30356 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF
CUPERTINO BUILDING-ELECTRICAL PERMIT NO 3 0 3 5 6
6UILDING DIVISION APPLICATION/ PLUAIRING-NIF:CIIANICAI,
BUILDING PROJFCf IDENTIFICATION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
100 3 ,ATI Gbh uua`f cuPER-TINO, Ch "16014 SK-z,�
NERS NAME �0�� � IHO 1.. CONTRAC'TOR'S NAME:�1"* LIC NO: !
ECT N l nY N/C "I OL p
RCIIITEC�INC� LIC NO: AD H.S.: � gGS D ❑
CDNTAC�T.1, 1 ,I W }}�" PFIQNLs: BUILDING FERN
IT INFO
`I t - �4.FC O�gVK\/a��J ❑ Consultant Fees Paid by Applicant(Initial) DG ELECT PLUMB MECH
❑ ❑
LICENSED CON'nsed unORSder
rp DECLARATION QTY. ELECTRIC PERM IT FFP.
mz thereby atom,tom1notfae Bu anternd previsions Chapter my license
FOB DESCRIPTION
Op with$ecreandeffec Divisinn3nfthe Rosiness and Professions Cole,:rod my licenseis FERMI FISSUANCE RESIDENTIAL'
tiro n,rm and effect.�VU� infull
Class I.icN ❑SFDWL [I KITCHEN REMODEL
an Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RB PIPE
ARCHITECTS DECLARATION PANELS
F.7rn El MULTI-UNIT ❑MODIFI MODIFICATION Z O-Z 1 understand my piens shell be used as public records MODIFICATION
oz-, UPHD 2(XIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
P js Licensed Professional 2111-IOMAMPS ' IMPROVEMENT
y�Y OWNER-BUILDER pr DECLARATION OVER IIXp AMPS
y W�6 I hereby affirm taro 1 am exempt promote Commmors license Law for the ❑BATH REMODEURFPAIR ❑DEMOLITION
>c a a{VA.., following reason.(Section 7031.5,Business and Professions Come:Any city or countySICNg ELECTRICAL ❑OTHER
quire
4F C N which res a permit to am sttvc6.hm
.her,improve,demolish,m repair m
any swcre
no,or its iwu.nce.alsoregmresne.pplicnnt for such perntino rile a signed statement SPECIAL CIRCUIT/MISC.
'j that he is licensed pursuant to the provisions afthe Contractor's License Law(Chapter 9 _
00 (commencing with Section 70a)(1)of Division 3 ofthe Business ant professions Code)or '(HMI'.METER OR POLE INS'(. COMMERCIAL eig
a.p,n that he is exempt Nerefmm and the basis far the alleged exemption.Any violation of
ped ❑DEMOLITION
al Section gran rive
any reddamforepermit subjects the applicant to acivil penalty of POWER DEVICES 0TENANT F DSERVIC-
f,,,Z}
an roam mon five hundred dollars y employees
IMPROVE
=� OLuowner
,and gunnery,oris
hwages erej fnstheiSac.compensation, SWIMMING POOL ELECTRIC
andwilBothe work,and the he onot Connectors License Law does rot apply or an Business ❑OT ER
t ant ery who b Cade:The hereoLicense Law does not apply s if owner of 'OCfLfifS-SWITCHES-FIXTURES l
property who builds or improves thereon,i and who does soca work himself or through Vr't���'�
his own employees,building that such improvements are on ,carol)ar,latio .for NEW RESIDENTIAL ELECfH SQ FT.
s:Jct.ILhower will the hvethe buninofprointithat he within on build or improvetfonthe SQ.Fp.PLOONrAREA r`1 $/SQ.FT.
