30571 CITY ONNCU BFILL IN RTINO INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
(WILDING-ElAiC'1'RICAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MEC-HA:NICAL
RUII,DING PRo1F.CP IDEN'T'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
S a s-CGG� cl —l 1� 6
OWNER'SNAME: P O +: CONTRACT 'S NAME:
NIC CON'1'ROLp
.i l M ` !-
kR IUhUI1ENGIN1iLR: LIC NO: ADDRESS: I _ ❑ "
D D Y'?i42
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTOR'SDECI.ARATION - QTY ELECTRIC PERMIT' FEE
1 hereby afirtn that 1 em licensed under provisions of Chapter 9(commencing JOB DENCRIPTION
OWoZ with Section 7")of Division 3 ofthe Busmen and Professions Code,and my license is
FOO in full force and effect. y PERMIT ISSUANCE. RESIDENTIAL❑ ❑
cgRIE- - SFDWL KITCHEN REMODELQ U U License Class hie.p
mZW Dam Contractor APPLIANCES-RES IDE NTIAL ❑ADDITION E)PLUMBING RE-PIPFi
f-�tio ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z C)do ZI understand my plans shall to used as Public records - MODIFICATION
OZ4 , UP TO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
[min- ELicensed Professional 201-1000AMPS IMPROVEMENT
-� OWNER-BUILDER DECLARAI[ON
6 1 hereby affirm that 1 um exempt from the Contractors License Law for the OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
iy5 G U following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
RI O E" which requires u Permit to amatruct,alter,improve, mre
demolish,or repair any strac -
potato l'orsuch perminoilam
asignedstament SPECIACCIRCUIT/MISC
d ,
� that he is
ntnooheprovisinronithcConwm
er'aLlcoretLaw(CM1apter9
(commencing with Section 7tklq)cI Divisionstills,13uxlnssand Prdleasions Cddolor TEMP.METER OR POLIS INS, COMMERCIAL:
a.ly o 1 that he'u exemDl therefrom:ted Ibc basis lir th,alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant Lor a peril subjects the applicant m a civil penalty of PO ER DEVICES
W~� nmm
me thin live oundrWdolbtca(S5E1). OTCNANT C1 FOOD SERVICE
t QO El L as owner of the propcny,or my en+ployaes with wages as their,.],compensation, IMMING POOL ELECTRIC IMPROVEMENT,
will da the work,and the,vu turd Is not intended mourned for snle(Sw.]044.Business ❑OTHP.R
a3 m and Professions Code:The Contmcmrs License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thdmon,and who does such work himself or through
his own com. aimprovements
s,Provided that ands arc not intended m offered for W RESIDENTIAL ELECTS SQ Pr.
sale.If.however,the building or improvement is sold within one year ofatimpletimi'mL SQ.F FI.00RAREA 5/SO.FC.
caner-builder will have the burden of proving that he did not build or improve for pur- e
pose of sale.). -
I,ae invo ph,p.,ny,em eadusively,murned.,with licensed counted...to
conduct the project(See.'/6W.Business and Professions Codd,The Coromandra Li- 17 1996
cense Law does not apply m an ovnerofpropeny whabuilds orimpown thereon and QTY ' PL LNG PERMIT FEE SEP
who contracts for such projects with a denmmur(s)licensed pursuant to the Cotnmdor's
License Law. PER C
m
❑Iaesemptunder Sec. ,B&PCfmthi,cd.Vm ,, -
sa
Owner Data
ALTER-DRI VENT-WATER IPA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations:
❑I have and will maintain v Certificate ofConcam aself-mount for Worker's Gambia- DRAINS-FLOOR,ROOF,AREA.COND, STORIES TYPE CONSTRUCTION
saint,as provided for by Section TIER of the Labor Cale,for the performance of the
work for which this Peril is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,ar required by Section
37Mofthe Labor Code,tor Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUT OCOGROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
s Cartier: Pol icy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEVINDUSTRI.WASTE INTERCEPTOR
' (Thissecnion nedl not herompleted dthic,annit isficamahundreddrdion(SI0)) - BUILDING DIVISION FEES
I or less.) I GREASE TRAP PLANCHECK FEE
I cenlfy that in the paifnntaneofob,work forwhlch thinpermit is inued[0mll SEWER-SANI'PARY-S'E)RM ITA.200 FT.
tat employ any pert in nny manner suits to become subject m the Worked Compen- ENERGY HE
'�z nnion l.:tws of California.Date
� � APP1it.m WATER HEATER WIVENT/IR,IiCI'It GRADING FEE
NOTICI3'CO APPLICANT:If,Mier makln this Cenlliam,of Eonatlon.you should
F P WATER SYS'I'GM/1'REA'1'ING
.� ; become suhj,en to the Worker's Coepen,mion pawkions of the Lahtr Code,you most SOILS FEE
Qforthwith comply will such provisions or this Permit shall be deemed revoked. WATER SERVICE .
CONSTRUCTION LENDING AGENCY NEW RESIDENT]AL PLMI3. SQ.IT. PAID
U O l hereby affirm that there is v communion lending agency for the performance of - Dam Receipt#
{1w the work for which this pemak is issued(Sec.3097,Cie C) .
0 H Lander',NameTOTAL:
r W Lender's Address TOTAL:
y 1 drolly that 1 have ad this application and also,that the above information is BUILDING FEE
iH. y ctrzdo.l agreema+mply with sell city and matey ominancds and sato,laws miming to QTY. MECHANICAL PERMIT FEC
U building construction,and hereby amlson'm represuddlives of this city to enter upon the SEISMIC FEE
above-mentioned p,,ar y(or Impdtion Purpose, PERMIT ISSUANCIi
(We)agree m save,indemnify and keep homeless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and,xp,naes which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of Ne granting of this peril. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ACL NON-POINT AIR HANDLING UNIT(TO 10.00)CPM)
SOURCE REGULATIONS. MECHANICAL FEE
� — (`1
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Sig ore of App manUCnmmctor )arc EXHAUST HOOD(WIDULT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appltcam nr future holdingoccupant smrt mhandle hazsrous ma¢nal HEATING UNIT(TO 100,11010 BTU)
to defined by the C.,mrs,Municipal Code,Chapter 9.12,and the Health end Safely
Code,Section 2 532(a}1sHEATING UNIT(OVER INDW BTU)
El Yea Fl No PAID
VENTILATION FAN(SINGLE RGSIU) Date Receipt N.
Will the air cont (it future building mainlby the H useequipmentAir Quality
Management
which BOILER-COMP OR 10p.001I BTU)
,ted hazardous air contaminants as defined by the Hay Area Air Quality Management 'TOTAL:
District?
❑Yea QNn BOILER-COMP(OVP,R ItM1,0E113'rut '
1 have read the hmmahms materials re uirctnems under Chapter 6.95 of the Call- AIR CONDITIONER
4 p ISSUANCE DATE
foram Health At Safely Cale,Section,21.50.5.25533 and 25534.1 understand that if the NEW RESIDENTIAL MEC((. SQ,I'L
building docs not enrzenRy haven tectum.that it is my respmnshility to dally the occupant
of the nd,o6ementa which note he met Friar to issamce of a Coralwalc of Occupancy.
Deo eror mb uriced.,cut Data TOTAL: ISSUED BY:
OFFICE