30398 Ial
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
30398BUILDING BUILDING DIVISION AtaPLICATION/PERMIT PLUMBING�AfEC[LANLCAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATF
Z/
-7-
OWNERS
OWNERS NAME. PHONE", CONT R;S N/C •-. CONfHOLp
RCHITECT/ENG EER: - 4 LIC NO: ADDRESS.
CONT .! / PHONE: .. BUILDING PERMIT INFO
✓p Y I a l I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Se-3- HO CJ
LICENSED CONTRACTOR'S DECLARATION QTY. x ELECTRIC PERMIT FEF.
1 hereby affirm that I site lirensed ander provisions id Chapter 9(ro amena•ag JOB DESCRIPTION
MZ with 7")of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL
O wt PERMI'TISSUANCE
F W in full force anJ effect. -
�UZU License Class Lie.N ❑SIDWI. [I KITCHEN REMODEL
I' fnQ� Date Contractor APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RRPIPE'
•]y ,. ARCHITECT'S DECLARATIONANSI ti El MULTI-UNIT ❑STRUCTURAL
F
Z O-Z 1 functional my plvns sheM us
ll cJ as public rccoNs - a - MODIFICATION'•
OZt UPT(32W AMPS ®.Alr,�.5".,5 Licensed Professional - - - t a ❑INTERIOR N �CHIh1NF:Y REPAIR
1.
2111-1001AMPS s - IMPROVEMENT
8T. OWNER-BUILDER DECLARATION OVER I"AMPS
ye4 Q L hereby affirm Ihuf I ver exempt from the Contract License Law for the ❑HATH 1i��19f :P R DEMOLITION
qxx 6 U fallowing reason,(Section 7031.5,Business and Professions Cale:Any city or county SIGNS L'LECIRICAI. s
]OTHER
a+�O(V¢"t' which resryires a permit to cd%tinct,alter,improve,demolish,or repair any strucwm
F+-+my.4 prior to it,issuance.also rtqulresthe a,heaut for such pennil to file a agred science, SPEC]A[,Cl RCUIT/M ISG.
a
that he is licensed palmae to the provision.onhe contractors License Law(Chapter 9,
OC (commencing with Section 7000)of Division of the Business and Professions Code)or 'TEMP.METER OR POLE[SPIT. .- COMMERCIAL: olav
a 6 m�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of - '�NIiW BLDG/ADDITION ❑DEMOLU'ION
t7�G Section 7031.5 byanyapplicam fore.,cnnitsubjwts theapplicant metcivil['e.alty.f POWER DEVICES NAM' ❑FOOD SERVICE
ION
not maty than five hundred date,,($500). a '
=Q has owner of the rt,arm IMPROVEMENT
O ❑ thempe ct ynnntended or fiarxide
as lhei(See,co1Businen. SWIMMING POOL IiLECTRIC ❑OTHER
C will dothewons andtheOneoreisnotLicense ow doesnotapply 1.4a Business
L and Professions Cos or improvers
orgtheContractors License Luo does not work
hi sun owner of OIJTI.Ii'IS-SWITCHES-PIXTUI2E5
his we who builds or improves thereon,and who does such work himalf or through - -
his we empiayccs,,molded thwsuch Impnrvcmentx ore nm imendeJ or n0ered for NEW RI:SIDCNTIAI.BLP.CfR SOT,
sale.If,traveler,the building or improvement is sold within one ycar.f completion,the -- SQ.F T]P It ABED_ 5/SQJ+I'. .
1 wnerbulderwll have theburden prayingIthtM1 itch lh TJ p f pur �ll�/`V/rI�/ ,
comm,sole) . -
❑h az owner of the propcny 1 .i dY c nasi 1 g m I .eJ roam rs t. " TOTAL: -
c nswet the.pm)om(Se. 7044 Bu.' and P f � Colo.,TheC t e sLt- -
censeLawdoesnotapplyt an owner of pmpcdy who builtsormpmvesmemon.and QTY. PLUMBING PERMIT FEI7
who car mes for such projects with a contraeaa(s)licensed personal to the Contract e's
License i.aw. PERMIT ISSUANCE /
❑-I are exempt under Site ,B&P Cf or this..,on
ALTER-DRAIN&VENT-WATER(EA),
.Dam
OV under
p COM of edie,or DECLARATION BACK IB.OW I'RO'fF.LT.DEVICE
'
CII hereb affirm under II f
y penalty perjury one of the following declarations: r � •
I have enJ will maimeina Cenificme of Cnn.enr to self-i...refnr Workers Compsm DRAINS-FLUOR,ROORAREA:COND. STORIES TYPE CONSTRUCTION
lion,as provided for by Semon 3701 of the Labor Code,for the perfnnitunce of the '
_ work for which this pennil is leaned. 0`0IXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,to.comfort by Scction
3700 oftbe Labor Code,fords, feral onhe work forwhich this pennil is isviel. GAS-HA.SYSTEM-1 INC.4 Ol1TLE'S - OCC GROUP. APN
My Workers Compensation lnsarance carrier and Policy number a re: GAS- -
Currier. Policy No,; EA.SYSTEM OVER4(EA)
CERTIFICATE OF EX GtBI'ION I-TOM WORKERS' -
COMPENSATION INSURANCE IGREASHANDUSTRI.WASTE INTERCEPTOR '
' (This section need not be romplemd if the permit is feline hundred Jolla,100) BUILDING DIVISION 12E5
or less.) GREASETRAP -
PLANCHECKFEE
L certify that in the performance of the work for which this permit is issued,l shall , S[Wf:R-SANITARY-S90RM EA.20111'1'.'
i....employ any person in any napper at as m become subject to the Workers'Co.,.- ENERGY FEE
,Z satim Laws of California.Date
Z O Applicant - .. WATER f1fiA'IER W/VENTIF.LECTR GRADING FEF, '
V) NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
'a become subject to the Workers Compenwted provisions ofine Labor Code,you must' SOILS FEF. :
fedevith comply with such provisions le Nis momilshall he deamed revoked. WATER SERV ICE
Q
V D 'CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
I hereby affimr mauherc is aconswction lending agency f�rthe performanceof 'Date Receipt If
L4 the work foi which this permit is issued(Sec.3097,Civ.C.) - _,
Q V lenders Name TOTAL:
lender's Address
I certify not I nerve read this uppiic tion.eall ,.at Bea the above inGamndop is BUILDING PEE
I�7q correct,Iagreem comply with all city mad .only mrdurenccs end Lime laws admingw QTY. MECHANICAL.PERMIT FEEV G7 bailding construction.unit hereby authorize cpresenatives of thiscity n enter upon the SEISMIC FEE',
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to save,indemnify and keep hanale.s the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acerae,against slid City ALCIRORADDTOMECI{, PLUMBING FEG
in asequence of the granting of this pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO 10,000CFM) MECHANICAL FEE O
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0(100 CFM) CONSTRUCITONTAX
Signature of ApplicanVConoactor - Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE -
HA7ARDOUS MATERIALS DISCLOSURE
Will theapplivanl or future buildingswcupanismie or handle tenable,milcold 1 IEA'fING UNIT(TO 100I)(10 RTID
as defined by the Cupertino Municipal Cafe.Chaper 9.12,and the Health end Safety
Code,Section 25532(a)7sHEATING UNIT 10.000 BTU) - -
C]Yes s ❑No g PAID •..
VENTILATION FAN(SINGLE RFSID)_ Data Rccey,#
Will the applicant or fume,building occupant use equipment or devices which
emit beemplaus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UHP OR Pat"BTU)
UisaieR. BOILER IW. IMI BTU) TOTAL:
O
❑Y ❑No "
I have read me baeerdnus mafcralarc ureme t der Chapter 695 of the Celi AIRCONDITIONER
4 ISSUANCE DATE
foredo Health&Safety Code e a trans 25505 is my t 23534 1made.tend ma if the NEW RESIDENTIAL.MHCH, SQ.Flt
buildingre I I whitey have Ise re n but t y r M asCertiy c rfy d Occupancy m '
of the requirements which mea be met poor to of a Certificate,of Occupancy.
Owner nr amhnriuJ agentDam TOTAL:
ISSUE 1)HY:_�\'
OFFICE s - '