30030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELFICIRICAL
TERM"
'NO. OO O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PRIIJECr IDENTIF'ICAT'ION
BUILDING ADDRESS: 7-- LL," SANITARY NO. APPLICATION SUBMITTAL DATE;
OWN R'SA ME: f PHONE —�/)�/I CONTRACTOR'S NAME LIC NO.
N1lO 77 7 NIC COMROLb
' , CT/EN�(eR7 fIGIV�/.
LIC NO ADDRESS: ❑
CONTACT. PHONE (G1 BUILDING PERMIT INTO
CSIODV-97 � EDConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Li K Irk S.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby nDirm that I am licensed under Forlorn,of Chapter 9(commencing _ JOB DESCRIPTION
Oa'Z with SaTfon 700(Bof Division 3uftbe Busineasand Profess ons CWc, nd my license isRESLDF TIAL
u100 wtpill pp PERMIT ISSUANCE 'FDWL ❑KITCHEN REMODEL
1—U_ kens, las ,Dent. e—� ' Y(D ,5.v(7
�UZV License Class Lic.M APPLIANCES-RESIDENTIAL. ADDITION [I PLUMBING RE-PIPE
y 6 0. Date—Camra CL
F,7w ARCHITECT'S DECLARATION PANELS
❑MULTI-UNIT ❑STRUCTURAL.
Z I u and my be uu us public records MODIFICATION
OZ— UPT0200AMPS ❑INTERIOR C1 CHIMNEY REPAIR
uI is Tessio 201.1000AMPS ,IMPROVEMENT
Q cn NER-11 LD DECLARATION
C OVER 1000 AMPS ❑BATH REMODEIIREPAIR El DEMOLITION
I hereby a e hat i ten este pt Baa the Cnn mi,Cas License Law for the
y2xO U following reason.(Section coni 5, t,sines and improve.
demolish,
CNe:Any city ar county SIGNS ELECTRICAL El OTHER
W O
I.
which requires o c.cels re construct,pplicuimforsu demolish, file
repair any structure
J
prior(I) issuance,also rcyuires the aFFlicum for such Permit Filca signal statement SPECIAL CIRCUIT/MISC.
F,�y thuheLslicensedpursumntothcprovisiomaftheComracmrxLirenwlaw(Cbapter9
W X00 (commencing with Section 7(KKgafUivisian3ofthe Business and Professions Galelor TEMP.METERORPOLE COMMERCIAL:
6 t1 p C thm he is exempt Ihercfmm and the basis for Nc alleged exemption.Any violation of ❑NBW BLDG/ADDITION ❑DEMOLITION
'^vi Section 7031.5 by any applicant for a permit subjecs the applicant to a civil penalty or POWER DEVICES ❑TENANT ❑Fool)SERVICE
^Z} an,aoremmi Five Warned dollars(E50hy, IMPROVEMENT
Z60Las owner nfthe pmpcny.or myemployees with wugesus lhcirsolucompenmtion, SWIMMING POOL ELECTRIC
will do the work,and the suucum is not intended of offered ror sale(Sec.T94,Business EI OTHER
Wand ffbnrsAans CWc:The Contractors License Law docs not apply m an owner of N OUTLETS-SWITCHES-FIXTURES
d 3.. Sperry who hmId,ar imFmves thereon, ad who docs such wick himself or through 3
his own employees,provided that such intprovenmms are not intended ar otTered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,however,the building or improvement is sold within one year ofeumpledon.He SQ.FP FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put,
pose of safe.). �wAy4
I.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: �(/✓� ice/
nnahun the project(Sec.7014,Business and Profession,CNet The Contractors,Li-
-` T
cense Ltwdoes not apply to nn owner of popery who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who romrams for such projecu with a contactors)licensed pursuanuo the Contmchs" _ o
License Law. PERMIT IS A E ..��''``)-.)1,6❑ am am exder Sec ,n ic P C for this reason
-- AIXER-1) VENT-WATER(EIG VALUATION
Doc gg U
WORKERS COlyof ,p,or DEC/RATION BA .O PRO .DF.VI E
1 reby tiff rte under pcneltY of ,p,ore of mt>�ninns: -
❑I haveand will maintaina Certilicacco C s self insure for Workers Cooper- D .00R.Ro01t. .A,CI S'TONIPq TYPE CONSTRUCTION
