30861 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
861
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANLARYNO. APPLICATION SUBMITTAL DATE
2�3crJ ST�.Vk-us cam. � ,
OWNER'S NAME: »/PPHONE:. '' `` CONTRACTORS NAME: LIC NO: ']�r�)�}/�J'
�i 0� N eq 0W�Jl' 2_ N/C CO ROLyT M'- V
�AR HITECDENGINEER: LIC NO: ADDRESS: ❑ ' {J.`( 191(.(_`�r
CONTACT. �y��I 1 (�/� rh-`3=•.PPH_ONEp-'-1 � pp - BUILDING PERMIT INFO
/-�M llJ.Jf-t1♦y-��' Q�kJ ne-1 I'QZl-O ❑ Consultant Fees Paid by Applicant(Initial) B G ,(<LWT PLUMBME
G rSTEl3 1Lky
LICENSSD CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aBTnn Our 1 an Ikense l coder provisions of chapter 9(commencing JOB DESCRIPTION
"Z with Section 70M)of Division 3 ofe,B.Sroccsand Profeoum,Code,and,,license is RESIDENTIAL in full fortis and effect. PERMIT ISSUANCE .
Iy-+ ❑SFDWL KITCHEN REMODEL
�UzV License Class m
CAPPLIANCES-RESIDENTIAL ADDITION PLUMBING RE-PIPE
hQL Date - omrmmr ❑ ❑
y ARCHITECTS DF.public 'ION PANELS, ❑MULTI-UNIT EMODIFI ATIO
OZOr24 ,understand my.Ian sM1all ha used es.chile records MODIFICATION
UPT'02D0 AMPS ❑INTERIOR ❑CHIMNEY REPAIR '
,
P:4Licensed Professional 201-IMOAMPS IMPROVEMENT
,y��y OWNER-BUILDER exempt
I n DECLARATION Comment's
OVER'1000AMPS' ❑BATH REMODEUREPAIR [I DEMOLITION
�C a 1 hereby affirm on 11. exempt frons the Cisions Co License Law fou me
Yp{YS5�O,V following reason(Section 9031.5,Business and Precisions Codec Any city or county SIGNS HLHC'_fkl ❑OTHER
t+t WO F" which requires a Permit to construct,alter.Improve,demolish,(r repair any structure '
F printed its issuance,also requires the applicant formed permit o file a signed statement SPECIAL
��Fggqq++++.... �, thin he is licensed pursuant m do provisions of she Conwe,orr License Lnw(Chapter 9
y..1p0 (commencing with Section 7WO)(f Division 3 ofehe BusLmsssnd PrefessionsCode)or TEMP.METE OR POLL INST. COMMERCIAL' ' .
d y o C
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
LLXl W Ivain(903 LS by any applicant for a perm,,subjects the applicanun a civil penally of POWER DEVICES �IilTENANT .O FOOD SERVICE
zzm notmorethan Ivo hundred dollars 6500). '
CEULI�RIC, IMPROVEMENT
❑Ido the work,the the mo,mmyemntended with for
sole cumpenxmien, IMMING POOL wJl tla the work,and deswtturc is not intended os offered far eale7 .Busbnss ndProfessions Codc'the Conlracmds License Law does nae apply to on owner n I1TLEf3-SWITCBS �..property who builds or improves thereon,and who doer such work himself lir ehrbughhis own employees,provided that such improvements are not intended or offered for NGW RP.SIDENTIASQ PT.
sale.If,however,the huildingor ire.mvemctnisedd within one yenrof atmplahon,the - - PT. LOOR AREA $/SQ.hI:
owner-builder will have the burden of proving that lm did not build or improve Por per,
pose of sale).
