30587 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. �O
BUILDING DIVISION APPLICKPION/PERMIT PLUMBING-MECHANICAL,
BUILDING PROJECT IOTiNTIFICNTON
587
BUILDING�ADDRESS ���� SANITARY NO, APPLICATION SUBML'FI'A1,DAPI
OW ,,vvaa'ss NAMG', ISL 1'HONI?: �jh�/ CONTRACT NAM LOA
Nq�(�l g NIC CONTROLar
ARCHITECT/FNGNEER: LIC NO. ADDRI?SS: El
Ffowend
PHONE: BUILDING PERMIT INFO
LESJConsultant Fees Paid by Applicant(Initial) � IV P�B MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEEy affirm mat I am licensed under p nsisions ofChapter 9(commencing JOB DESCRIPTION
z ")ofDivisim , RESIDENTIAL:
Opd effis,iQ��yi � PERMIT ISSUANCEUV _S�Lic.p asrS ❑SFDWL ❑KITCHEN REMODEL
vzw '����_ Cont,cmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION C1 MULTI-UNIT ❑STRUCTURAL
z O y z 1 understand my plans shall he used as public retorts PANT-LS MODIFICATION
Oz=O UPTO 200AMPS El INTERIOR C1 CHIMNEY REPAIR
[-•4F'LL1 Licensed Professional 20I-1051AMPS PROVEMENT
�S4 OWNER-BUILDER DECLARATION OVER 11100 AMPS - TH REMODEUREPAIR C3 DEMOLITION
i C Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the
Sl O W U following Mason,(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL C1 OTHER
I1+z11 0 y which requires a pe.it to connote,alar,improve,demolish.or repair any xwewrc
I'-LL� prior to its issuance,also requlms the applicant for such permit to file a signed statement SPECIAL CIRCUCOMISC.
SS�}� mat he is licensed pursuant to the prvisionsor the Cammetors License Law(Chapter 9
q^'p0 (commencing with Sectinn]OW)ad Division3of the BusincssaM lto&ssiom Coddw TEMP.MHTER OR POLE INST COMMERCIAL:
a o•ca z that he is exempt thcrebor nand the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ro ScOion]03L56yany applicm forapermit. is the applicant to a civil penalty of POWER DEVICES
^ta 1 ❑TENANT ❑FOODSERVICE
I-=0not mare man five him dol ($500). IMPROVEMENT
❑ I,aso ias ep ipcuY,. )' plo xswim wages as their sole compensation, SWIMMING POOL ELECTRIC
P. wd[d,Oh k,end th t tint ded or offered for wile(Sec.]Oi4.Business OTHER
3—� and Professi C C io No se Law docs nr apply to an owner of OUTLETS-SWITCHES-FI%TURFS
^ property w o i p mercon.and who dos such work himself or through NEW RESIDFNfIAI.[LECTR S FT.
his own erplo s,provided that such improvements ore not intended or rffereJ fur Q
sale.IL howeve the buiidrg orimprovemem is enlJ within ane y<arofrompinion,the RAREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build of improve for puf-
poseafsale.).• / n '
1,as owner of the property,am eulus and comrcons with licensed Contractor's
[m TOTAL: `/
cense La the project(Sec.o 14,Business and Professions Code:?The Contractors Li- $
wase Lawdoes nrnapply manowner ofpropeuy who
sedporimproves thereon.and QTY. PLUMBING PERMIT FEE S 2t7 1996
who contracts for such projects with a contmcmrts7licensed punuam lathe Commctor's
Licenu Law. PERMIT ISSUANCE
❑ lamexemptunder Sec. .B&PCforthismason
ALTI?k-DRAIN&VENT-WAT ER(EA) t r �•t vVALUATION'—
Owner Da¢ �1k
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I
1 hereby affirm under penalty of perjury one of the following declarations: `
❑Ibuvennd will r.intuin.Certificateof Conscntt.clf-inure fnr Workers Compcn- DRAINS-FLOOR.ROOF,AREA,GOND. STORM TYPE CONSTRUCTION
cation,as provided for by Section 3400 or the Labor Code,for the performance of the
.�r which thh permit is issued. FIXTURES-PER TRAP
It
I have and will maintain Worker's Cumpensation lnsumnce,as required by Swtion
"Llf. the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUT OCC.GROUP APN
My Worke' Qq aseri= ante tier and lsa icy
Carrier: ur Polley No; GAS-EA.SYSTEM-OVER CF.RTIFI ATI?OPE%EMITION FROM WORKERS'
COMP17NSATION INSURANCE GREASHIINDUSTRL WASTE INTERCEPTOR
(This section need not W completed if the permit is for one hundred dollars($1W) BUILDING DIVISION FEES
or less.) GRI?ASB TRAP PLANCHECK FEE
I cenlfy Into in(ho perhirmnwnfthe wnfkfor whlchmis Lose rntitisi...W,Witill SFWBR-SANITARY-STORM EA.200 FP.
not employ anypefsnm I........rrso as to heaoni suhjed to the Worked Compen. _ ENERGY FEE
Z salon Laws of OJiform e.Date WA'1'HR HEATER W/VEN'I'/ELECTR
Applicant GRADING ME
z rr NOTICE TO APPLICANT:If, making this Cenilicateof H am i should a
g ampti you s n WATEk SVSTLM/TNEA'1'ING
a became subject to the Worker's Compensation this
envisions of the Labor Calc,you most SOILS FEE
IiI
forthwith comply with such provisionsas or pencil shall Is,Jc:nted revoked WAI'lik SERVICE 06
Q
CONSTRUCTION ONLENDINOAGENCY NEW RESIDENTIALPLMB, SQ.FT. PAID
V p Iherehy affirm that thereiis saconstruction lending agency Lonna parfonnunw of Data ,keceiptN
4s the work fnr which this permit is issrcJ(Sec.J(M)],Civ.CJ
O (.l Lender's Name - TOTAL:
Lenders Address TOTAL:
y1 certify that 1 have read this application and state that the above information is BUILDING FEE
(Z) correct.l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city ,,enter upon the SEISMIC FEE
above-mentioned prapeny for iaspcainn purposes.
(We)agree to save,indemnify and keep harmless the City of Cupedino against PERMIT ISSUANCE 021,qELECTRIC FEF.
liabilities,judgments,costs and expenses which may in any way acoroe against said City ALTER OR ADD TO MECH.
in consequence of Ne g inting of this permit. PLUMBING FEE
APPLIC NT UNDERSTA.'SS AND WILL COMPLY WITH At.],NON-POINT AIR HANDLING UNIT(TO 10,(00 CFM) fair
MECHANICAL FEE
[ Z AIR HANDLING UNIT I OMs)CPM) CONSTRUCTION TAX'
H N .
g- 3-q6
/ St pplicant/CoWaruo Data EXHAUSTHOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stone urhundle hazardous material HEATING UNIT OTO Pro, IX1 LIFE)
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section V 532fa)] HEATING UNIT(OVER 100,0011 BTU)
❑Yes ❑Nn VENTILATION PAN(SINGLE RE.SID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt M
emit maintains air conterminous as defined by the Bay Ata.Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
District?
❑Yes ❑No BOILER-COME(OVER 100,000 BTU)
I have read the Woundous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505.25533 and 25534.1 understand mat if the NEW RESIDENTIAL.MECH. SQ,Fn
Wilding does not currently have a¢rant,that it is my responsibility to unify the ucurcum
of me requirements which must be men prior to issuance of o Certificate of Occupancy.
Owner or aumorized agent Data TOTAL: ISSUED BY: AO
OFFICE