30402 APPLICANTTO FILL IN•INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BUILDING-ELECTRICAL, PERMIT NO. 3 0 ^ O 2
BUILDING DIVISION APPLICATI0N/PERMIT PLUMBING MECHANICAL L'f L
' C �9 ItU11.D1.G YRO .Q'IDI:NI'IPICA'1'I0N
BUILDINGADDRESS: SANITARY NO, APPLICAI'1O SUBMITTAL DATE
3�rJ la3 s g7ik/91,
OW&i! /N;aeT �!OC��C YJLiNa PHONBi C0NTNACT0R1l'NAME: - LICNO:
1. NIC "' (} C/0N'1'N0Lp
J� XCq�. IENGIN�k.R: LIC NO: ADDRESS: ❑
1-4
CONTACT. ����/ PHONE: BUILDING PERMIT INFO
T/m / Vll!/Y [^g/ ��.y ❑ Consultant Fees Paid by APPlicant(In ItIRI) BLDG ELECT PLUMB MECH
J IO T ❑ ❑ ❑ ❑
LICENSED CONTRACT R'S DECLARATION Q•rY. ELECTRIC PERMIT FEB
1 heaby af0nn that l am licensed ander provisions of Chapter 9(commencing ]OB DESCRIPTION
�„C`Z wiNSmicurade)ecDivisionlnfthe Business and Pndessionx Catharine!my limnsc is RESIDENTIAL
00 in full force vnd effect. PERMITISSUANCE F.VU License Class Lica ❑SFDWL ❑KITCHEN REM0DEL
NQ� Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Z Oon ARCHITECPS DECLARATION PANELS ❑ -UNIT UCTURAL
rr1 understand my plans shall he used its public records MODIKATION
O Z`=� UPM20(1 AMPS I ❑CHIMNEY PAIR
W Licensed Professional 201-100OAMPS IMPROVE T
`aj OWNER-BUILDER m Ce Conte ON 0VER]NO AMPS ❑BATH RE F 'P IR
O W U 1 hereby effinn that 1 em exempt from the Contractors License Lex•tier the d
ad following repson.(Section 70]1.5,Rusinew and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHEN
which unquires a permit In constmet,alter,improve,demolish,or repuir any structure _
.7prionudsissuance,lsnrcgoires thcapplicam for wch permit to file.diaredsmlement SPECIAL CIRCUIT'/MISC. t
V, u
that he is licensed pursuant the provisions ofthe Contractors License Law(Chapter 9
�O COMMERCIAL
(commencing with Section 7000)(if Division 9 efthe Business and Professions Cnde)or TEMP.ME'T'ER OR POLE INST. L:
a y m ev mm he is exempt therefrom end the basis dim he alleged exemption.Any vitilminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
IaSection 7011.1 by any applicant for o permit subjects the applicant 10 a civil penalty of POWER DEVICES
>y}
ma marc than five hundred dollar, ❑TENANT ❑FOOD SERVI
SM ❑ 1,us owner nl'ihe properly,onny empinyces with whges at their sole cnmpensntinn, SWIMMING POOL ELECTRIC IMPROVEMENT
F- wildo thework dant the structure it not intended oroffered for mle(Sec.7rk14,Business [D OTHER
6 a end Professions Code:The Cmaracom's License Law dues not apply m im owner of OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thereon,and who does such work hlnuclf err through
his own employees,provided that such impfovemems arc not intended or offered for NEW RESIDENTIAL 17LECTR SQ FT.
sale.lf.however the builJing or improvement is sold within one year ofcumpletion,me SQ.FT.FLOOR AREA .$rSQ.1'r.
wour-hudder will have the burden of proving that he cal not and m Improve for par-
po¢al'sale.).
