30931 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 30931
BUILDING,PRodfici1'IDENTIFICATION
BUILDING ADDRESS: SANITARY N(s. APPLICA'1'RON SUBMITFAI,DATE
O NER:SNAME: PHONE-Cc !ZJe2. e?—Tz 23`L3 CO. �{'pR'S N�ME� SO 4r)q_
Aw �.IK !1 T y NIC CONTROL#
A CHI'fBC'I'IENGINP.EIi: LIC NO: ADDRE,57V 5, " C LO� s )
- ❑
CONTACT: PHONE: JxIf BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEL?
L hereby affirm that I oat licensed under pireisiom of Chapter 9(commencing JOB DESCRIPTION
OWZ with Section]000)of Divisinn3 of the Business and Professions Cale.end my license is RESIDENTIAL:
W O O . PERMIT ISSUANCP.
full force and effect. i
�Uz��3 License Class Lic.# GSPDWL [I KITCHEN REMODEL
y6H Date--Contractor APPLIANCES—RESIDENTIAL. ❑ADDITION O PLUMBING RE.PiEF.
y
ARCHITECT'S DECLARATION El MULTI-UNIT 05'FRUCTURAL
F� PANELS
OZ lunde�stand my plain^hull M1e used us puhlic records MODIFICATION
� UPTD 2W AMPS C3 INTERIOR 11 CHIMNEY REPAIR
W Liceread Professional 2111-1000AMPS IMPROVEMENT
S� j
OWNER-BUILDER DECLARATION OVER IINN7AMP5 ❑BATH REM ):, EPAI% G�nEMMOOLITIO,
srjj�iy4 6 I hereby esthete that I 1 exempt from the Continuants License Law(or the
W OaV following reason.(Setlinn]Ol LS.Business nnJ Pml'oesloos Cude:Any city or county SIGNS ELELTRICAI. �OTfiER
'3 4 which isuires a permit re^mss the alter,improves demolish, file
repair any swdurc - FAXA-
41—
poor
h—
F_,at.Oe pdonoiucensed prlso mantto the thovisio so for such Commutminoicense Law
(Chmmrnt SPGCIAIapter 9 .CIRCUIT/MISC. 9u (K(r(
f y that menccenmd pu6tion7 Nc provisions of the the
nd Professions
Codeine
U p0 (commencing with Section Division 3nf the Business and Professions CUJe)or TEMR MIT ER OR POLE INST. COMMERCIAL:
d n y that he is exempt therefrom and the basis for the alleged exemption.Any violation of _ ❑NEW BLDG/ADUITION 0 DEMOLITION
_44 Secrian]111 IS byanyapplicant for.permit,uhjeas the npplicint roes civil penulry of POWER DEVICES
F„ not more Ilan five auIMPROVE
ndrul dollars(5500). GT F1 FOOD SERVICE
❑1,as owner of the property,or my employees with wages as,their sole compensation. SWIMMING POOL ELECTRIC IMPRO �- J
will do the vv k,amd the srucme,isnot intended proffered for wile(Sec.]014,Business 0_OTHER �n.fj,�kCs�eOy
�W 3
on and Professions Code The Comment's License Ian does nor apply w an owner of OUTLETS—SWITCHES—FIXTURES Pt(/
property who builds or improves thereon,and who does such work himself or through
his own employees, msided that such improvements are nm intended.,offered Iia NEW RESIDENTIAL ELECfR SQ
sale.If,however,the building or improvement is sold within one,aarof completion,the SQ.FT.FLOORAREA VSQ.I'L
owner-builder will have the burden of proving that he did not build or improve for par
pose of sale^)[
0 as 1, r of the property,our exclusively contracting with licensed contractors to TOTAL:
construct the pwject(See.7144,Business and Professions Cale:)The Contractor's Li.
cense law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING FERMI FEE
who oonrnctx forxuch projects with a contmeoAO licensed pursuant to the Contractors '
License Law. PERMIT ISSUANCE?