fila,o Balder will have the burden of proving that he mint nen huIIJ or Improve for bur-
- iu+sc of sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TO AL: AUGA13 1(]Q(N
construct the project(Sec.](144,Basmess and Professions CMZ:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves themun,and QTY. PLUMBING PERMIT [ZEE
IQw7{)
who contracts for such projects with a contractions)licensed pursuant to the Contractors r I F
License law. PERMITISSUANCE VI VVrLI r111V(J
C3 I am exempt under Sec. ,B&P C for this.,on
ALTP.R-DRAIN&VBNT-WATER(CA)
Owner Dote VALUATION
WORKERS COMPENSATION DECLARA'I']ON 13ACK FLAW PROTECT.DEVICE
1 hereby affirm under penult,or perjury one of the fol lowing Jes9arminns:
I have and will maintain a Cali finale of Consent oself-insom for Worker's Compen- DRAINS-FLOOR,RODR AREA,CONU' STURICS TYPE CONSTIiUCf10N
cation,as prnvide l for by Section 371X1 of the Lahr Codtt es for the performm� of the
work for which this permit is issued. FIXTURES-PER TRAP 91 11
El 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the lab ffwrd edormantt ii work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTI.17 OCC.GROUP APN
My WorkersC nmmm carrier and Policy mailer are:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CW. 'KATE OP EXEMIHON FROM WORKERS'
COMPENSATION INSURANCE OREASE/INUUSTRL WASTE INT[RCHPfOH
phis section reactor be annplemd ifthe penal is yearn,hand r..tdollam($IBB) BUII.1 GI ISI FEES
or less.) GRBASH TRAP PLANCHECK FEF
Ife.m.inthe perfnnnanncol.1 to work beefar wbjett1s the,it Wrken,'ed,lehml SEWER-SANITARY-S'IDRM HA.2W Fr.
nmolIw employer,f person in any manner sn es m become suhjcd m the WnrAer�Compen- ENERGY FEE
z Appliances of Cmifomia.Data WATER HEATER W/VENAR.EC1Fist
z Q Applicant' - GRADIN
y NOOGETD APP LICANT:e,aftermaking this Crnins of of l"For Code
youshoal. WATER SYS'fF:M?REATING
became subject m me Wodere Compensation provisions of the IaMr CMe,you mmt SOILS FEE
Wa., foMwith comply with such provisions or this permit shall M dernmad evoked. WATER SERVICE
CONSTHUCI'ION LENDING AGENCY NEW RESIDENTIAL PLMP, SQ,Pf. PAID
L)p Iherchy affirm that there ixnconsvuctinn lending agency for the performance of .Date HeceiptM
W the work for which this pennit Is Issued(Sm.3094,Civ.C.) -
U I<nJer's Name TOTAL:
Lender's Address TOTAL:
pt 1 certify that 1 have read this application and state that the above information is BUILDING FEE
r V) correct.l agree ro comply with all city and county ordinances and state laws relating to QTy, h1ECHANICAI,PERMIT PEE
U z building construction,and hereby amborize representatives of this city to enter upon the SEISMIC HE
ah ve-mentioned propeny for inspection purposes.
(We)agree to save,indemnify and keep harmless the Cnyof Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way inane against said City ALT ER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT(Tn In.tNXl CFM)
S)URC 111 REGULATIONS, MECHANICAL ITIS
����• �nr� �-t, if7 �� AIH HANDLING UNIT(OVER III,INN)CIsM) CONST RUCTION TAX
arsrmture fA icartsCmaria /dor }—/ RXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MNFERIAIS DISCLOSURE
Will the applicant or future building occupant storm or handle harardous material HEATING UNIT RD 100,000 BTU)
as ddnM by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100.003 BTU)
❑Yes ❑No VENTI LATION PAN(SINGLE RES ID) PAID
Date Receipt0 _
Will the air coularcant or future building by the
useea Air Qanot uality
Marraes which BOILER-COMP OHP OR 100,(NN)9'IU)
'mit huaallons air conmminanu its define)by the gay Area Air Qwtlipy Management TOTAL:
Dielricl'1
❑Yeal No 13011,ER-COMP(OVER I00,0111 BTU)
I have read the Recen us materials requirements uMer Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE E
forma Ilemth&Safety Came,Sections 25505,25533 aM 25534.1 understood but if the NEW RISIDENTLAL MECH. SQ.FT.
building does ma comedy have a tenmq drat it is my responsibility to notify the occupant
offt requirements which must be mat prior to issuance of o Cenificme of Occupancy.
Owner or numnnzed agent Date TOTAL: ISSUED BY:
OFFICE 4