30355 APPLICANT TO FIL'L•IIN INFORMATION WITHIN REDLINES-USE SALL POINT PEN ONLY
CI'T'Y OF CUPERTINO - } BUILDING-ELECTRICAL. PHRMITNO. 30
'BUILDING DIVISION` APPLICATION/PERMIT- "['PLUMBING-MECHANICAL
BUILDING PROJECT I1I-0NTIFICKTION -
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAII'.
� �.
O NER' IS / a, PHONE: NTA TORS.AMC: /^ - LIC NO•,k
I/ , ' Iv JN� �j 2 I ` 7 C' NIC CONTROL#
RCHITI"CUENGINFER:' LIC NO: UR tS$: ' ,�''^^- `^' ❑
�
CONTACT: PHONE: BUILDING PERMIT INFO
- . ❑ ConaDltant Fe esludid by Applinnt(Initial) I BLDG ,' ld= 'PLUMB, SUCH
❑ ❑ ❑
r LICHNSEDCONTRACTOR:S DECLARATION - QTY. IiLF.CTRIC PERMPI' IEE I r
kfs
I hereby affirm thus I am licensed under,mw isionv of Couple,9(commencing JOB DESCRIPTION
Poo with Sorm.]001I.Mivision3of the Business end Profcssiuns Coda and myliwnx is - t
00' PERMITISSUANCE -,RESIDENTIAL: - '
in full force and effect. r - ❑SFDWL- ❑KITCHEN REMODEL
6F.UyU licens CLI.' Ci V Lia#�Z / /2� -
NQL Dme Q(. Coil - L APPLIANCES-RESIDENTIAL �•,I D'ADDITION OPLUMBING RI-PIPE'
I...vs ARCHITECTS UCLRI ION PANELS' ❑MULT-UNIT C:1 STRUCTURAL
yp nZ I title d my iia sshsllb used .pubTcrc oda MODIFICATION
k"1 UI'102W AMPS. .
O L ❑INTERIOR ❑CHIMNEY REPAIR
F+�f'W LicFnsed Pnifcssionnl - 201.10WAMI'E IMPROVEMENT -
y}y}�� r OWNER-BUILDER m Ce Como ON OVER I"AMPS• ❑BATH REMODEUREPAIR ❑DEMOLITION
W U 1 h r byaffirm that 1 an exempt from the f ni um(n d Lorene Law for the
ip$I ig U film S (S els ]Bol S II e, dP f:' is Code Any eny nr county e SIGNSELECTRICAL �GTHBR
lu'3 0.y wh ch req Iry pe mit t t tier, p demolish,or«•pair any structure '
c)g poor toll 's. also q "h -pplic If h Permit to file augned statement ` SPECIAL CIRCUITIMISC. -
f y that he lsLcensed pursuum to the pmnsions of Ne Commcmr's License Law(Chapter 9 '
1i1 p0q (cnimnam'my with Secant,7tmTof Division 3 mf the Business and Pmromitunv Code)., TCMR METHR OR POLH INST, COMMERCIAL; s'
d n 4 that he is exempt therchom and the basis for the alleged exemption.Any violation of L1 NEW BLDG/ADDITION ❑DEMOLITION
Y• Section 70315 by any applicant for a Penal subjectsthe applicant ivil penay on
hf POWER DEVICES - `
y canm a c ❑TENANT [ 50 FOOD SERVICE
p, not more than five hundred darters(ESW)' .♦
F� A: IMPROVEMENT
HdQ Dlaeowner afthe pnipany,or my employees ns(
h i6: slhevnolcnnnpcnIionSWIMMING POOL ELECTRIC
will Bothe work.and the stmeture is not mended! offered for mile(Sec.]6f4.Business 2OTHI?R'
63m and Profesmon Code.The CoNmctors L¢enx-law Docs nor apply to an owner of OVI'LE-fS-SWITCHES-FIXTURES
' AUG .( —
Property who builds or improves thereon,and who does such work himself or through rJ.f e__ _ fqVb
his ,an employees,provided thin such,improvements um not intended ar mBbmd for 'cy NHW RESIDUNTIAL F.LI!CTR SQ IT.
sale,If,however,the building or improvement is sold within one year ofcompletion.the SQ.FT.FLOOR AREA E/SQ.FT
•a wna-builder will have the burden of proving that he did not build or improve for par• �rl(iry�
p(ix ofsnlr.) I .