Fl L as ownernt the property,am exclusively eomtuning with licensed contractors to O 1
construct the projeel(Sac.7044,Business and'Professions Code)The Cpmrecrors Li- -
censeLawdoesnotapplymanownerofprepenywhohuiids or improves thereon,and QTY. PLUMBING PERMIT FEE
- who contracts for such projects with a comraam(s)licensed pursuant to the Contractor's I �'� SF re
License Law. PERMIT ISSUANCE U I ..T r
❑ 1 am exempt under Sec. B&P C for this reason '
ALTER-DRAIN&VENT-WATER(EA)
Owner Owner Date - 2 �(+��
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE L L 7
I hereby afr..n under penally of perjury one of the followeclara
following dtions: J(,,,
0Ihave and will maintain a Certificate of Consent to sell insure for Workar's Compen- DRAINS-FLOOR,EDOP,AREA,COND.
action,as...video for by Section 3700 of the Labor Code,for the perfonniume of she STORIES TY�PeE•rCONSTRUCTION
work for which this Permit is issued. I - FIXTURES-PERTRAP 1,1 �C✓�
❑ I have and will maintain Worker's Compensation Insurance,as resryired by Section
37M ofthe Labor Crude,for the peformrrom of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OFrLETS -OCC.GROUP APN
My Workers Compensation Insurance evrrier and Policy number are: -
Ca,H,,: Policy Ne.: ' GAS-_EA.SYSTEM-OVER R ., !1]-/V1 ,v O�CI
CERTIFICATEOFEXEMPTION FROM WORKERS"
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOk
BUILDING DIVISION FEES
(This ction need not hecomp,eted if tin pnrmh is borons,hundred dollars($100)
se
or less J, .GREASE TRAP - PLANCHECK FEE O
I certify thin in the performance ofthe work for which this permit is issued,l shalt SEWER-SANITARY-STORM EA.20)n
nor employ say person in any rammer so me.became,abject to,he Workers'Comport- ENERGY FEE
O Z ,deltic Laws of California.Date I
WATER HEATER WNENTIELECTR
Z Applicant GRADING PEE
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYS'fEM/TkGTING
become suhjen to to Worker's Compeomtion provisions of the Labor Code,you must SOILS FF.E
rr forthwith comply with such provisions or permit shall he deemed revoked. WATER SERVICE
aG
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F. PAID
I hereby affrtm that(him iso construmion tendingagenny,for the pe of..nonceof ata kedeip,N
Is ti the work for which this permit is issued(Sce,301 Co.C.)
W h Lender's Name IZ� TOTAL:
WLend Address _ L. -
1 cartify that Ihaw r d this application dd scene that bb information is BUILDING P pi, 0.
Fr V) correct lagrees, comply ',h II city and county finances and state laws totaling to QTY, MECHANICAL PERMIT E `
V Z building construction,and hereby ntdhonze op .onmuces tn'to 'lye re....a the SEISMIC FEE
above-memioned.rnperty for Inspection purposes. PERMIT ISSUANCE '
(We)agree to save,indemnify and keep harmless(he City of Cupertino against ELECTRIC HE,
liabilities,judgment,,evil,and expenses which may in any way.,cine against said City LTER OR ADD TO MECH. JX 40
consequencein of the starting of this permit. - PLUMBING FEE _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGULATIONS, MECHANICAL PEE
AIR HANDLING UNIT(OVER 10.000 CFM) ' CONSTRUCTTONTJX
Signature of Applartm/C(ntmctor Data EXHAUST HOOD(W/DUCT) HOUSING MI't1GATION FEE
MATERIALS DISCLOSURE ,
Will the applicant or future building occupant store lir handle harroma.v matenat HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely -
Codc,Section 25532(a)^ HEATING UNIT(OVER 00,000 BTU'
❑Vas r ❑No I I - PAID '
" VENTILATION FAN(SINGLE RESID) - Data ReceiptN
Will the applicant or future building occupant use equipment or devices which
BOILERCOMP(3HP OR IW,(IW BTU)
emit InteractionsInteractionsair contaminants us defined by the Bay Area Air Quality Managem -
ent A
District?❑Yes i]No BOILER-COST(OVER 100,000BTU) IF
1
I have boundthe hezmmm
dous ntana,$)egaireems under Chapter 6.95of me Cali- AIR CONDITIONER - ISSUANCE DATE
fdmia Heald&Safety Cade,Sections 25505,25577 trod 25530..i understand that if the NEW RESIDENTIAL MECH.
building does not currently have a tenant,that it is my resptmsibitity to notify the occupant
bide requirancos which most be mm.berm issuandeofa Cenifevreof0ccopancy.
Ownermaumorizedagent - Data TWO. 1 ISSUED BY:
OFFICE
' t