0 l am exempt under Sec. - ,B&P C for this reason
Owner Dare
ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKERS COMPF,NSAT'ION DECLARA'HON BACK PLOW PROTEI UBVICE
I M1ereby uFlirm radar pcnalBy of perjury ones pr'rM10 following JaaHmdpns: '
O lhave unJ will maimninuCcdiOcate of Comenunsdf-insure fof Worker's Compete DRAINS—FLOOR,ROOF(AREA,GOND, STORIES T'YPG CONSTRUCTFON
cation,as provided for by Section 37W c f the Libbsr Cale,for Ne pci f..nOO of the
work for which Be,permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,m'reyuimd by Section
3700of the labor Code,for the performance of the work Saw Inch this permit is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My War •r' omp��s��i��n�l,n�xurmv:c[artier it n I Policy^ e a •
Carrier: e;il Policy No.:���_� GAS—Pq.9YSTP,M OVEli4(EA)
CERTIFICATE OF EXEMPTION FROM WON li S'
COMPENSATION INSURANCE - GREASErNDUSTRL.WASTE INTERCEPTOR
(This section mad not be completed if the permit is for one hundred dollars(S IoM tlU1LDING DIVISION FEES
or less.) GRIiASE TRAP PLANCHECK FEE
""'"'don' t "noumance ofthe work lies which rats permit is iasued,ishall 513W17µ—SANITAIIV—S'FORM Ii A.21X1IT.
nor employ any pc any atanncrs rn�g}tp unthe Wnrken'Cnmpem ENERGY FEE
zZ eland Laws ofL u .Date —'``sa=s � WA'1'F.R HEATER WNENTMLECTR O
Q Applicant O GRADING FEE
.w y NOTICE TTi A I A :IL after treking this Certificate of Eacmption,you should WATER SYSTEM/I'REATING
F^ become subject to the Worker's Compensation provisions of the labor Code,you must SOILS FEE
LaLIforthwith comply withsuch provisions or this perout,fral be council revoked, WA'FI?It SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW REIDplait,PLMB. SQ,FT. PAID
U O l hembyaffrm Bandana iso comstionamn Itudingogency for the performance of Data eceip
OH the work for which this permit is issued(Sec.3ND,Civ.C.)
U Lender's Name TOTAL:
Lender's Address • TOTAL:
yI certify that 1 hnve rend this application and sate that the above information is BUII.DING F L
h [otract.I agree wcmT with all city and county ordinances and state laws relating On QTY. MECHANICAL PERMIT FEE
U z building amswction.and heathy nmhorize represanmtivesofthis Outywenrerupouthe SHISMIC FEE
alcove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agate n save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs andexpenses which may i n any way aeon against said C'nY gL'I'1?R OR ADD TO MECH. PLUMBING PEP
in consequence,of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT TO 10.100 CPM) MECHANICAL PE
SOURCE REGULATIONS. -
AIR HANDLING UNIT(OVER IB,000CFM) CONSTRUCTIONTA
SignawreofA,hestmlCemncnr Date EXHAUST HOOD(W/DUCT) IIOUSLNG MITIG,A'1'ION .E
HAZARDOUS MATER IA I.S DISCLOSURE
Will meti,pllemt or farm building wer,antstme pr handle hazardous material HEAT'INGUNIT(TO 1I0,000BTU)
or defined by the Cupertino Municipal Cale,Chapter 9.12,and the HeAN and Safety '
Code,Section 25532hol HEATING UNIT(OVER 100.000 BTU)
O Ycs ONn - PAID
VENTILATION FAN(SINGLE RESID) Date Receipt a
Will the applicant or future building by,the B y A co Air Quality
or Man,a which BOILER—COMP G01110R 100,0011 RTU)
Dituhazardous air rnntwninunly as defined by,Ne Buy Arca Air Quality Management TO'I'AI.:
Uisr cBp
❑Yes 0 N BOILER—COME(OVER 100,000 BTU)
I have read the hasalloos materials re mo mere under Chapter fi 95 of the COB - .
9 p AIR CONDITIONER ' I$SU-N�F;�kTE
fnmia Henhh&Safety Code,Sections25505,s 5.13 anyand25534.i to notify
be occultism
the NEW RESIDEN'1'IAh MIiCH. SQ.FT. �� 1 //
building doorre s currentlyhaveamoan'had hiesmy res ponsibilitycaeotifO'c oaculNtm
of the requirements which must he at'do,to ofa Certificate of Occupancy. /•�
Owner or authnrzal agent Date IOTA ' S ISSUED BY: Tih'I
OFFICE