30005 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30005
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
IIUILDI 'G PROJECT IDENTIFICATION
BUILDING ADDRESS: o`, - SANITARY NO, APPLICATION SUBMITTAL DATI
CD ht
02@ , S-- ict av :so a7
OW 'S A PHONE: C yffACT'O 'S NAME: TI LIC NO:
re ��C ODO G.S ve/o IT+ YI• NIC ONTR .q
CH TECf/ENGINET:R: LIC NO: ADDRESS: ❑
e rI*I% �iJ� 1�s a D ece J~o a60
CONTACT,. PHONE.: BUILDING PERMIT INFO
_ ❑ Consultant Fees Paid by Applicant(Initial) Bi ELS PLUMB B MECH
me r P d Jbm
LIC SED CONTRACTOR'S I 'CLARATION QTY ELECTRIC PERMIT PEA
I hereby affirm thin I nm IicenseA under pmvisiom of Chapter 9(commencing JOB DESCRIPTION
�OIy�O ZO wird Seninn]000)yd Divoywr3ofrhe Business and Prnfcesiom Code,and mylicenu is PERMIT ISSUANCE
F0r in full farce mW effat. FOWL ❑KITCHEN REMODEL
�Z t�,,3) License Close LIC.N APPLIANCES—RESIDENTIAL. ❑ADDITION [3 PLUMBING PE-PIPE
�<a Date Cnnuucmr
ARCHITECTS DECLARATION - �s1ULTI-UNIT []STRUCTURAL
L.,D y PANELS
Z Orn2 I understand an,plain shm11 be mud ns public records MODIFICATION
OZ�` UlIT02fMAMPS ❑INTERIOR El CHIMNEY REPAIR
P�3I= Licensed Provisional 201-1000AMPS IMPROVEMENT
Sgs5� OWNER-BUILDER DECLARATION OYER IO0AMP5 ❑BATHREMODEVREPAIR [I DEMOLITION
LL 1 hereby affirm on 1 a.5 exempt from the Coni ns Co License cLawity
o for the
pj O a 4V. following reason,(Section]on tru Business mpr Pre,de oat Code:Any city nrmumy SIGNS ELECTRICAL El OTHER
^I�4 O which rcquircs issuance.permit re car swn,oder,improve,demolish, fie a sir any swment
pratheissnsMpun6 ntquiree the applicant for CoM1pctor'& ice seLaw( amment SPECIAL CIRCUIT/MISC.
> Net he ie li<ereed pmrsuanuo Ne provinons of the Conunctor's License LawlCheper9
CSO (commencing with Seninn]IM,O)of Division3 ofthe flusineas and i'rnfeesimeCode)or TEMP.METER OR POLE INST
a p, C
that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of -OCT NEW BE UADDPDON DEMOLITION
fiXl Y• Set 101 LS by any applicant for a permit subjects the applicant no,civil penally of POWER DEVICES (]TF.NAM' ❑FOOD SERVICE
oat mine than five hundred dollars($500f IMPROVEMENT V.
