30848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.AIECHANICAL yV(
BUILDING PROJIiCT ILIENTIFICA'i'ION
ED Lp1NG '•� '/�yI, �/��V' 1 y{_� A
0
✓ NITARY NO. APPLICATION SUBMITTAL DATI
��/� 1�1 '1' ✓✓ ('. 7 /_ /��� /nn�.{�r NIC (�/��) CONTROL 1p
AR `' I E'AIW/ W1U)P4xrICNOo15 1 1 %. VFX It- , —.r..l ❑ V i �V
�C[okrAAC,T.. 4 PHONE: U7 - BUILDING PERMIT INFO
�i� .0
)5w ❑ Consultand Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION ~•Ml QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 em licensed under provisions of Chep¢r 9 ho mmencing P JOB DESCRIPTION
4'Z with Section Division J fine Bassocosnd Profession,C de.roomy license is
Cp - A PERMIT ISSUANCE RESIDENTIAL:
f-wr in full force and,Red4 r-7- /, ❑SPDWL ❑KITCHEN REMODEL
�UU License Cl win I.ic.k ❑ADDITION ❑PLUMBING RHPIPE
FzW Date ♦♦1—�Conhnnor APPLIANCES-RESIDENTIAL
9 ARCHITECTS DEC[ T N
Fly PAN ELLS ❑MUISI-UNIT ❑STRUCTURAL
Oo n Z 1 understand my plans shall Is,used as public records MODIFICATION
:JJ UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Professional ON 201.1000AMPS IMPROVEMENT
OWNER-BUILDER exen a(,DCdic Com ups.
xy 1 herehy aflinn that I am exempt frmn the Cnntrunor's Liana,haw for the OVER 11x0 AMPS ❑BATH REMODEL/REPAIR'0 DEMOLITION
W W
34 U followingvtoicuires a (Section 70nstru Busher,i pr ve,demolish,
Coda:,orep i city somea a SIGNS ELECTRICAL [I OTHER
=IY whichrequits rene.also re cores thestnsimprov,,h permit t or repair anytatemem
C m poor to at beislcense pursuntto the thrviviappocant for sucContrartniuofile aicense ned Law
SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant to the provisions of the Contractor's License Law(Chnpmr9
1+1,.00 (commencing with Section 7")of Division 3 of the Business and lhofcscions Gude)or 9'EMP.METER OR POLE INST. COMMERCIAL:
4 0 4 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
:' Section 7031.5 by uby applicant pplict for a permit subjects the appn,bit penaltyol' POWER DEVICES
rn liw �. ENANT [_1 FOOD SERVICE
F } not more than fivehundred
pany, ,m SSW). IMPROVEMENT
G ❑ Lusownm of the propenctu myot intended with mothered
us their stile cnmpenemion, SWIMMING POOL ELECTRIC
Cl wdldo the work,and the awcmrcis not intended mrmffercd fur sele(Su.](k4,Bu sin ❑OTHER
and Prnfessims Calc:The Comment's License Law it.nm apply m un ow OUTLETS-SWITCHES-FIXTURES
4 a-• pmpcny who builds or improver thereon,and who docs such work himself or thr
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT.
sale.I I:however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA S/SQ.PT.
owner-builder will have the burden of proving thin he did not build or improve for pun-
pmsemfsde), . .ry g y LkO 10 �+
C]1,as owner of the property,am exclusively contracting with licerned contrumm to 7O AL: /��\'
construct the project(Sec.70,14,Insdnas and Professions Code:)Th,Ceasmatoe.Li
cense law does not apply to an owner of propcny who builds or improves thereon and QTY. PLUMBING PERMIT FEE -.p '
who contracts ar
cts for such projects with a con owtorbo licensed pmam m the Commmo /1 r's 11
License Law. PHRMIT ISSUANCE V
I am exempt under Sec. ,B&P C for this sown
ALTER-DRAIN&VENT-WAI FR(EA) ON
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE C'' gka a r�
1 hereby affran under punchy of perjury one of the following declarations: Ur V
a]Ihuve anA will maintain eCeniOcate nfConxmmeelGinsure for Worker's Compete DRAINS-FLOOR.ROOF.AREA,COND.
