30612 e APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO. ^ 0612
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING-MECHANICAL J< il�J L
BUILDING PROJECT IUENTIF•ICAI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI£
ZZS E E P4 ��j,q 6
OWNERS NAME: x�# PHONE: COME RAC']OR:S NAME: LIC NO:
tnA J f'1 1S-Is Z -Ml) NIC /CkOWROL#
1RCHITECTIENGINEER: LI NO, DURESS: ❑
CONTACT: PHONE:.(Jo8' BUILDING PERMIT INFO
CCS, ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
HSz- AVO ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
1 herehy affirm mm l am licensed order provisions of Chapter 9(commencing ]OB DESCRIPTION
'OZ with Section]o01B.f Division 3 ofthe Bminess and Prllfnd011n Code,and my licenne is RESIDENTIAL
F O in full foteeand effect. PERMIT ISSUANCE
❑SFDWL ❑KITCHEN REMODEL
aVW License Class Cora APPLIANCES-H•'
G i Uam Contractor RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
F.O to ARCHD'ECT*S DECLARATION PANELS ❑MUI.TI-UNIT ❑STRUCTURAL.
I um
ndean l my plans shall be used or
as public recds MODIFICATION
OZ—O UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
h..4 f'; Lnemed Prole.ni.nal 201-1000AMPS IMPROVEMENT
Y OWNER-BUILDER DECLARATION OVER 10MAMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
9�< i herehy aIfon thin I ant cxcnlpl from the Commcun''s License I,aw fur the
a O d U following mason.(Section 703 I.S.Business and Professions Crile:Any city or county SIGNS ELECTRICAL El OTHER
3 W ye which requires a per nit to constmct alter,improve,demolish,or repair any structure
F-LL V, prior m its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. '
,E(7 y ctrant that he is Iicocif Mr to the pmvisiom of the Contractors License Law(Chapter 9
�a�p� (commencing with Section 7000)of Division 3 of the Business and professions Codd or TEMP.ME'T'ER OR POLE COMMERCIAL:
d c y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0NEW BLDG/ADDITION ❑DEMOLITION
Y• Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
=fin ❑TENANT ❑FOOD SIiRVICii
`z ofmort than five hundred Jollan($SW). OTHER EMF.Mjts /, nl)rlfTla� i
� 6Q QI,eme—,ofthe theperly.rrmyemPloycenwish wage.as theirrolecompemirels SWIMMING M)OL ELIiCTRIC (�.r��JIV�'r...�r/
will dothework,andthe Am man isnoti License Law Nsorale(Seo.]EFW.Bunions OTHER
find Pmfessinnn Cede:The Contractor's License Law Jnxs nm apply m an owner of OUTLETS-SWITCHES-FIXTURES /
property who builds or improve..limnon,and who docs ouch work himself.,through PA
his own cmployres,provided that such impmvcmenta are nm intended oroRerW for NEW RESIDENTIAL ELECTR SQ ET.
sale:if.however the building or imprrvenrem is wild within nuc year ofrnmpletion,the SQ.FT FLOO A F 5/SQ.Fr
rycr-builder will have the burden of proving that he did not build m improve fur put- �B
se ,talc).
❑I.n owner of the properll,am exclusively contracting with rcemed coomators to
mesal the project(See.ALM,Business and Professions Code:)The Contractor's U.