E)1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER. 5rt s
will do the work,and the structure is not inrendedmoffered for sale(Sec.]04L Business
Wand Professions Code:The Contractors License Law does net apply man owner of OUTI.fTS—SWITCHES—FIXTURES
63 property,who builds or improves me.,., ad who does such work himselfor through
his own employees,provided may such improvements arc nm intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If.however,the building or improvement is sold within one year ofemopletion,the ^ �r SQ.ITL'.FLOOR AREA �a $/SQ.FE
owner-builder will have the burden of proving Had he did no build or improve for put-
pose of sale.). ^
01,as owner of the property,am exclusively contracting wit licensed crntmem �
rs to F TOTAL:
construct the project(Sec.7044,Business and Professions Cod,)The Cotnrauore U. �y//�g
Genu law does not apply to an owner of Tropicallywho builds or improves thereon.and QTY, PLUMBING PERMIT FEE. a]3o `�' ,0,2,
whocoatmets for such pmjecbswith acnmincom )licensed pursuaduo the Commuters oofL
Licen3e Law. PERMIT ISSUANCE
❑tum exempt un rSce. ,B&P C fmouisle t 'on
',}���y.—.��� Data ALTER—DRAIN&VENT—WATER IEA) VALUATION
Owner WO r.`R'SC PEWS(fi1 ATIONDECLARATION BACK FLOW PROTECT DEVICE
66 y
1 hereby nation under penalty of perjury one of the fallowing declarations,
orl I have and will maintain a CenificataofCoewcnt to selFinsum for Workers Compton DRAINS—FLOOR,ROOK AREA,COND. STORIES 'IYPECONSTRUCTION
tabun,as provided for by Section 3]0)of the Labor Code,for the perfamearee of the
work for which Nis permit is issued. FIXTURES—PER TRAP
1 have and will muinain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for IM1e performance of the work for which this pemtil is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy M, GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEM17ION FROM WORKERS' GRGSEIINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This union need not becompleted ifthe parmil is for onehundad dollars(SIDE) GREASETRAP
or lest.) - PLANCHECK FEE S
I certify that in the perforrance of the work for which this Permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as m become sobject to the WorkersCompee- ENERGY FEE ITSi
oZ cation laws of California.Date WATER 14EATER WNENT/ELECTR GRADING FEE
Z Q Applicant
s.e rNi NOTICE TO APPLICANT.if.after making this Certificate of Exemption,youshould WATI7R SYSTEMOBEATING SOILS FEE
a became subject to the Worker's Compensation provisions of the Labor Code,you must f
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
�L Q
t7. Z CONSTRUCTIONLENDINGlNG AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date RaeiglM
L)O Ihere111.mlhm Nem iaymcd Oce.
30 leading7,Ce.agency for thepWbrmance of
fus " Ne work for which this permit is issued(Soc.309],Civ.CJ
U Lenders Name /n G TOTAL:
Lender's Address TOTAL: 12.2k,
a1 certify that I have read this application and sae that above information is BUIfA1NG FEE O a
fA combat.I agree to comply with all city and county refinances and state laws relying to QTY. MECHANICAL.PERMIT FEE
V building construction,and hereby amhofze representatives of Nie city to enter upon the SEISMIC FEE
abovememioned progeny for inspection purposes. PERM11'ISSIIANCE J
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FE.I2
ILabilities.judgmwts.costs and expenses which may in any way accrue against sand City ALT ER Olt ADD TO MECH. 'a�G
in nsequence of the granting of Nie permit. PLUMBING PI?E 4
APPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH'('1'0 10.000 CFM)
SOURCE REG TICKS MECHANICAL FEE iaa�r
s '/ / ey��/�� AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUC IONTAX a� �
Signaef�o pplicanVConmw10 /S Ume EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupanumre orhandle hazardous material HEATING Upfl rFi0100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(.)? HEATING UNIT(OVER 100.00)111 U)
❑Yes 0N VENTILATION PAN(SINGLE RESID) PAID,
Date Receipt
Will the applicant or future building occupant as,equipment or devices which BOILER—COMP(3HP OR 100,000 BTU) '
mit hutnrdous air contaminants at defined by the Buy Area Air Quality Management TOTAL;it ?Agin
Whiffet? BOILER—COMP(OVER 100.1100 BTU)
❑Yen ❑Nn
I have read the harmdrms materials requirements tinder Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE'{/
famin Biennia&Safety Code,Sections 2595.8533 and 25534.1 mdersand mal if the NEW RESIDENTIAL MECH, SQ.FI'.
building does not currently haven waal that it is my rcspnnsihllhy m notify the occupant
of the rtquirements which must be met prior to issuance of a Cenificare of Occuptay.
Ownerrr umthodzed agent Date TOTAL: �pf p
p. p ISSUED BY:
F4
OFFICE