.saline,as provided for b Section 3700 of the Labor Cale,Lor the STORIE V TYPE CONSTRUCTION
prov y, perinrmence of the V
k for which this patent is issued. FIXTURES-PLR TRAP
Laveand will maintain Worker's Compensation oftewrkfor hi usrequired l i Semina
]W of the Labor Code,for the perfmmmnce of the work for which this pemdt is issued. 'GAS-FA.SYSgEMd INC.40UT1,1?TS Q OCC.GROUP APN
My Workr'x Compcnsatin imnce canicrund Policy i e:
Cornier. Walk No.: 11 IrA51�_ GAS-EN SYSTEM-OVER 4(EA)
C•R ICA 1'LXEMPTION FROM WORKERS' 11
COMPENSATION INSURANCE GRFASFJINDUSTRL WASTE IM'ERCEPTOR
(Thissection need not be completed ifthe permit is forms,hundred dmllatx(EIW) UILD1 DIVISION FEES
or less.) GREASETRAP PLANC T, 2 ��
I comfy that in the perfotmanaofthewick for whiehthis permit is issued,lshall SEWER-SANITARY-STORM CA.2W P1'.
mot employ any person in any manner an sate become subject m he Worked Cn a,,, F.NER
Z ration Laws of C.1ilmont.Date
O Applicant WATER HEATER WNENT/ELECIR GRADING FEE
to NOTICE TO APPLICANT:IL aper making this Cenificate of Exemption,you should WATER SYSTF.MRREATING
a � become subject to the Wnrkera Compensation provisions of the Labor Code.you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
ate. O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID
I hereby affirm that duce is a convection lending agency forth,performance of Data A.R ' t
IL d••t the work for which this permit is lwhed(Sce.JW],Ci,.C.) -
Q V Lendc/s Name
TOTAL:
Lendu'.Address TAL'
Hy 1 certify that 1 have read Illi,applieramin and state Ihm the above information is BUILDING FEE
LI) correct 1 agree to comply with all city and county ordinances and state lows relating to QTY, MECHANICAL PERMIT (' FEE
CJ Z building construction,and herehy authorize representatives of mix city to enter upon the as- SEISMIC FEEt �ss
`•" above-mentioned property for inspection xinous, PERMITISSUANCE n
(We)agree to cavo,indemnify and keep harmless the City of Cupertino against U ELECTRIC FEB 7 6 ,
lixbilitiesjudgments,costs and expenses which may in any way dame against said City ALTER OR ADD TO MECH.
in asequence of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10.00(CFM) 2 O
SOU .ERLGR(� ULATIONS. c J D MECHANICAL FE
tyl{.{I•,{•,{-
0'-)- AIR HANDLING UNIT(OVER 10toradCIM) CONSTRUCTIONTAX
Signadmof ApplicantaCmnracnr """///- Doc EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thespplicaut or funs,buildin nectoantstore or handle hazuNmue material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532LBI HEATING UNIT(OVER 1(1(1,000 BTU) toO
L3 Yea �No VENTILATION FAN(SINGLE RE,SID) PAID
Date Raei A Is
Will the applicant or owe building acopro t use equipment or devices which
_ mit hnzmdnm air amsminanta ea defined by the Be,Anes Air Quality Management BOILER-COMPGHPOR 100,000BTU) •T
District!
❑Yea IFri BOILER-COMP(OVER 100,000 BTU)
I have tend the hamsters materials requirements under Cha 6.95 of the Cali. AIRCONDITIONER
9 veer /w r IqeIIAMrn
1 ATE
Tania Ilcahh&Safety Cade,Sections 23505,23533 and 8534.1 underswnJ that if the NEW RESIDENTIAL.MECIL SQ.IT. IIIJJV//
building dm not iswhich
currently have s tenant,that o is ua ce ofa Certificate,
to edify the poccupant
anty,
of the requirements which muse he met plot m issuance o(n Cenif¢ate of Occupancy.
A soOwner or authomud agent Date TAL ISSUEDBY:
OFFICE