30115 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 30115
BUILDING PROJECT IDENTIFICAI'[ON
BUILDINGA�RF,SS: VR. eac(o w GT. GT �]Y ' SANITARYNO. APPLICATION SUBMITTAL DATE
OWNERS DAME: PII(lNl,�� CON'{iA fl0�fAfe 'A/ 1�✓(J LIC N
UU VV !(pp�"777 IdI I1 7 V r of NIC CONTROL M
ARCHITECT/ENGINEER: ) ADI 9 ❑
4� �✓�"�' �`�'' I aYrH S n!3as 8(vd
CONTACT: PHONE: BUILDING PERMIT INFO
V�� E:1 Consultant Fees Paid by Applicant(Initial) BLDG ELECT
ART. Lk- PLUMB MECH
LICENSNTRACT. 'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby err that 1.m licensed under provisions of chapter 9(commencing JOB DESCRIPTION
Z with Section 7000)of Division 3 ofthe Bannessand Profess:.sCode,vndmyluta,cis RESIDENTIAL'
11--F�. in full force and eD _ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
aUV License Clercs I _ Lic.p APPLIANCES-RESIDENTIAL OADDITION [I PLUMBING RE-PIPE.
Q a Da¢ TS DELL
A CffITECI'S DECLARATION ❑MULTI-UNR [I STRUCTURAL
Z O w Z 1 understand my plane shall M used as public records PANUS MODIFICATION
OZNO UPTO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F�F¢1 Licensed Professional 201.1000AMPS IMPROVEMENT
ad i OWNER"BUILDER DECLARATION OVER IIXI(IAMPS C1BATH REMODELIREPAIR [I DEMOLITION
C 6 1 hereby affirm that I am exempt farm the Contractors License Law for the
yKj 3 LL F following reason.(Section]031.5.Business end Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y which requires n permit t.comtrmL altar,improve.demolish or repair any gmemre
F 'Det prior to its issuance,also requires the applicamfor such permit to file a signed statement SPECIAL CIRCUFUMISC.
f Y� that M is licensed pursuantto the previsions of the Contractor's License Law(Chapter 9
W�C0 (commencing with Section 70(1pofDivnion 3 of the Business and Professions Coda)or TEkIP.MISTER OR POLE INST. COMMERCIAL:
E EN C mat M is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Scetion]031.5 by any applicant for a pctra.mbjects the apilicirmm.civil penalty ❑
of POWER DEVICIS
EI FOODSERVICE
not more than fve hundred d.11ars($500). IMPROVEM N' .I L
� ❑1.as owner of the property.or my employees with wages as their side compensation. SWIMMING P00I.ELF.CPRIC �N Or
asFin will dome work.and thesuuoure is not intended or offered formic(Sec.70M.Business ❑OTHER r
Wil:m and Prefic,m.ns Ca :The Commoner License Law does am apply to on owner of OUTLETS-SWITCHES-FIXTURES V� 1
6 deproperty who builds or impmves thereon.and who docs such work himself or through
his own employees,provided that such imparvemcros an not intended or offered for NEW RESIDENTIAL ELECIR SQ FP.
sole.If,hnweveethe building of improvement is sold within one year efcomplenon,the SQ.FP.FLOORAREA $/SQ.rp..
owmanbudder will have the burden of proving that he did not build or improve for or.
pme of salc.)
❑I.as owner of the parpmy,am exclusively contracting with liccnscd contractors no TOTAL. 'T
construct the project(See.]aLL Business and Professions Code:)The Promotion s Li. AVG 21
nx law doe,not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FE 1991
who comm n,for unb Io jests with a contmcmq,)licensed Formenun the Contmonh I f t
License Law. PERMIT ISSUANCE. I
0 lam exempt under See. ,B&PCformiareamn
])am ALTER-DRAIN.&VI7NT-WATER(EA) VALUATION
Owner
WORKER'S COM perT10N DECLARATION BACK IlOW I'ROIECI'.DEVICE
I herehy,(firm under penaoferp
lty of pryone of the following Jcdamfinm:
I Mvs.nd will maintain.Certificate of Cmvmmlo self-inwre for War kers Cnmpem DRAINS-FlAOR.ROOF,AREA,CONE, STORIES TYPECONSTRUCTION
wdon,as provided for by Section 3]1X1 of the Labor tide,for the performance of The
k for which this pemsit is Isvaed. FIX'T'URES-PER TRAP
1 have and will maintain Workers Conlimcation Insurance,m required by Section
3] ofthe Labor Code.for the performance ofine units for which this permit is issued. GAS-IiA.SYS'I'IiM�I INC. OUTLETS OCCGROUP AM
.
