30708 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30708 0 7 O H
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J
- BUILDING PROJE(J IDENTIFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�aoq ,zoo-uxr o� c+�a
WN- I Nt`NB;: PHONE CON'I'RACTOR'g NAME: LIC NO:
NIC CONTROL st
QCHITECf/F.NGINEF.R:' LICONO: ADDRESS:
CONTACT. 7q�PHONE: Q BUILDING PERMITINFO
l!Ila El Consultant Fees Paid by Applican[(Initial) - BLDG ELpCT PLUMB MECH
.Sol-ws�,J 3aIr,�yT►_ ' \
LICENSED CONTRACTOR'S DCCLARAT'ION QTY ELECTRIC PERMIT PE
1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
{"{yZ with Soctial,7 )of Division 3ofthe Businessland roons
d PfessiCode,unit my license is
F00 in full farce unA effect. PERMIT ISSUANCE RESIDENTIAL
J{..�VV License Class Lic.A - ❑SFDWI. ❑KITCHEN REMODEL
all Dare Contractor APPLIANCES—RESIDENTIAL �QDDITION El PLUMBING RI}PIPE
ARCHITECTS DECLARATION pgNEl ti
F,�H ❑MULTLUNIT El STRUCTURAL
Z p,-,Z� ' 1 understand my plana shall be used as public records MODIFICATION
OZ.. UP TO 200 AMPS 11,,jj..aa k�Lk
S FCFq yI Licensed Professional 201-1000AMPS ❑IMPROVNMEf{q ' p DCIIIMNF:Y REPAIR
a2� OWNER-BUILDERDE Ce Contractors
�¢ E hereby affirm Nm 1 um exempt(tete the Cunnumor's Limnse Law for the OVER lots)AMPS ❑BATH RCMODF.UREPAIR ❑DEMOLITION
>(a 0.F following nation,(Section]0314,Business and 11Professions,laalCalc:Any city orcoumy SIGNS CLEC'fRICAL ❑OTF A
LLF WO which requires n permit m clansman,alma improvq demolish,or repair any xlrucmre (j 1 �(
m prior to its issuance,also requires the applicant for such permit to file u signed statement SPECIAL CIRCUIT
�<S that he is licensed pursuanuothns
eprovisioofum Commm
rr's License law(Chupmr9
X00 (commencing with Sectio](NIB)of Division 3 ofthe Business and Professions Code)On TEMP.METER COMMERGIAIRVrCI•I
that he is exempt Therefrom land the basis far the alleged exemption.Any men".of ❑DEMOLITION
i� ly C1 NEW BLDG/ADDITION
Zy Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TIiNANT ElFOOD SERVICE
Y not more Nan five honored dollars($500).
�^ q
E)1,as owner of the property.or my employees with wages as their will compensation, SWIMMING POOL ELECTRIC - IMPROVEMENT
will do the work,and the structure is not intended oreffcred for sale(Sec.9014,Business ❑OTHER
and Pmfessions Coal:The Conacm
br'x License Low does not apply m an owner of OUTLET'S—SWITCHES—FIXTURES
�'3.. prnpeny,who builds or improves thereon,and who dues such work himself or through ��
his own employees,provided that such improvements an not intended or offered for NEW RESIDENTIAL ELECIR SQ FT. ���OOOQQQ�RR
sale.IL however the building or improvetneat is sold within one year ofcompletion,the S �REA $)SQ.bT.
owner-builder will have the harden of proving that he diA not build lar improve lbr Aur- ®� �w
- Pose of selene 71
❑1,m owner of the property,,B exclusively Professions
with licensed contractors m d
construct La the Aruna.(See..1,oBaa,Business and Professions Code)The Contmaor. Li-
saLawdwanot",lin .aFF miaOl to wwne of amooduerty whasedpmimproveethereon,and QTY. PLUMBINGP FEE ItO
who ate Low.for such projects whin v conwdor(s)licvmsed pursuant m the Cnmmdor's n
License Info. PERME'T ISSUANCE
❑lam exempt under g<c. ,B&PCfor Nis mosun '
ALTER—DRAIN&VE —WATER( A7
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTIi .D P
I herehy affirm under penalty of pe jury one of Ne following declarations:
Ihave arowill maintainstion 37ateofContentr Code,sure for Workersce of th- DRAINS—FLOOR,ROOF.ARBA,CO S / .� HCO3KRUCTION
vve,k,as pmvidcd far an Section 3100of the labor Cndc,for me performance of the 6 ��(�i.