ceme Law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT I FETE V UrL V
who contracts for such projects with a contmcoms)licensed pursuant to the Cnmmcaorn l
License Law. PERMIT ISSUANCE 'I /,YO
I am exempt cede,Sec. _ .B&PC for this rentor
\ Ownc Dom ALTER-DRAIN&VENT-WAT17R BA) VALUATION
WORKERS compiiNrATTDN D eCLARATION BACK FLOW PROTECT.DEVICE �L��M### `
I hereby affirm under penally of perjury one of the following declarations: 7 Nc/
I have end will matnmin a Cent ficateofConsem t.self-inure for Workds Co.,.- DRAINS-FLOOR.ROOF,AREA.GOND. STORIES TYPE CO STRUCfION
radon,as provided for by Se,tion 3]00of the Labor Code,Gu the p:,t.rnluncC of the
work or which this permit is issued. FIXTURES-PI7R TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Cade.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.a OUTLETS OCC.GROUP APN
My Worker's Con,insation In.sumnce carrier and Policy number am:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER J(EA)
CER I1FICATE OF EXEMPTION FROM WORKERS'
C0M1'INSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
B .DIN:DI SIGN IBES
(Thin xcmian need not be rompincd if the Permit is for one labored dollars(SIM) GREASGTRAP
or less.) PhANCHECK dE
I certify that is no perfmmuoceofthe wok for whichthis frrmit is is sued,10oll SEWER-SANITARY-STORM G.200 FT.
not employ any person in any manner so un it)become subject to the Worker<Cn.N... ENERGY FEVA
Z anion Laws of Caltfomia.Date WATER HEATER WNENTMLECTR
es
O Applicant GRADING F I
y NOTICETO APPLICANT:If.after making 11111 Certilicum of EXemphtlo,you should WATER SYS'I Ill BEATING
a , become a bjtat m the Workers Compensation provistuns of the labor Code,you matt SOILS[ZEE
forthwith cnnply with such pmvininns nr lh,,mmit Ionil he deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U Z Ihemh affirm met is.ananaunion lendln for he fommnceof Dam Receipt#
W. Oy ga.) per
the work far which this permit is issued(Sm.300],Civ.CJ
0 U Lender's Name TOTAL:
W Lender's Address TOTAL: BUILDING FEE
I certify That 1 hove mad tots apPltcatton and state tbar the above infomlmtun isF H correct.l agree to comply withal)city and county ordinances and store laws relmingof QTY. MECHANICAL PERMIT FEE
building conswction.and hereby amharrze representatives of this city to enter upon Ne SEISMIC FEE
above-memimted property for inspection purposes. PERMIT ISSUANCE
(We)agree to ave,indemnify and keep harmless the City of Cupertino against ELECTRIC PGE
liabilities.judgments.costs and expense.Which may to any way ucerueagainm said City AITERORADDTOMECIL
in consequence of the gratnting of thin Permit.
PLUMBING PEE
APPLICAVP UNDERSTANDS AND WILL. OMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO 10,000
CFM)
>11 EGULATIONS. ii. MECHANICAL H1
AIR HANDLING UNIT(OVER I0A00CFM) CONSTRUCTIONTA
oattac.1 ApplicerwConecton Dam EXHAUST HOLD(W/DUCT) HOUSING MITIGATED FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant mre or handle hazardous material HEATING UNIT LO IW,WII BTU)
m defined by the Cupertino Municipal Cede Chapter 912,and the Health and Safety
Code.Section 25532(a)^ HEATING UNIT(OVER 101.000 BTU)
❑Yes - ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the appltcam or(arum.building rccupam use equipment or devices which Uate Recet #
mil hazardous air contaminants as deli tied hythe Bay Arca Air Quality Management BOILER-COMP(3HPOR IW0MIBTU)
TOTAL:
Utsmct^ BOILER-COMP(OVER IW,000 BTU)
❑Ycs ❑No
Ihuve real the hvaNnun materials rttp:ircments under Chnp¢r 495 of the Cali- AIR CONDITIONER ISSUANCE DATE
(emir Health&Safety Cade,Stations 25505.25533 and 255Y1.1 understand Jul if the NEW RESIDENT1A1,MECH. SQ.Pit
h ildingd not currently haveu�t% hoity to nmify the occupanto mhe temenuwhich mu enilicrteofOccupancy.ret or amhon"agentUutc• TOTAL: ISSUER BY: VVr Y1J
OFFICE