30773 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, �O "3
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
007.-). s� rv4, CA r /-/Yr97
OWNER'S NAME: -1 - PHONE: CO/yTRACI'OR'SnNAME: LIC NO:
I LL W &s. #L-s.,V\� La < f'� US NAC CONTROL#
ARCH 11 ECT/ENGINE HE: LIC NO,- ADDRESS: ❑
L, W22-1 , di-pi
CONTACT. 7 J�`c�+6/_Cl/ PHONE: BUILDING PERMIT INFO
7 ❑ Consultant Feer,Paid by Applicant(Initial) BLDG ELECT PL1IUUqMII B MECH
1-1 ❑ ;9 ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
N
I hereby affirmat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
woo with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
~Wr in full force and effect. PERMIT ISSUANCE
�U ❑SFDWI. ❑KITCHEN REMODEL
License Class Lie.p
ul Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBINGRE-P[PE
F p' ARCHITECTS DECLARATION PANELS ❑MULTFUNIT []STRUCTURAL
Z,O Z 1 uodersta d my plans shall be used in public records MODIFICATION
GPT0200AMP$
E-t4 El INTERIOR ❑CHIMNEY REPAIR
(-s�i{sl Licensed Professional OVER
IMPROVEMENT
`3$ a"i` OWNER,exempt
IIt DECLARATION OYER IIXNIAMPS,
yy I herchy sffirm thin 1 nm exempt from the Contractor's License Law for the [I BATH REMODEURF.PAIR [I DEMOLITION
x 3 L U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
LLLL1l U.�a which requites.permit in consumer,almr,improve,demolish,or repair any stmctum
0�1 prior to its issuance.also requires the applicant for such penuitto file a signed statement SPECIAL CIRCUITMISC.
} that he is licensed pursuanto the pervismostuf the Contractor's License Law(Chapter 9
COOa (commenaingwith5ectian7o1x0of Divlsinn3aflhe Businessund NafessinnxCWe)oI TEMP.METMOR POLE INST. COMMERCIAL:
a c W that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 1031.5 hymyapplicant for a permit subjects the applicant o a civil penalty of POWER DEVICES
roto ❑TENANT ❑FOOD SERVICE
not more than five hundred Jolters(S500). IMPROVEMENT
❑4o the work,the progeny,re is ompltuyeewioffend asthei(role compensation, SWIMMING POOL ELECTRIC
will do the work,and the he Cmc is not initiated Licee Law du,cal u(Sec.7044.Business ❑OTHHR
0.. anderty whoty Code:The Canvhemis License Laws suc rotapplytolf owner,of OUTLETS-SWITCHES-FIXTURES
.. progeny who builds or improves thereon,and who does such wink himself at through
his own employees,e provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
maramde -boweve¢the buil ding men of Temcnt issold wiid n build rimprovetion,the tl�S .FLOOpR AREA LSQ.FT.
poc cur ullder will have the harden of Teasing that he did not buil)or improve!or put- r M1 O
pont of owner
r N Y
1,as owner of the Sm.70,1 oro exclusively contracting with licensed contractors to TOTAL:
cense La the project(Stu.7M4,Business and Professions Code:)The Contherrn',Li. n 14 RUT
seLawdceatrotapply totsowner ofprogeny who builds or improvesthereon,and QTY. PLUMBING PERMIT FEE Dn
who contracts for such projects with a tontmcmHs)IittnsN pursuant mncc Ctumracmrs
License Law. PERMIT ISSUANCE
as
❑ lamexempt under Sec. ,0&PCfor this reon CITY Ur vurtMI140
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Uare
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hemby M.under penalty of perjury one of the following declanamine
I have and will maintain a Certificate of Convent to self-insum for Workers Comber. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3700 of the Labor Code,for the performanw of the
work for which this Permit is issued. A FIXTURES-PER TRAP #
❑I haveand will maintain Worker's Compensation Insurance,as required by Senior,
37(IOofthe Labor Code,forthe perfamtaus Ofthe work forwhich this permit is issued. GAS-G.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My WorkCo penin' cec artier and Policy mmnbcr
Cartier. Panty Na:a7��1'S 003361 GAS-EA.SYSTIiM-OVER4(PA)
CETIFICA eOFEXEMI?ION FROM WORKERS'
COMPENSATION INSURANCE GREASPlINOUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed ifrhe permit is fortune hundred dollars($100)
m lav) GREASETRAP PLANCHECK FEE
Icmify that in the Performance of the work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.20)PT.
not employ any person in any manner so as m hecume adtiart to the Workers'Compen- ENERGY FEE
z sution Lows of California.Duro WATER HEATER W/VENT/ELECTR
O O Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should WATER SYSTENVMEATING
became subject in the Warker's Compensation provisions of the Labor Cade,you most SOILS FEE
WQ> forthwith comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION[.ENDING AGENCY NEW RESIDENT'IAI.PLMR. u SQ.FT. PAID
U O I hereby affirm thin there is s conswctiun lending agency fonhe performance of Date Receipt N
L4. I--r he work for which this permit is issued(Sm.3097.Civ.C.)
O F+,` Leaders Name TOTAL:
�Wf Lenders Address TOTAL:
I ttnify that 1 have read this application and state that the aboJ ft
ve infonniumo is BUILDING FEE
((Ap corect.I agree to comply with all city and county ordinances and state laws relating to Q'Ty. MECHANICAL PERMIT FEE
U 9 building cansuuction.and hereby authorise representatives of this city to enter upon the SEISMIC FEE
above-mentimted progeny far inspection junpmee PERMIT ISSUANCE
(We)aa.,....indemnify and keep hamJess the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way secure againstmid City ALTER OR ADD TO MECH.
in consequence of the grand ng of this permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signomre of AijuicmUCcntmctor Dam EXHAUST HOOD(W/DUCO HOUSING MITIGATION ITL
HAZARDOUS MATERIALS DISCLOSUREWill the applicant or future building occupant store Or handle hazardous material HEATING ON['1'(TO 100,000 B'I'(f)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532mo? HEATING UNIT(OVER 100,000 BTU)
❑Yw ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Rereipt#
emit hazardous air contaminants as defined by the Bay Area Air Quality Management ROLLER-COMP(3HP OR 1110,000 BTU)
Disvin? TOTAL.
❑Yes FIN. BOILER-COMP(OVER 100,1100 BTU)
I have read the hazurdous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DA
fomia Health&Safety Code,Sections 255115,25533 and 2.5534.1 understand thin if the NEW RESID17NTIAL MECH, SQ.FT.
building does not currently have a tenant,that it is my responsibility to ratify the Occupant
of the requirements which must be,mail prim to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE