30934 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 0 9 3[�/1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.NIF.CHANICAL J
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
)53 srArR) .D Dr-. a �q T
OWNER'S NAME: p� u)N H(�pE — C1' "W'S X
OR'SN ' ! 0; T NIC CONTROL#
Al
ARCHITECT(ENGINEER: LIC NO: RESS: r ��L 4��l0 ❑
CONTACT: PHONL: BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLU B MECH
LICENSED CONTRAC YOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 horchy afr n that loan licenwd node,prn,i,cinns of Chapin,v aommear'ng JOB DESCRIPTION
Woo, with Section 7000)ofuivision Infant,Business and Professions Ctde,and my license is
F in full Pomc and crcccl/� s/� (( PERMIT ISSUANCE RESIDENTIAL
<U' License Class e-ao Lic.a Joy /�� ❑ShT)WL I-]KITCHEN REMODEL
HQd Dam Contmanr APPLIANCES-RESIDGNTIAL ❑AUDITION ❑PLUMBING RE-PIPE
h-pm ARCHM I`C'IS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
zOyz I understand my plari,hall be meed rte punlicrecnd, MODIFICATION
O 2�O UP TO 200 AMPS
b-.'n-t:W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
G f'1 OWNER-BUILDER DE,CLARAI'[ON 201-1000AMPS IMPROVEMENT
U14C Q 1 nereby afHnn that 1 am exempt from the Commctnr's License Law for the OVER IOW AMPS ❑BAT 'MOOEIIREP IR DEMOLITION
X34 U following rea.nn.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTH R
Y, which rcyuims a permit to construct,alter,improve,demNish,or repair any vlrunu e
,F., �
prior itissuance.also requires the applicant such permit to file a signed.aoamem SPECIAL CIRCUIT/MISE.
5to that he is Iic,rmd
} pursu:muothe Provisions of the Contractors License Law(Chapter tyCC� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
a a e at that he is eaempt thetefmm amt the basis for the alleged t,zemption.Any violation of ❑DEMOLITION
y y Section 7031.5 h ❑NEW BLDGIADDITION
y hundred dollars
5000 permit the applicant too civil penalty mf POWER DEVICES CITENANT ❑FOOD SERVICE
^�}
nor mom than five ePmprfi uof my employees
�=a0 ❑Lomevioas nd solus, agormy employeeswjNlared astheir
Sce.7compensation, SWIMMING POOL ELECTRIC OTTERIMPROVEMENT
Cd h' will do the work,anA the strvetum is nal intended tar offered forsWe(Sec9tY4.Business COTTER
3 and Professions Code:The Contractn''x License Low dose not apply to an owner of OUTLETS-SWITCHES-Fl%TURES
property who builds or improves thereon,and who taws.such work himself or through
hik own employees,provided that such improvement.arc not intended or offered for NEW RESIDENTIAL ELECTS S FT.
salt.If.hownan'he buildurlimimprovement viscid withisineynurofcoundetion,the SPT'Fl.L�Ij,pRLA g/SQ.FT.
owner builder will have the burden of proving that he did not build or improve for par- A �JJ
pnseof sulnd.
❑L as--act'If the property,um eselteivcly m uniae ing with licensed contractors to TOTAL: � �
crammer Ne pr (S
oject e,741,�Business and Pr m xions Codc:)The Cmaftem's Li- {�V '9 ��
cone Low docs net apply m an owner of property who builds or improves themon,and QTY. PLUMBING PERMIT EIT
whoconuact for such projects with a eontrarmrts)licamed punuanuo the Centrucmrs
License Law. PERMI'1'ISSUANCE IrY Ut- UUr
❑Iamexempt under Sec. B&P C for thismeco. tM1INU
OwnerALTER-DRAIN&VENT-WATER(EA)
Date VALUATION—
WORKERS COM
ALUA'f10NWORKEN;SCOM of NSAI[ONpartyron DECLARATION BACK FLOW PROTFiCI'.DEVICE
1 hereby a1Rrm under penally of perjury one of the❑Almwing Jedamtium;
❑I have and will maintain a Cenificam ofComentto.elf-insum for Workers Comfier- DRAINS-FLOOR,ROOF,AREA,COND.
