJ Pmfe,sions Cate,cad my license is RESIDENTIAL:
FOOin fall fame suit effect. PERMIT ISSUANCE
W= []SFDWL [I KITCHEN REMODEL.
Q V U License Class Lic,It i APPLIANCES-RESIDENTIAL []ADDITION 0 PLUMBING RE-PIPE
yDatc Comment,
tn ARCHITECTS DECLARATION PANELS [IMULTLUNIT ❑STRUCTURAL
Zp ZF Iunderstand my pians shall he rind us public records MODIFICATION
OZ-- UP TO 200 AMPS [_1 INTERIOR 0CHIMNEY REPAIR
Llansul 11 ficcvinnul 1111-IgN)AMPS IMPROVEMENT
OWNER BUILDER DECLARATION
C OVER IWBAMPS O BATH REMODEUREPAIR 0DEMOLITION
6 I hereby affirm that 1 um exempt from the Contractor',Laccii Law f u the
6 O a.U following mason.(Section 7031.5,Business it Professions Code:Any city ry county SIGNS ELEC*DUCAL D OTHER
tat
0�+ � which requires a permit a emou" alcor,improve,demolish,or repair any swcture
priorm iuis,uarme,al.m"iti.flis.pbicam fiesuch PemkaFfiks,,red,amm,o, SPECIAL CIRCUTUMISC.
E } thmheishoorrdpursannu.file provisionsafthe Comredors License Law(Chapter9
� 90
5p0Y fcsmm,.mg;with Scene.7WOUF Division 3 of the Business and Professions Cade)nr TEMP.METER OR POLE INST. COMMERCIAL:
a a e Lk he is exempt animators and the basis for the alleged exemption.Any violation of 11NE LDG/ADDITION 0 DEMOLITION
m Section]031.5 by any applicant for a strah subjects the applications a civil penalty of POWER DEVICES ANT [:1 FOOD SERVICE
FZ
not more than five hundred dollars(SSW). N 0 EMENf
ppQ D1,as owner of the property,or my cmpici with wages as their sole compensation, SWIMMING POOL ELECTRIC
C2C2 L�`` will Jo the work.and the swcare is not intended muttered for sale(Sm.]fW,Business []OTHER
W and 1'rofeomes Code.The Contractor's License Law does not apply a a wter of OUTLETS-SWITCHES-FIXTURES
4i property who baled,or improves themon,and who Joe,such work himself nr through
his own employees,provided that such ingsmvensenrs arc not intended or offered far NEW RESIDENTIAL ELECI'R SQ FT.
sale.IL however,the building or improvement is sold within one yearofcomplction,the — SQ.PT.FLOOR
AREA
, $/SQ.FT
noholder will have the burden of proving that he did nos t build or improve for put. 1
erif sale,. �1
h us owner of the pnrpeny,am eaclusivcly contacting wird licensed comment to an
1`
onswe,the project(Sec.TfWJ,Business and Professions Cade:)The Contracmr s Li-
cense Law does not apply to an owner of progeny who builds or improves forever.and QTY. PLUMBING PERMIT FEE
whaeonemets fear such prefixes with a emrtmcun(q licensed pursuwt to the Contracmex
License law. PERMIT ISSUANCE
I furn Jer Seg. " ,B&P C forth' re
`\ tar n
(1S1•er ext ALTER-0RAIN&VENf-WATER ILA) t VAI-UAI'1(IN
tie �•`l9Q
WORKERS COMP' Df: .ARATION BACK FLOW PROTECP.DEVICE
her yaflinn under Penalty of Perjury one oll cfollowing dcc kc,xom:
Thaw and will for
Se Corti firm etthe Lab Code,forthe Worker's Ce It'he
DRAINS-FLOOR.ROOF,AREA.CON[]. /) l Ili vUr[f-STORIES 'I'YFIi CONST'RUCfION
smirk, r provided fnr rd Section Tl(NI of IM1e Lubar Code,for the performance offs t•p aS/
work for which he,permitis issued. FIXTURES-PER TRAP
1 have and will maintain Wo effor Compcmation rk for ce,h sox peed by Section
My3700ofthe rger's o Codofonhsurance cancer and Polis fnumbir aw: permit is issued. GAS-EA.SYSTEM-]INCA OUTLETS OCC GROUP MIN
Cm WorkeYs Compensation Insurance carrier and Policy number are:
Carrier. Policy No.: GAS-FA.SYSTEM-0VER q(EA7
CMTIFICATEOFEXLMPf10N FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Him section need not be completed rm
Jifthe peit is for one hundred dollars(SIM) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the Performance ofthe work liar which this permit is issued,l shall SEWER-SANITARY-ST ORM EA.21X1 FT.
not employ any person in any manner sit as m subject become suhjeco the Workers'Compen- 12NERGY FEE
,Z .anion Lawsof Culifvemlti.Dam. WATER HEATER WNEN'WELECTR
O GRADING FEE
z o NOIAppI ant
NU 1me object
APPLICANT:If,ulcer necking Tis Provision,
o of Exemption,you should WATER SYSTEMIMEM ING
F-• ^ Mantic mM1 cet to the Worker's Com tion f the Lahr Csde.you must SOILS FEE -
j pcort permit
nnan
forthwith comply with such provisions or thin Mnnil shall be deemed revoked. WATER SERVICE
:DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FL PAID
V O l hereby affirm that fere is a construction lending agency for the performance of Dae Receipt
the work far which his posit is issued(Ser.309],Civ.C.)
U. E-' Lsndet's Name TOTAL:
Linden's Address TOTAL: BUILDING FEE
y 1 certify that I have read this application and sate that the above information is
C..)rI,I correct.l agree to comply with all city and county ordinances and sate laws relatingm Q1 Y. MECHANICAL PERMIT FEE
Z building construction.and hereby rmhorim representatives of this city to enter upon the SEISMIC FEE
xbatc-earntiered property for inspection PurTuw%.
(We)agree It)save,iadentney and keep hnmdes,the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liahilitles,Judgmentx.cosh and exlen,es which tray many w,ryacerveagair teaid CityALTER OR ADDFO MECIL
in consequence of the grating of his peraf.f. PLUMBING FEL
LA
APPLICAN"f UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER In."CFM) CONSTRUCfIONTAX
Signature of ApplicanVxa
Comrr Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or fmure building necupamstotc or handle haonaous material HEATING UNIT(TO IW."BTU)"
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cute,Section 25532h)P HEATING UNIT(OVER I W.W0 BTU)
Ye, No
VENTILATION FAN(SINGLE RESID) PAID
Dote Rereipt x
Will the applicant tar future building scuupunt use equipment or devices which
Yiit hac..do.,air cormminnms us defined by the Bay Arca Air Quality Manegcnegt BOILER-COMP(3HP OR 100,00)[1 DO)
1'(1'1'AL:
Of..int'! '
Dye, E]No BOILER-COMP(OVER IW.(xN)B'FU)
I have read he haespinow materials requlmm<nts under CTapter6.95 ofthe Cali AIR CONDITIONER ISSUANCE DATE
begin Health&Safety Cade,Sections 25505,25533 set 255Mq I understood!that if the NEW RESIDENTIAL ME CH. SQ.FT.
building does ret currently have a tenant,ding it is my mspo otbllity an amity the occupant
of the requiremen¢which must be met prim m issuance of a Cenificme of Occupm e, �'''J��J
Owner or amhorted agent Dam L' C ISSUED BY: `a ✓`
OFFICE