30229 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. O //�L Z Q V
BUILDING DIVISION � APPLICATION/PERMIT PIAMBING-MECHANICAL
BUILDING PROIEC'F IDENTIFICATION
BUILDINGADDRFSS: I �� / SAN]PARY NO. APPLICATION SUBMITTAL DAT
OW iR�NAMIi: I'1 ON� •OD. - CONTRACTOR'S NAME:�w � - LIC NO: NIC CONTROLM
ARCFiI(,TECfY NGINFOER b L C NO: Jf0 ADDCRC�Cs%'S'7 Ip� Yf.u� I e-u ❑
CONTACT C�F-v PHONE: - V, BUILDING PERMIT INFO
/ �� ❑ Consultant Petits Paid by Applicant(Initial) BLDG ELS PLUMB MEECtH
LICENSED CONTRAC'TOR'S DECLARRAATION QTY ELECTRIC PERMIT PEE � L'h kAJ
I hereby affirm that I am licensed under provisions of Chapter 9(comunemcing JOB DESCRIPTION
X00 with Section1")of Division 3 ofthe Business and Professions PCRMIT ISSUANCE Code,and my lieciseix / SRESIDENTIAL,p : i 7
ydyin full force and effect. - ❑SFOWI. ❑KITCHEN REMODEL.
6UU License Class Lias - APPLIANCES-RESIDENTIAL F1 ADDITION ❑PLUMBING RE-PIPE '
Naw
Dem Contractor
ARCHITECTS DECLARATION I�MULTbUNIT ❑STRUCTURAL
Z p�Z 1 understand my plans shall be used as public records PANELS _ MODIFICATION
OZ•.A UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Imo tri did Licensed Poetesrlonul - 201.10N)AMI'S IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELREPAIR ❑DEMOLITION
W st 1 hereby affiNm rm I ora exempt ftom the Contractors License Law for the o
❑OTHER
ig5Oa.U following reason (Section 7031.3.Business and Professions Code:Any city or county SIGNS ELECTRICAL
su a di fvvll which requires u permit to construct,alter,improve,demolish,ur repair any swaure
�7�Q pri... it isomer,also requars the applicnm ornich, ITo Clensigncdall SPECIAL CIRCUITIMISC.
} that he is licensed purmamuo thepro,nimnaf Ne Convectors License Law(Chapter 9 �-
0�0 (commencing with Section 7")of Division 3 ofthb Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
dyx e that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NF.W.BLQG/A4DIT i0 ❑DEMOLITION
W^w
Section 7031.5 by any applicant for a pemdt subjects the applicant to a civil penaltyof POWER DEVICES Cr O°�
y ❑TENANT �POOD SERVICE
not marc Nun rive t hundred ,,at t y employees
IMPROVEMENT '
< ❑Lasowner ofthe pro pent',onnyemntendev wiNfered as their solero4.Business SWIMMING POOL ELECTRIC
eo and Pr Newurs,Codd:swcmmisto intended Law
and
alytoIN4.Business ❑OTHER
and Professions Cale:The Cnnttacmfs License Law d«s not apply o an owner of OUTLETS-SWITCHES-FI%TURES
property who builds or improves thereon and who does such work himself or lhmugh
his own employees,the
provided that such ment is sold w arc not intended of or offered for NEW RESIDUE'1'IAL ELEC'fR SQ PT.
sale If.however.Ne building or improvement is sold within one year of completion,the p M SQ.FT.FLOOR AREA $ISQ.FT.
owneobuilder will have the burden of proving Nat he did not build or improve for pur. jJ LX D`4zS, I I 2- 0 Z
Pose of salt.).
