30893 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES:USE BALL POINT PEN ONLY "
CITY OP CUPERTINO BUILDING I F.LECTRICAh - PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI.
BUILDING PROJECT IOP"FICATION
iess-BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
�oee M� Wray Cui�w""* CA ! . ol4 ►-t-"Aql
OWNER'S NA E PHONE: C ACTOR'S NAME LIC NO:
,134.0 Gay IN O NIC CONTROLN
CHITECP/ENGINE1 LIC NO: DRESS: F-1J J
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) W E ECf PLUMB C!
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Ihzt 1 an licensed under previsions of Chapter (commencing JOB DESCRIPTION
CZO with Section]IlOa)of Division3 nfne Busieess and Professidns CMJe,andmylicerseis PERMIT ISSUANCE g R SIDS ENTIAL' ,
n full Terminal offim.•
�FUZ�j License Class Lic.It _ SFDWL ❑KITCHEN REMODEL
t W Dam Contractor APPLIANCES-RESIDENTIAL DITION ❑PLUMBING RE-PIPE
n' ARCHITECTS DECLARATION
;U - PANELS MULTI-UNIT [I STRUCTURAL
z O n z I untlenund my plans shall be used as public awards - MODIFICATION
OZ-pp ' - r UPTO 2W AMPS [3 INTERIOR El CHIMNEY REPAIR
�HW Licensed Professional 2lILIWOAMPS - IMPROVEMENT
Jy Om I arm cD ti fir DECLARATION CmdoeN ,�I,�s
y�y� 6 1 hereby effinn that 1 am exempt from the Comrectnts License Law for the OVER IIIBO AMPS ❑PATH REMOpEy�wEAl:0 DEMOLITION
s!31.V following reason.(Section]031.5,Business and Profe.ions Code:Any city or county SIGNS ELECTRICAL ❑OTHER .I
s- O which requires a permit to contract,alter,improve,demolish,or repair any swclure J
mxo wits issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. --{I
gggrW'v�,{sy that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9 99.9 FI
C,da (commencing with Section](g10)of Division 3 ofthe Businessland Professions Code)or TIME METER OR POLE INST /p/
Y o tee!that he is exempt therefrom and the India for the alleged exemption.Any violation of ❑NEW BL �I 'ION DEMOLITION
rn Section 7031.5 by any applicant fora pcmtit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT /-'�Hr"I/(j.. �]f00D SERVICE
} t ream than five hundred della.S500).
G ❑I,as owner ofthe property,or my employees with wages as their sale compdrmum, SWIMMING POOL ELECTRIC .IMPROVEMENT -
will do the work,and the airmium is not intended proffered fursale(Sea 7044,Business ❑OTHER
and Pentagon,Code:The Ccommus s License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
n' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT TO SQ PT.
aide.IL however.the building or improvement is said winds one year of completion.the SQ.FT.FLOOR AREA $/SQ.Ff.
,anenhuilder will have the burden of Proving that he did not build or improve for put-, &L
pose of sele
C] Las owner A the psmpmt�7(9,B exclusively Prntecdns with licensed contractors t.
cense ect Law project(Sec.o ren Business and Professions ds or
The Commcton,and
ase law does not apply to an owner of progeny who builds n improves hereon,and QTY, PLU G PERMIT FEE _
who contract 6r such projects with a enntrucmr(s)licensed pursuant m the Conwemr's
W0°°ae mow' _RMIT ISSUANCE
C l am exempt under Seca ,B&P C for This reason
Owner Dam
R-DRAIN& R(9er VALUATION
'—
WORKERS COMPENSATION DECLARATION B PROTP.CT. C
I hereby ill mou under penalty of perjury one of The fallowing declarations:
❑Ihnve and will for
n a Section icate37W of the Labor
Coda,surefer Warkcreecof the
GRAINS- )R,ROOEA D. STORIES TYPE CONSTRUCTION
amid,,os provided for by Section 3]W of the Labor Codc,for the performance df the
work far which this gamut is orW. FIXTUR -PE P
E21 have and will maintain Worker's alwo ofthe a Insurance,ss requited by Section
My oRhe Labor Codgfonhsurance cancer and
work(number i e.permit is issue.). GAS-EA.S EM-1 IN LETS - PCC GROUP APN
Ca Workers Campenutian Insurance carrierroli Policy number are:. - GAS-EA.SYST ER4
Cuniec Policy FROM
CERTIFICATECOMPENSATION
INN FROM WORKERS' GREASEIINDUSTRL WASTE INTE R
COMPENSATIONINSURANCE BUILDING IVISION FEES
(This eectiomtttd not to completed if the Permit is forone hundred Rollers($100) CREASETRAP
or less.) . PLANCHECK FEE
Loy any pennon any
work for subjectell to the W rkes'Car shall SEWER-SANITARY+STORM Pw1.200 Pf.
not employ any perssm in any manner mi as m become subject m The Workers'Compen- ENERGY FEC O ota"
z station Lawsdf California.DateIIIV
Q - - WATER HEATER W/VENT/ELECfR
Applicant GRADING FCE
NOTICETO APP LICANT,IL Compensation
th Exemption,youshould WATERSYSTEM/1'RLATING
becomes comp to the Worker's Compensation previsions of The labor Cade,you must SOILS IEE
kLl forthwith comply with such provisions or this permit short hedttmetl revoked. WATER SERVICE
UOQ t CONSTRUCTION LENDING AGENCY NEW RFSIDENTIAL PLMB. SQ.FT. PAID
I hcmbyuffnrn that hem is a couslructionlending agency manic performance of Data Receipt#
the work for which this pemdt is issued(Sec.3097,Civ.C.)
Q Lender's Name TOTAL:
WLindera Adds. t TOTAL:
I ceril'y that 1 have real this application and state that the above information is BUILDING FEE
ycorrect.l agree m comply with all city and county mciumacesvnd state lows relining to QTg M ECHANICAL PERMIT FEE
V building constmmion,andhereby aatlarixampresernedivesofthis city menter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City,f Caperton against ELECTRIC FEE
liehilides.judgments,casts and eapenms which may inany any dame aglainm said City ALTER OR ADDTO MECIL
in .sequence of the Rending of this permit PLUMBING FEE
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,0W CFM) MECHANICALFE
SOURCE 1ILATIONS,
AIR HANDLING UNIT(OVER 10,0010 CFM) CONSTRUCTION AX
Signmure p csnVContmcmr Data EXHAUST HGOD(W/DUCT) HOUSING MITIGA .E
HAZARDOUS MATERIALS DISCLOSURE
Wdl The applicant or fuwre building occupant smmmhendle hezmdnus mmcrial HEATINGUNITITO 100.00)BT'U)as defined by the Cupertino Municipal Code,Chapter 9.12,and the Dearth and Safety
Code,Section 25532nd? HEATING UNIT(OVER I W,OINI BTU)
0Yes Otho VENTILATION FAN(SINGLE RESID) PAID
Date Reecipt M
Will the applicant or fume building occupant A equipment or devices which BOILER-
COMP OLT OR 1 W,Ti00 BTU)
emit hazallous air comlaminanu m defined by the Bayy Aree Air Quality Management TOTAL.
Distriot
❑Yes .Otho t BOILER-COMP(OVER 100,000 BTU) -
I have read the herardnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 25505,M533 and 25534.1 understand that if the ry8W RESIDENTIAL MECH. SQ,f>r.
building does not currently hive v action,that it is my responsibility to notify the Receptor
df The requiremcros which mum he ren prior to issuance or o Cer ifiewn of Occupency.
Owner m i nthanze l.,cou Data TOTAL: ISSUED BY:
OFFICE