cation,u provided for by Section 37 theLShnr Code,for the Import of the 1 1
work for which Nis permit is is FIXTURES- n
❑ 1 have and will mai Of nrker Cympensuinn Inwmnce,us rtquirW by Section
3]W nl the Loon Gale, rhe peRfitare eof the work for which Nis pemtit is issued. GAS-EA.gYSTE -I I 2.4 OUTLETS OCC.GROUP AI'N
My Worker',Compens; m as nee carrier and Policy number we:
EA
OVER 4 SYSTEM
-OVER GAS- A. - ( )
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GNEASFIINDUSTRL WASTEIMERCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
or less.)This,welm.aced oat be completed ifthc permit is forone hundred dollars($100) GREASE TRAP
1'IANCHECK PER
I cenifyNatin Ne perfonnen¢nr the work for which this Fennit isissued,lshall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to hecome subject to the Worked Compcn- r
,7, nation Laws of Califon..Date WATER HEATER W/VENTIELECTR
OGRADING TEE
Z O Applicant.JM NOTICE TO APPLICANT:IL after making this Certifcmeof Exemption,you should WATER SYSTEMaREATING
a' became subject to no Worker's Compensation provns of the Labor Critics you of SOILS FEE
isio
W forthwith comply with such provisions oc lbi,wifitshall he deemed revoked. WATER SERVICE
Dz CONSTe I%a constriction ONLENDINGAGENCY NEW RESIULNTIAI.NL,MB. SQ.FT. PAID Dote ece"
V 0 I for by whichaffirin
this a rrot i i,aed(See3lending agency for the performance of
(, Nawar,Na which this permit is issued(Sec.309],Civ.C.) /
U. Isnders Name TOT 1.:
U Lenders AJdres TOTAL:
y1 certify that 1 love mad this application and state Not Ne above Information is - BUILDING FEl3
RI correct.l egreem comply with all city and county ordinances and sm,laws relating to QTY, MECHANICAL PERMIT FEE
V Z buildingeomtruction.ondhembyamilimixe represmasn'esof this city toemerupinthc SEISMIC ME
above-mentioned m,ay for inspersion purposes. PERMIT ISSUANCE l
(We)agree to save.indemnify and keep harmless the City of Cupertino against _ ^ ELE
CTR
liabiliti s,judgments.costs and expenses which say in any way arrive again.sinid City ALTER OR ADD TO MECH. Z. (.a/ PLUMBING FEE Q g
in consequence of the Stoning of this permit. J
APPLICANTUNDERSIANDS AND WILL COMPLY WITH ALL NON.POINT/ AIR HANDLING UNIT(TO 10,000 CFM) MEMNICAI✓FEP" crll IN, I
7Y,4101
SOURCE REGULATIONS.
/> Y7 AIR HANDLING UNIT(OVER 10.00 CFMI CONSTRUCTIONTAX
Signal/tire of Applicant/Convammr te EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE .n
Will theapplicant or future building occupant store or brundlee Zmaterial HEATING UNIT ITT)I(M,IXIO BTU) •!.v S
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Hwlth and Safety 1
Code,Section 25532(a)T HEATING UNIT(OVER 100.00)BTU) �.+/►��/F
❑Yes XNo PAID!`LL.I
VENTILATION FAN(SINGLE RFSID) Dam apt M
Will the applicant or future building occupant use equipment or devices which
mit haaudous air contaminants as defnW by the Bay Area Air Quality Management BOILER-COM'(3HP OR 100.000 BTU)
District? 'TOTAL:
emit
AN- NT)ILER-CMP I(IB,(NIn BTU)
I have read the hdmNm
ous rtmrials requitement,under Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health A Safety Code.Section,Z505,25533 and M534,I understand that if the NEW RESIDENTIAL MECH. SR FL
building Jens not come, thm it is my res possibility to notify the occupant
of the tequiremc sour prinno issmnce of a cemr, e n Oreu y
Owner., oacd agent Dme TOTAL: ISSUED BY:
OFFICE