Salton,as provided for by Section 3700 of the Labor Gale,for the Nom mance of the STORIGS TYPE CONSS'RUCTION
for which this panni,is issued. FIXTURES-PER TRAP
Is 1 have and will maintain Worker's Compensation Inspmnee,as required by Section
37110if the Labor Cole.fon he pefunermariflbe work far which this permit is joined. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Wnrk 's r npen.c 'on nsumrvc ra.iInier and PnBcy X19 Jle �f r OCC.GROUP APN
Carom. P YNo.:`'`--� 7 (L� GAS-F.A.SVS'ITiM-OVER4(EA)
CEkTIFICA'1'E OFEXEMP NPROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thiasecdon orad not be c.mplamd ifthe pnmit is for one bondmd dollars(s l W) BUILDING DIVISION FEES
on Ia,,,) GREASE TRAP
I crafty that in the perfor,nance of the work for which this permit is issued I shun PLANCHECK FEE
not employ any final.to any manner so as to become zabjen 1. he Workers'Compmr SEWER-SANITARY-STORM EA,200 FT
z Nation Laws of CalifurNa.Data ENERGY F[E
z O Applicant WATER BEATER WNENTm.EC'IR CRADLNG FEE
y NO,ICE TO APPLICANT.If.after making this Cenificam of Exemption,you should uWATER SYSTEM/TREATING
f
become subject the Worker's Compensation provisions of the Labor Cale,you must
forthwith comply with such this SOILg hIiE
W Q provisronc or permit hall be docmed revukeJ. WATER SERVICE
a
'Jz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
U O I hereby aRrm that is a consweimn lending agency for performmnce of Dat miff of
D. Ne work for which this permd uM(Sec.is is 309],Civ.C.)
O U Lenders Name TOTAL:
W Landers Address TOTAL
pr L ccnify that I have read this application and state that the above information is BUILI3IN .E
In current 1 agree m cnntply with all city and county ordinances and state laws mladng to QTY MECHANICAL PERMIT
V Z buildinflommonwdon.Ind hemhymomian mpresentativesof this cityto corer upon the FEE SEISMIC
above-mentioned property for inspccbon purposes.
(we)agree 1.use.indemnify and keep harmless the City of Caption.against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgment,costs and expenses which may in any way accrue against said City
in consequence of the granting crams permit ALTER OR ADD TO ME,CH, PLUMBING FE
APPLICANT UNDERSTANDYAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000 CFMI
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER I0,000 Cl
CONS'TRUCfION TAX
Signature of ApplmaH,kZA DO Data EXHAUST HOOD(W/DUCT)
HALtR W e building MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willthe ytheCupemoofutureiploft.Chaptr9.12,handle Health us and Safety EATING UNIT CTO IW,000 BTU)
as defnW by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Gale,Section 25532fifi! HEATING UNIT(OVER 100,1100 BTU)
❑Yes YFo
''J�` VENTILATION FAN(SINGLE RESID7 PAID
Will the applicant orin rats a building by ific B use equipment or devices em eh Dae Receipt p
emit hazardous air contaminants as Jcfncd by the Bay Area Air Quality Management HOLLER-COMP(THE OR 100.1100 BTU)
District? TOTA
CI Yes T1'fJo BOILER-COME(OVER 100,000 BTU)
I base mad the haaardeusmaterials mgahcnien,under Chapter 6.95of me Cali- AIR CONDITIONER
fomja Heals&Safety Code,Sections:5505,25533 and 25534.I understand that if the ISSUAN
looldingdoes not curremly have otenant,Nat it is my mspinsibilitym notify the occupant NEW RESIDENTIAL MECH. SQ.FE
of th requircmen¢which up,hemnpmrr issuance ofuCe 'icnm o'(ka:uomm
Own nfeuthoriant agent Dae TOTAL:
ISSUED BY:
OFFICE