30897 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
�UILDI/N�G ADDRF,SS: �'J �7� T SANITARY NO. APPLICAl ION SUBMITTAL UNIT
/ —fP— � _ 11 /Ili q 'Zl
OW C/J:R'S NAME: PfiON{;.� TRACTOR'. VA :r-0 � isIC�vO�O3/ N/C CONTROL#
ARCCHCHHNEC3ll'I` >(/ENGINEER: LIC N(• ADDRIiSS: ,(! -/ ❑
CONTACC PHONE: BUILDING PERMIT INFO
E1't'a-F [�-f-E ? 9_6 3�/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby affirm thou I am factual under provisions of Chapter 9(commencing JOB DESCRIPTION
O d'2 withSectio�Iwdow
usinessmfessinn.00Nnd ylicensc is F
WOO (Q // PERMIT ISSUANCE R -ID NTIA r
Fy�UF nfull tune ❑SFDWL ❑KITCHEN REMODEL
UU License licAPPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
WDmeFm SIlEC1H" PANELS ❑MULT[-UNIT ❑STRUCTURAL.
Z I undersand my plans shall be used as public records MODIFICATION
IUPTO200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
F.�'fi] Licensed Tromso.nal 201-1000AMPS IMPROVEMENT
C .] OWNER-BUILDER DECLARATION OF DEMOLITION
< I hereby affirm,bat I um earns form eLicence the Coatmmr's Licee Law fordo, OVER 10X1AMI'S E)BATH k1iMh
Xil LL which L U following remon.(Section]031.5,Business and I'nd'essinws Code:Any city or county SIGNS ELECTRICAL [IOTHI3R _
twhich".I.,u permit m erwourec,,e]ler,improve,demolish.or repair any slm,tum
F�0 poor o its issuance,also requires the applicant for such Permit it)file a.signed statement SPECIAL CIRCUITIMISC. It llgo�
Ey that he is licensed pursuant to the provisions of the Commences License Law(Chapme9
�eI (commencing with Section 700o of Division 3 ofthe Business and Professions CIAO or TEMP.METER OR POLE INST. COMMERCIAL:
a o that he is cwmpl therefrom and he basis for the alleged eaemptiow.Any 4,11.1lrnt of ❑NEW BLDG/AUDITION ❑DEMOLITION
_ Section 71131.5 loyalty applicant fora pennitsubjectslhe applicant ma civil penaltyaf POWER DEVICES
not mor,than five hundred dollars(5500). ❑TENANT ❑FOODSERVICE
F Z r IMPROVEMENT
=Q ❑I,othewerofthc property.„,myemntended or offend
d a.alt(Sedecom,Business SWIMMING POOL ELECTRIC
g. Owill Bothe work,Cod the he Com isnes intended Lawe does not
apply to an
os ❑OTHER
F
L 3 end Prty who
Cotte:The oes there,, License Law docs trot nk hi to if owner or OUTLETS-SWITCHES-FlXTURFS
progeny who bullus or improves thereon,and who docs such work Bed or f through
his own employees,provide),hal such ensisoldimprovements arc not intended or offered lire NIiW RESIDENTIAL EhELTR SQ F-I'.
sola If.however,the building or improvement is sold within one year of compininn,the SQ.17,1100E AREA bISQ.FT.
owner builder will have the burden of proving that be did not build or improve for par-
pom of soled.