rk(ave and tills Armor is mored b ITX'1'UkiiS—PER TRAP e
E have and will maintain Workers Co rt,aft
e w Insurance,h requited by Section
My ofthelCor Cade.for Insurance
canceofthewurk for which this permit is issued. GAS—G.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: -
Cnrrier: Polley No,: GAS—EA.SYSTEM-OVER 6(EA)
CERTIFICATEOF EXEMPTION FROM WORKERS' 1 11
COMPENSATION INSURANCE GREASIYINUUSTRL WASTE INTERCEPTOR
(fhis section need nrn Mermpined ifthe patent is(Drone hundred tlollan(f I W) BUILDING DIVISION Piping
or less.) GREASE TRAP
PLANCHF.CK
(certify thanPian ia I.perl'nnnanccnf ,1.bthe ee for winch lijerathis primulaesn Carl(shall- SEWER—SANITARY—STORM EA.200 FT.
not employ any Califon in any manner ut as m become xubjee m the Workers CmnFen- _ ENERGY FIiE a
Z xation laws of California.Date
0O Applicant WATER HEATERW/VENDELECfR GRADING FEE
NOTICE TO APPLICANT If.after making this Certificate of Exemption,you should WATER SYSTF.MlfREATING
a , herome subject m the Worker's Cnmpenstatch provtnlons of the Labor Code,you man SOILS FEF
LTI forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
7. CONSTRUCTION LENDING AGENCY NEW RESIDF.NTIgI.PLMB. SQ.Ff. PAID
V'Q k for
rte tMdtthere issued(See 3 len ding agmmy for the performmmr n( Uma Receiptp
0 H the work for which this permit is issued(Sec.3(191,Civ.CJ .
0 U Lendefs dre TOTAL:
I Address
Lcndebdddress
Alpy eenify that I have read this application and emm that the above information is BUILDING PEE 40ae►�
tr V) concert.I agna te comply with all city and county mdiaonces and state laws drilling m QTY, MECHANICAL PERMIT FEE
LI Z building construction, nt
ction,and hereby nationals,representatives ofmis city toeeruptm the SEISMIC E'ER
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC HE A
liabilities,judgments.costs and expemen which moy lnsnywayucemeagainnxnid City ALTER OR ADD TO MISCII.
in comeyueme of the granting of this Fault. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AI R HA NDLING UNIT(OVER 10,000 CFM) CONSTRl1CTION TAX
Signature of AllplicanUCtmtractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Wflltheapsicam or furore buildingrccupant storeor handle hazardous material HEATING UNIT(TO II0,0110 BTU)
as defined by tine CuPedinr Municipal Cndc,Chuptcr 9.12,sold the Heelm and Said,
Code,Section 25532(a)9 HEATING UNIT(OVER 100,009 BTU)
❑Yes 1-1 No
' VENTILATION FAN(SINGLE REID) PAID
0001 the applicant or Patio building occupant nsr equipment or devices which Mato Receipt 11
BOILER—COMP(311P OR 100,000 BTU -
u hazardnun air conmminvms as defined by the Bey Area Air Qual'ny Management )
buret? TOTAL:
❑Yea [I No BOILER—COMP(OVIiR 100.000 BTU) �
I have rend the hazmdousmateial I romAreauns under Cluptef 6.95 u1the Cul,- AIR CONDITIONER - ISSUANCE DATE
fomie Health At Safety Cale,Sections M505.25533 end 25511.1 understood Nm Hill, NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenter that it is my us Feasibility to notify the occupant
of the departments which must he met prior to issuance of Cenifictte of Occupancy.
Owner or i umcamed!agent Date I ISSUED BY:
OFFICE