30228 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY //�
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30228
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING.PROJECTIDENTIFICATION
BUILDINGADDRESS: ^^ P— SANITARY NO. APPLICATION
NNNSSSUBMITTAL DATE
D PSAP—
V
O ER'S NAME: PHONE: C NTHACTUHR NA E: LIC NO.
`_!� d IQL �L�. N/C CONTROL#
kRCHITECDENG EER: LIC NO: ADDRESS: - �• ❑
SfJJ ���P.OaOTdF�r ,e/�.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELI: PLU ME'
LICENSED ID CONTRd under S DECLARATION QTY. ELECTRIC PERMIT FEE
I irm 70 arefDvix l am fdjoB.ima,mroPidana mm Codx.r dm,ficeneing 10 DESCRIPTION
�WZ th Senion]tY10ITaDivixionlof the Business and l'rofcssions Code wd my license is IA .
FW. nhfull Tome an R ^ PERMIT ISSUANCE
ym 12 00m SFDWL ❑KITCHEN REMODEL
FlzW Liun Contra
APPLIANCES-RESIDENTIAL
oo<L Dam a. Comm ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION, ❑MULTI-UNIT ❑STRUCTURAL.
F O lin I'ANE1 ti
Z O r�,z 1^^dent^nil my plans vhall he used m Public record - MODIFICATION
OZ-0 UP10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
E.yfW Littnsed Professional 201-1000AMPS IMPROVEMENT
44 _3
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
tY 6 1 hereby affirm that 1 am exempt from the Contractor's License Law far the
XOaV following mason.(Section]0315.Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
3 LL� which mgahma a permit to construct.alter,improve,demolish,or mpair any structure
F�'O Prior to ns I.........No"Nur"do MImant ln.uch Permit o Ile asignedslammcm SPECIALCIRCUIT/MISC.
WS }� That he is licensed...uam to the provisions of the Contractor's Licen.w Law Whapmr9
QD (comnancing with Serf 7(wf of Dmkinn 9ofthc ltuxinexe and Pn resxions Cade)or "TEMP.METER OR POLE INST. IAL,
that he k exempt lhcrclmon and the Thai,for the alleged exemption.Any violation of ❑NL�- LDSDDITION ❑DEMOLITION
H
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
n mom than five hundred dollars($500), ❑TEN NT ❑FOODSERVICE
f=C ❑I.as owner of the progeny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC I QVEN
RV
1. will dothe work.and the nmemre is not intended proffered for sale(Sec.]Di4,Business jR
W-m and Pfofenions Cale:The Cantmcmr's License Law does not apply a on owner of OUT -SWITCHES-FIXTURES
a 3 property who builds or improve.,thereon,and who does such work himsaf of through
his own employee.,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELECT SQ FL
sine.If however the building or improvement issold withinone year ofsnmpletio l,the SQ.FE FLOOR AREA $/SQ.VT
ooner-builder will have the burden of proving that he did not build or improve for put-
"se allude),
01,at ownerof the property am exclusively contracting with licensed comracmrs to TOTAL:
construct the project(Sm.7113J,Raciness and Rufessions Cut The ConlmetOrs G- ' -
nmtawdoesnotapplytoanownerofpropertywhobuildsorimproves themon.and QTY. PLUMBING PERMIT FEE
who contacts for such projcets with a contracmr(s)licensed pursuant to the Contractor's JUL 17
License Law. PERMIT ISSUANCE 1996
711 am exempt under Sec. ,B&P C for this reason
Owner - Date AI:I'Ek—DRAIN&VENT'—WA'1'Ek(EA) W I Y VALUATION
WORKIiR'S COMP[NSATION DECLARATION Ut `Vr Lftl fV J
Ihereb affirm under It f HACK FLOW PROTECT.DEVICE
hereby Penalty perjoryoncofthefollowingderket's ns:
❑ Ihave andwill for bynetion 37W of Ce Labor self-insure Workersce of the
DRAINS-BOOR,ROOF.AREA,GOND.
codon,as provided for by Section 3]fK1 of the Labor Code,for The Performance of the STORIES TYPE.CONSTRUCTION
work for which this permit is issued. FUTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
PI)ofthe Labor Code,lin the performance of the work for which this Permit is issued. GAS-P.A.SYSTEM.)INC.4 OUTLETS OCC.GROUT' APN
My Work Coit vrsmiottZo currier a. l•alicy °� -
Curzler: TllRs �'Y� Policy No.:� (JI�d-�r
T� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This sationnrnlnot be complaed if the permit i.Torose bundro1Jn11un($100) GREASETRAP
on las.) PLANCHF,CK FEE
I certify that in the Ferforancc oftbe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pcnm in any manner su as ,,beconm.ubjecuo the Workeri Compcn- ENERGY FEF.
z sution Laws of California.Date WA'T'ER HEATER W/VENT/ELECTR
00 Applicant GkADING FEE
zed NoTICETO APPLICANT:11,after makingthis Cenifeme of Exemption,you should WATER SYSTEM/TkEA1'INO
F� ? brit..subject to the Workers Coor,mmun provisions of the Labor Code,...must SOILS 19711:
forthwith comply vithmch provisions or this permit shall be deemed revoked. WATER SERVICE
a0
7
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLhIB. SQ.FT. PAID Dae Recei t#
L) 0 l hereby affirm that them is a construction lending agency for the performance of P
Ne work for which this permit i.ismed(Sac.3097,Civ.CJ
u' F'' 1.ender',,Name TOTAL:
0 V Lcnder's Addrea OT
1 certify that I have read this application and sem that the above information is BUILDING FEE
FlA correct.I agree to comply with all city and county ordinances and sum lows relating to IVY. MECHANICAL PERMIT FEE
U building construction,and hereby auNmiu representatives of this city to enter upon the SEISMIC FEE
ohove-mentioned propany for inspection pm,aws. IIIPERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgmentx,costs and expenses which may in any way accme against wid City ALTER OR ADD TO MECII, PLUMBING FEE
qurri.ofthegrard get pcmhit.
APP T UNI - x D Wll.l.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('TY)11,11110 CPM)
S kC MULA MECHANICAL FEE
S
-7k/46 n` AIR HANDLING UNIT(OVER 10,000 CFM) CONS'I'RUCTIONTAX
Signamm ofA,f...VComacmr 1 Q DamEXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hvardous material HEATING UNIT(TO 100.000 BTU)
us defined by the Cupertino Municipal Cafe.Chapter 9.12.and the Health and Safety
Calc,Section 25532(x)] HEATING UNIT(OVER 100.010 BTU)
❑Yes ON. PAID
VENTILATION PAN(SINGLE RBSID) Data Rccript#
Will the app onta m furore building bylacce,ximB use equipment or device which
'mit hazallous coli contaminants as defined by We Huy Arca Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
District^ TOTAL:
❑Yes ❑No HOILL'R-COMP(OVER 100,0010 BTU)
I have real the Immoralists materialsrequirements under Chapter hAIR CONDITIONER95 of the Cali- ISSUAN TE
fnmin Health&Safety Ced,Sections 25.105,25533 and 2551.1 understand that if the NEW RESIDENTIAL MECII. SQ.ET.
building Jae no¢mrrsnty aa,..tenant,that It is Illy«spnn.ihility m notify the occupant
of The requlmnhatc whichmuM bemet Prior lo inmaecof.Certificucof Occupancy.
Owner m auboriud agent Date At' ISSUED IT VW
OFFICE