My workeeJyayP+y g�)syrpy corticrand Policy nu sFr{yy-,.-w-a�p/
Carticcy1 QL IV IJ P,,Ii,y Na.: JVIID'II7 GAS-LA.SYSTIiM"OVIiRJ11iA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiASIIINDUSTRL WASTE IN'I'ERCF.ITOR
BUILDING DIVISION FEES
(Tl+ls rcmion reednot be nnnplaN if the pcnnit is fnnmc M1undrvd Dollars($IIXD GREASI?TRAP
or less) PLANCHF.CK FEE L-
Iccnifythminmcperforanufenrlhc work(..which Thispcnnit is k,imd.Ishull SEWER-SANITARY-STORM PA.20(1 IT
not:employ of Person in any m:mncr nn us I to the Worker,'Cnmpcn. ENERGY FEB
Y Y Person �J'��q ufX(t
',� is Dam 3f= 4^710 I WA'I'IiR 11 PAPER WIVIiMPIIiLECTR
I NOTICE
P 9_ AAULVL/_ GRADING FEE
NOTICE;TO APPLI�ANT.IL nfl�/nmking Thie Ccnilicnm of Excn+ptinn,You ehoNd WAI HIR SYSTEM TRHAI'INC, SOILS FEE
F" - bcoure mi,jecl m the Wnrkcr's Componsmom provlsinm of me labor Code you mug
� s.-T forthwith comply with suchp,ovisionsar this pvorn,adl hcdexomdrevokcd WA'1'IiR SERVICE
Q
p• CONS"PRUCTION LENDING AGENCY NEW RESIUEN'1'IAI.YhMH. SQ.FI'. PAID
DZ T hereby affirm that there is a construction lending agency for The performance of Dow Recciplp
L)P the work for which this pcm+iti,issued(SeeNy)].Ci v.C.)
ULender's Name 'TOTAL
{T7 Leader,Address TOTAL:
y I certify that I have mod! his indication and stow Ihit the above informal..in BUILDING FEE
F+ 0 coon.l agneem..,I,with.11 shy and countydnaneas anal law,relmingto QTY. MECHANICAL PERMIT FEE
V Z building constriction.and hereby authorize representatives of this city to enter upsm the SEISMIC FEE
above-mentioned proWny for inspection pumotes PERMIT ISSUANCE
(We)agree festive,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD*10 MECH.
PLUMBING FEE
inconsequence of the granting permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IIl.000CFM) MECHANICAL ME
SOURCE REGULATIONS.
I j�Miyur�Q/1 a"Aa ) gel[/gab AIR HANDLING UNIT(OVER IQCW CFM) CONSTRUCTION TAX
Sign reof ApplicCon—tractor Date EXHAUST HOOD(W/DUCP) HOUSING MITIGATION FEE
n'
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupon store or handle bazaWous material HEATING UNIT(TO 100.000 BTU)
as dquai,by Be Cupcnino Mun/icipal Cale.Chapter 9.12,and the Health it Safety
Code.Station 25532(a)P / HEATING UNIT(OVER 100,00)BTU)
❑Ycs VENTILATION FAN IS INGLE RESID) PAID Date RettiptM
Will IM applicant or future building aecupant use equipment or devices which
emit M1aurdous if contaminants as defined bytbe Bay Area Air Quality M...gemem BOILER-COME(3HP OR 100.0110 BTU) TOTAL:
Distrix] BOILER-COMP(OVER 100.000 BTU)
❑Via, ❑No
AIR CONDITIONER
I have mad the h ode,S s materials 5.a 533 a under Chapter understand
of the Cali- ISSUANCE DATE
forma Health
acSafety Cade.eamrar.thati 25533esp255JJ.1 innely a IMIifthe NEW RESIDENTIALMECPI. SQ.FT.
building docs not currently which have1 tenant,that it is ua ce of
responsibility mm o newly cuxcupant
of me rtquimmen¢which must be met prion.issuance of a Certificate of Qapaay.
Owner or authnrizm agent Date TOTAL: ISSUED BY:
OFFICE