L] 1.as owner of the property, on
am exclusively contracting with licensed contractors to TOTAL:
,,wstrau the pmje4(Sec.9(114.Business wad Profcusiam Cndef The Coal mc,or'a U-
whuLaw does not apply to an owner of prolw'rry who builds or Improves thereon,and QTY. LU PERMIT FEE
o contracts 1'o,such projects with a can..c.mfs)licensed pursuant to the Cnmran^r's
License Law. PERMIT ISSUAN
Iamexemplmlder Sse. ,B&PCfor Nisreamn
ALTER-DRA1 VE - 17R( VALUATION
Owner Dme
WORKER'S COMPENSA'1'ION UECLARAI'iDN HACK FLOW( :CT 'VICE
I hcnby affirm undone peltalty ofln juryone of the fallowing declarations:
�e and will maintain a Cenifica,ofComeut mself-imvre for Worker's Compen- DRAINS-FLOOR.RODE OND, STORIES TYPECONSTRUCTION
smion,as provided for by Section 32W of the Labor Cade,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
L have and will maintain Worker's Compensation Insurance,as required by Seainn
3900 OI the Lobnr Code,for the ped'ormanceof the work for which Ibis permitk oohed, GAS-EA.SYSTEM.I INC.0 OUT1,iT. OCC.GROUP APN
My We 'z penav nlnsu cccan'•rand l'nlicGAS-EA.SYSTEM OVER qBEA)
Came, CER IF ATE OFE(vMYf10NyMo
1ROW �—
COMPENSATION INSURANCE GREASERNIDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisacction need on,aennodddolls,permit I,fornnchundnddoll...SI00) GREASETRAP
or Iess.7 PLANCHECK PEE
Icenily that in the perLmnanee of,he work for which this permit is isweJ,[,hall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner m as to become subject to the Work, 'Compcn- ENERGY FEE
Q Z nation Laws of California.Data WATER HEATER WNENTTMLECTR GRADING IRE
Z Applicant
NOTICE TO APPLICANT If,after making this Certificate of Exemption,yo.should WATER SYSTUTATREATING
a 7 became subject m the Worker's Compensation provisions of the Labor CNet you,neat 3FEE
LS THE
LV
F-, fonhwilh comply with such provisions^,this pem,if shall be dccnmAre—ked. WATER SERVICE
n.
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.ITD Dara «cipt#
V Q (hereby affirm that is a construction lending agency for the performance of
Hthe work for which this pemtit is issued(Sec.314.99.Co,C.)
Lenders Name TOTAL
ULcnder'a Address TOTAL: BUILDING LLE
G I certify that 1 hire read this application and dam Thal the all m ormutinw is
l)1 cam�..Ingreeto comply with all city and county ordinances and arm laws minting to QTY. MECHANICAL PERMIT building construction.and herebyImburirerepresentativesofthiscitytoenterupnthe SMIC FEE
mane-mentioned property to,inspection puyanes' I'IiRMIT ISSUANCfi(Wer)agree,,,save,indomm[y and kegs hunwle➢stheCity ofCupertinoagainst CTRIC FET?Iiabili,ies,judgments.c,,Us and expenses which maymany way rommeagani said City ALT ER OR ADD TO MECH.inconsequence ofthe growling of0is pennil. UMBING LLE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) ,0
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signature of Applican,/Conlmctor Dam EXHAUST HOOD I WIDUC*U 1 i0USINGMI'rIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Win the applicanlo,future building oecupamswern,I mJ It hazardous material HEATING UNIT(TO LORNI BTU)
as definN by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Cale,Sectio r 25532(^(? BEATING UNIT(OVER I00,000 BTU)
❑Yes ❑No VEN11 TATION FAN(SINGLE RESID) PAID
Will the u Beam or future mildira rem m,use a ui ,nr devices which- Data Receipt p
PP 6� P nt P^tc^ BOILER-COMP0HP OR 100,0)11 BTU)
emit hmurdnus sur conaminana m defined!by the Bay Arta Air Quality Management BOILER
District? BOILER-COMP(OVER 100.000 BTU)
Yes ❑No
Ihavc read the hazardous materials require cars under('hapmr695 of the Cali AIR CONDITIONER ISSUANCE DATE
humAH ]h& aMyCNet Sermons 25505,L5 34� yIwmytdaecc.jwa
1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT, / lIte” s rrtn0yhaveamna ,,h nyIle fiW' foo,
O hall o.imd ugctufly, Dac TOTAL, ISSUED BY:
OFFICE