❑ 1,as owner of the property,am eacltionelY amtmcting with licensed contractors to TOT
cumbout the project(Sec,7044,Badness and 14off cions Clio—The Cnmmctor's Ll-
useLawdoesnotapplymanownerofprrpenywhobuildsorimprovesthereon.vnd Q'FY. PLUMBING PERMIT PEE
ameratmets for such pmjn
es with a contmns
etor(Oliceed puru
suano the Commorea
License Law. PERMIT ISSUANCE s
❑I am exempt under Sec. ,13&P C lot his rwsam
Owner Date ALTER-DRAIN&VEST-WATER(EA) VALUATION
WORKTIR'S COMP ENSA'L'[ON BECLARA DUN BACK FLOW PROTECT.DEVICE
I hereby ammo ander penalty of perjury one of the following declarations
�❑I have and will maintain a Certificate ofConscnt to salf-insure for Workers Compen- DRAINS-FLOOR.ROOF,AS G,COND. 'GmHh; TYPEC0NSTRUCDON
sation,as provided for by Section 9700 om
f the Labor Code,for e pertinence of the
work for which this permit is issued. FIXTURES-PERTRAP
❑1 have and will mainmin Workers Compensation Ina meace,os required by Section
37M or the Labor Code.lit the pcdarreameafthe work for which this permit is issued. GAS-EA.SYSTEM.I INC,4 OUTLET'S OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number ate:
Cartier: Policy No.: GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not becumpletcd if the pemtit is for one hhndred dollars($100) 11
or less.) GREASE TRAP PLANCHECK
terrify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. Q
not employ any person in any manner so res ,,become subject to the Weaker;Compen- ERGY PEE
O Z sation Laws of Cnlifomia.Data WATER HEATER W/VENT/IiLECTR
z 0 Applicant 1141DIV,
FEE
N NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you shouldWATER SYSTLMRREATING
F become subject to the Woofers Compensation provisions of the Labor Code,you must SOILS
0.j ,'moi forhwith comply with smh provisions or this permit shell be deemed reveked. WATER SERVICE
4a•I Q
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL,PLMB. SQ.LT. PAID
U 0 k far
rwhich thi lot, is,construction lending agency for the pMormuace of U Receipts
� `+ the work for which this permit is issued(Sec.3097,Civ.CJ
O U Lenders Name TOTAL:
W Lenders Address TOTAL: _
ly nil'y That 1 have d thin application and shoe that the above InEmmminn is BUILDING FEE
h7 corms.L agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V G building contraction,and hereby authorize representatives ofthis city to enterupon the SEISMIC FEE
ubuvemtentioned property for inspection purposes. PERMIT ISSUANCE'
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,jullarams,consand espenus which may in any way accrue,pnotsaid City ALTER ON ADD TO MECH. PLUMBING FEE
in onsequ0 enf the gmntingor t hit permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ITO(O CFM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,01)CFM) CONSTRUCTION TAX'
Signature of ApplicanJContrector Dam EXHAUST HOOD(WTDUCfT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material ORATING UNIT(TT IOLONI BTU),
as dcfned by the Cttpenino Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU) - -
E]Yet -1 No VENTILA'T'ION FAN(SINGLE RESID) PAID
Will the npplicam nr fu[ure building xcupam um equipment nr devices which Da¢ cnigt C
hazardous air confinement,'vs defined by me Buy Alan Air Quality Maragement BOH.ER-C0MP(3HP0R 100.00OBTU)
H 1'AL:
Disitrict? BOILER 100,00)BTll)
❑Yes• 1_]No Lill or t,uri-unM.,
I have o a l the
hazardem,materialsAlit CONDITIONER
rryuirememx under Chapter h95 of the Cali- ISSUANCE DATE
fumia ll.IN&Safety Cale,Sections 25505,2S513 vad 25534.I unumnand Net if the NEW RESIDENTIAL MECH. SQ.FF.
building does me currently have a mutat,that,,is my mtponsihllity to nuify,he 0ampum
ofine enchantments which must b,mel prior b issuancent.Cenificeteof Occupancy.
Ownero emhnnzed ogeof Data TO'T'AL'
0FFICE