❑ I,as owner of the property,um exclusively contracting with licensed contractors m ' IZ$ TOTAL: ��7
construct the project Net:7044,Business and Professions Code:)The Contractors Li- 2 �•
cense Law does not apply to an owner of property who builds or improves Merton,and QTY, PLUMBING PERMIT FEE $Z
who contracts mrsuch pmjeas with a conowtur(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑ IumexempI dcrSec. I ,B&PC�nr this��awnn
//// o AFTER-DRAIN&VENT-WATER IRA) VALUATION
nW ��'r
WORKER'SC MPENSAHONDECLARATION BACK FLOW PROTECT.DEVICE
lei I humbyaflirm under pen lty of perjury ane of the following declarations:
❑ I[caverns]will nraimeina Cmtilicam of Consent tovelf-in.mrc fa Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONI). STORIES TYPE CONS'rRUCT106
cation,m providW for by Section 37M of Ne Labor Cotte,for The performance of the
wnrk far which Nis peodt is issued. FIXTURES-PCR TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section 11
3](Hl of the Labor Code,for(be performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' A 11
COMPENSATION INSURANCE GREASEVINDUSIML WASTE INTERCEPTOR BUI VISION FEES
(Thissection need not becompleted fNepermit is for one hundred dollars($IN)) ORHASETRAP
or laza.) PUANCHECK FF. 93 3 �
Loy,any that in the aMamancerllhe become
this permit is Issued,lso.. SEWER-SANITARY-STORM EA.200 PT.
nes employ,any person in any manner sea as m became subject m the Worsrn'Compen ENERGY - Z.-
�.. cation Laws of California.Da: WATER HEATCR WNENTIELECTR
`!O O Applicant GRADIGIFBE
F" ^•' become subject tICE TO o Ne W�elr%Compensationing his provisionsate of of Ne Labortion.you Gge,you mos WATER SYSTCh1RREATING SOILS HE '
Wforhwith comply with such provisions or this permit shall Let deemC
ed revoked. WATER SRVICE
Q
CONSTRUCTION LENDING AGENCY N EW RESIDENTIAL PLM 13. SQ.PT. AID
L)O lfor by which
that isoconstructioned(SeND,Cis.agency(robe performance of
Date Receipt p
the wars for which this permit is issued(Sec.J09],Civ.CJ
Rv Lenders Name TOTAL:
U .
W Lcndcr'I minty
TOTAL: 1-7,72,S
L BUILDING FEE Z .•�
1[emee Nm I have rend this and coup and dina that the abnvc information rmning iv
Lot) buildiLlagreemcn,and with all cityandcepresnNiwncesand cstate ity to
retrains QTY MECHANICAL PERMIT FEE /
G z building construction,and herby nuNorixc representatives of this emit':amen upon The SEISMIC IEE 303_ 50
aMwe-mentioned property for inspection purposes. PERMIT ISSUANCEELECTRIC FEE
(We)agree in save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH,
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO TO."CFM) MECHANICAL FEE 'L
SOUR GULATIONS.
AIR HANDLING UNIT(OVER IO,gNI CPM) CONSTRUCTION TAX 7j- Q
Sik tial Artificial cto Date (� EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
EAZAR OUS A TERIAIS DISCLOSURE
Will the applicant of future bei 2g,occupant store or handle hmurdous material I(EATING UNIT(TO I FILM)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Code,S.B.25532(a)? HEATING UNIT(OVER INt"BTU)
1:1 Y. ❑No VENTILATION VAN(SINGLE RESID) PAID
Date Receipt
0, Will the applicant or(atom building occupant use equipment or device,which
T hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I(N),fX10 BTU7 TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes ON.
lz'jz5o�e.
'1 1 have read the haxenloux menials requirements under Chapter 695 of the C.B. AIR CONDITIONER ISSUANCE DATE
(roma Health&Safety Cale,Sections 8505,25533 and 8534.1 undermad ohm if the NEW RESIDENTIAL MECH. SQ.FT.
building does not curtrntly have C tenant.That it is my responsibility:notify Ne occupam
.fine requiremer.which must be met prior to issuance of a Certificate of Occupancy.
Owner or amhurittJ agent Doe TOTAL: ZL ISSUED BY:
OFFICE - `