❑ h as owner of the propeny;am es,imm,ely contowdii,with licensed wmosca s iii
construct the project(See.9044.Business and Profesimns Codep TM1e Commctnr's Li-
cense,Law does not apply to an owner of pm,vemy
i-nseLawdoesnotapplytoanownerofpmpeny who huilds of improves thereon,and QTY, PLUMBING PERMIT FEE
who contractsfur such pro]mts wllhucontnmor(s)I1ceneW punumn m the Comoi,mds
a
License Lew. PI3RMIT ISSUANCE % +
1 sm exempt under Site - ;B&I, far this rcoxn
Own Date
AI:ITR DRAIN&VENT WMT;R(EA) VALUATION
''
WSCOMPENSATION DCCI-ARATION HACK PLOW PN(YI'13CI DEVICEVX
Ili by-ffmd underpc by ofperjury one oflli following dI fns
®❑
I have and will t ' C of t fC t. xlfmsur f rW k .Coater- DRAINS FLOOR,ROOF AREA,COND. O TYPE CONSTRUCTION
ad..;as po,idml torhy Set 9700 of the Lubar Code ran the ar,mmone.of the
work fur which Nu permit is issued FIX'I URE.S-PHR TRAP "
Fl I have and will maintain Worker's Compensation Insurance,as required by Sadon
37W of Ne Labor Codc,for the l,rfomaoce ofthe work for which this p mann i.issued GAS-EA.SYSTEM-)INC.4 OUTIATS
My Werke s n •nsI m Ins mow ori d Puliu nu he arc. s OCG_ GROUP APN
s cr,and
Cuoic, _Policy No.; GAS-EAS.SYSTI!M-OVHR4(EA)
CERT] CATEOPEXEMPI'ION FROM WORKERS' -
COMPENSATION INSURANCE. GREASUINDUSTRL WASTE INTERCEPTOR -
t ('Phis seetiiin naAnor tecntnplered it Oiapermit iv Torous hoodreddolhas($IW) 13UHAINO DIVISION FEES
or lessJ- "" Oltl!ASE TRAP PLANCHECK PHI?
Icmify that in the Feromnunceofthe work for which this Penni[is issued,[,hall SEWER-SANITARY-STORM IIA.2W IT
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
sation Lnwsof C.Iifo...in Dmc •' •` g r
WATER I{fiA'I'IiR WIVHKI'/ELLCI'i n
Z � Applicant � k � GRADING FEC '
y NOTICE TO APPLICANT:If,aper making this Cenificate of Exemption,you should WATER SYSTEMOKEATING -
f`# haomeh orarr t y the Wnrku'x Comparison this provision of the Labor Code,you matt - SOILS INCE
Lak1 V
forthwith comply wills such provlsihns nr this permit short he JecmcJ revnkcd.'r WATER SERVICE ,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIdvUE SQ,FT, PAID
w,F
IHerebyafrbnuhm ibero i9nconmvtcnion lending ngcney fnnhe perrnnnanw of Date Receipt#.Ihewnrkfor which(his permit i.issued(Set,309]]Civ.CJ
01entices Nam, TOTAL:
U Lender's Address a •TOTAL:s
PE
G 1 ani fy that I have read hi,applicailna and suao Ilial the above is BUILDING E
rp ,concer,legmeto comply with all city and county ordimnces and state laws relating to QTY. MECHANICACPERMIT FEE - -
U Z Imildingconamaion,and hereby outhorize re,actim nivel ofthis city to emcrupon the SEISMIC FEE
ahmve-mentioned propeny for inspection purposes. PERMIT ISSUANCE.
(We)agree(11 snve:mdeuu sty and keep harmless the City of Cupertino against ELECTRIC FEE
itbilides,judgutm""osts and expenses ukah may io lin,amyoamc again said City AITERORADDTOMECH. - - '
PLUMBINGME
conquence of the granting of this permit.
I x
APPLICANT'UNDERSTANDS/IND WILL COMPLY WITH ALL NON-POINT
SOLU ?REGULAT�. AIR HANDLING UNIT(101Q(Nq CPM)
1 sE
MECHANICAL FE
Alk HANDLING UNIT(OVER II,tNICFM)
639'6
CONSTRUCTIONTAX `
Signamreof Applicum/Commc� Dam EXHAUST HODD(WIDUCD HOUSING MITIGATION FEE
a - IIAZAROOUSMATIiItIAL.SDISCI,OSUItli a
Will the applicant or future huddling(weapon.store orhandle hazardous material HHATING UNIT TO INt,I)00131'U) -
as defined by the Cupenino Flunicipol Code.Chapter 9.12,and the Health and Safety
Cale,Section 25532(u)'t HEATING UNI"T(OVER IW."BI'U)
❑Yen ,1 ONo * PAH)
VENTILATION FAN(SINGLE RP.SID) Date Receipt
-
Will the applicant or Rome building occupant use equipment or devices which BGILER-COMP(SHF OR I W,(N1Il PTU)
mit hazardous air couWarm n,us defined by rhe Buy Are.Air Quality Me at,co eat 'TOTAL:
�DlsvlcR _ - BOILER=COMP(OVER 100,WBIITU) - •
'(]Yes C]No "
- I have read the hazmdmo materiqui
als rerements nmder Chupmr695 of the Cali- AIN CONDITIONER ISSUANCE DATE
form.Hwlth&Safcy Code,Sections 255115,25533 and 25534.1 undermand that if me NEW RESIUCNTIAL MIiCH. '- SQ.PT. - 'r
building does not cummly have a tenant Nms
at it is mypa, ilubly it)notify are occupant
of the mquiremenls which mum he mel prior In issuance of a CeniticateofOccupancy
s Ownernrauthnnzedugenl Date TOTAL: ISSUEIJBY: - mss^ - •-•
OFFICE .,: