30263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
'r CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMIT No. 30263
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
" BUII,DIIyGp DRESS. .I ,I/ - ` God ^ SANITARY NO.
OOyy�"�//((�'// 4 APPLICATION SUBMITTAL DATE
OWNERAME: - PHONE: C 'RACIOMSNAME'. IC NO' AY �g
's L NIC CONTROL#
ARCHITECT/ENGINEER: _117LIC NO:
rADDRE
CONTACT: PHONE: /99
❑
BUILDING PERMIT INFO
i- /Qf70 ^ 07y
❑ Consultant FUS Paidby Applican[(in itial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
" LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm that i am licensed under provisions of Chapter 9(commenting LOB DESCRIPTION
WOO with Section 20D0)ofDivision3oftheBminee,and Professions Cada,am my license is RESIDENTIAL "
FW" License Class
and effect, PERMITISSUANCE '.El SFDWL ❑KITCHEN REMODEL
�U�] License Class 'a CLi,.isom
F�W Data Commcmr APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
Fa
ARCHITECTS DECLARATION, nPANELS El MULTI-UNIT ❑STRUCTURAL
ZO-� Iuderxmnd mYP.nssh II beusedmi publit,recods
"MODIFICATION
oz—, 'r I1PT0200 AMPS ,El INTERIOR [I CHIMNEY REPAIR
�� , Licensed Prnres.vional ° 201-IOOOAMPS IMPROVEMENT
dy .]
OWNER-BUILDER DECLARATION
G�id I hereby affirm that 1 am exempt from the Contractors 1000AMPS's License Low for the ❑BATH RP.MODEUREPAIR,'ODEMOLITION
ippi55...O m V following reason.(Section 7031.5,Business and Professions Code:Any city or county - ❑OT ER
u+ W E which requires a permit m ameho r..her,improve,demolish,m repair any structure SIGNS ELECTRICAL.
'
F�y 1.0 prior in its marrice,alsoregmires me.ppllcant Nissan permiue file asignbd.tromeart SPECIAL CIRCUIT/MISC.
a dE that he is licensed Ignition.the pre visions of the Contractor4s License Law(Chapter 9'
W�AO (commencing with Section 7000)of Division 3 of the Business and Professions Code),, TEMP.METER OR POLE INET, - -COMMERCIAL• - - -
M y m y that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDTTION ❑DEMOLITION
fiXl Wy
ZSecti 10315 by any applisionf permit subjects theappliater,t a IDandt,of POWER DEVICES -[]TENANT ❑FOOD SERVICE
,nonce he.fise hundred dll ($500)
QO ❑1 Ith p pc ty y pl,y d g m I put.at n, SWIMMING POOL ELECTRIC IMPROVEMENT -
wdl d m - k d m rcome
t e: tI' ted offered f (Sea.9044 Business ❑OTHER _
and probations Code:TT Contractors I.i a sb Law does not apply m an owner sf OUTLETS=SWITCHES-FIXTURES -
property who builds or improves,thereon,and who does such work himself or through
his own employees,provided that such improvements are nm intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If.however the building or improvement is sold within one year ofcomplation,the ^ SQ.FT.FLOOR AREA $/SQ.IT
owner-builder will have the burden of proving that he did not build or improve for par- V
pose ti sale.)
❑1,as owner of the properry,am exclusively contracting with licensed contmcmrs to TOTAL: -
v construct the project(Sec.1044,Business and Professions Coda:)The Contractor'.Li- -
me Law does not apply to an owner of propeny who Indic°m hnproves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cnntmctor(s)licensed pursuant o the Cou¢mmr's,
License Law. PERMIT ISSUANCE r "
I.m exempt under Sec B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner` '- Date '- VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
� 1 hereby affiini under penally of perjury one of the following declarations.
,.
❑.Ihave and will mainmina Certificate of Consennnself-insure for Worker's Compete DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 3100 of the Labor Cede,far the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP _
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the La or Code,forte performance of the work for which this permit isiA-,lied OAS-EA.SYSTEM-1 INC.40UTLETS OCG GROUP ANN
My Work el Hien nsuran" tier and Policy numberam:
Caries q Policy Nn.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFI TEOPEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This if..need am be completed ifthe pannh is ronme hundreddelleasSI(m) - ? BUILDINQ DIVISION FEES° -
orlast.) - GREASETRAP ,
PLANCHECK PEE
Icenify that in the performance of the work for which this permit is issued,lshall SEWER-SAKI TARY-STORM EA.20(1 FT.
ngemployunyp n ny manners as s hjccrto the Wmkem'Compen- - ENERGY FEE '
z cation Laws of 't l WATER HEATER WNENOELECTR
0 O Applicant ori a ` t aLrr�a►. GRADING FEE
�7 to NOTICE TO APPRICAIN T.If,otter ntakmg mN Cart-Timate of Exemption,yna should WATER SYSTEMITREATING
-H #� beembe.vubjeet to the Worker's Compensation provisions of the Labor Code,you most SOILS PEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q n.
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, 'SQ.FT PAID
U I hereby affirm that them is a construction lending agency for 0th Iced..hat - Date Receipt#
W.
Fthe work for which this permit is issmoil(So,.3097.Civ.G) '
Q U Lender's Name' - TOTAL:
L71 Lender's Address TOTAL:
a I ability that I have read this application and state that the above information is BUILDING PEE
V) correct.l agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
U `jay building concoction,and hereby authorize representatives ofthis city to enter upon the SEISMIC PEE
above-mentioned propeny for inspection purposes -
(We)agree m cove.Indemnify and keep harmless me City or Catchier,against PERMIT ISSUANCE ELECTRIC FEE '
liabilities,judgments,costs and expenses which may in any way acerae agains.sed City ALTERORADOTOMECH,
in consequence of the grantin6 of lith enniL: PLUMBING FEE
APPId INT UNDERSTANDS D W la,COMPLY WITH ALL NON-POINT qlk HANDLING UNIT(TO Il1,IHN1 CPM)
SOU ' 2 iULAT10 5. MECHANICAL FEF.
,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAXS
gnmure ofAtiplicardsConatilketor mw EXHAUST HOOD(W/DUC19 HOUSING MITIGATION PEE
.HAZARDOUS MATERIALS DISCLOSURE
Will Er.pplicunt or future building oceuprramemor handle havardons material HEATING UNIT TO 10(1,0(10 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codes,Section 25532(.)7 ''„ HEATING UNIT(OVER I WWII BTU) N1 �J b
❑Yes ❑No - PAID �. "!
VP.NI'ILATION PAN(SINGLE RE9ID) CC __Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,0110 BTU)
emit hazardous air tb nwminams ac defined by the Be,Area Air Quality Management TOTAL:
Dishic[1 � - BOILER-COMP(OVER I On'"BTU)
,QYcs F-1 No - -
I have read the hvardnns materials AIR CONDITIONER
req m s der Chapter of the Cull- _ ISSUANCE forma Health&Safety Code.Sea...ns 25505 25533 125534.1 understand that f the NEW RESIDENTIAL MECH. SQ.PT.
building dnev net currently have a tcwm that i - y responsibility to notify me occupant
of me he
which must be net prior[ f Cannibals,of Oceupaacy,. 6/
Owner or amhorzed t" I -
gen Date TOTAL: SSUEDBY:
OFFICE