30332 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMO'N030332
3O332
BUILDING DIVISION APPLICATIOINTERMIT I'LOMIIIN6-MECHANICAL
BUILDING PROJECT'IDENFIFICA'I'[ON
SANITARY NO, APPLICATION SUBMITTAL DATI
ct
D {��/) NIJ''R 1 k-f�.y /� p(/�f p N10� y/
OWNE ' NAME /W `A&M- O 11 RS-I I,M s'L LI 1, LIC YJ:� f/I
NIC CON'I'NOLp
ARCI TECEIENGINEER: IJCNO: A D ' S' l rf,rs S )rd. ❑
CONTACP. PHONE: - 1,`Li BUILDING PERMIT INFO
(n LA_ A D Q�q C ❑ Consultant Fees Paid by Applicant(Inftlalj BLDG ELECT PLUMB MECH
/t o W ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
z I hereby affirm that I am licensed under provisions of Chapter Y(ammenci"B LOB DESCRIPTION
with Sation]qp)a Dlvbmrlofthe B.1aw,so dProfe in Is Code,andmylicenseis -
�� in full frceond cH �f PERMIT ISSUANCE RESIDENTIAL:
�WF+ 1 ❑SFDWL C)KITCHEN REMODEL
U�J License Clas Lic.N APPLIANCES-RESIDENTIAL
til Dam TSDElpr ❑ADDITION El PLUMBING RE-PIPE
n' CHITF.CTS DECfA A N
FolttZ lunderstardm 1 rill be used as hlic recorts PANELS ❑MULTI-DNR ❑MODIFIVRAL
Z O y p ons a s pu MODIFICATION
OZ�n UP TO 200 AMPS
O [I INTERIOR ❑CHIMNEY REPAIR
�.Pj.(q..W] Licensed Professional - 20b10XIAMPS - IMPROVEMENT
�yZ, OWNER-BUILDER DECLARATION
tY 0.W'6 1 hereby office that I am exempt from the Contractor's License law for the OVER 1000 AMPS ❑BATH REM L/R P IR eDEN 0 ITL N 6
3 0.VU following reason.(Section 70JL5,Business end Pmfessions Cnde:Any city or county SIGNS ELECTRICAL. - 11 OTHER —OJBKi���—/'7
Wp which requires a permit to aam,tmer,alar,improve,demolish,or rcpeir may strucmm n I/I�Q'}'�('- •e r
Prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC. �l
} that he is licensed pursuant in the provisions of the Canrracmr's License Law(Chapter 9
00 (c
ummmem,with Section )of Division 3 oft he Business and ProP.Professions Code)or 'TEMMIG1HR OR POLE INST. COMMERCIAL:
d ry�M C that he is exempt thercfmm and the husis for the alleged exemption.Any violmief nl ❑NEW BLDG/ADDITION ❑DEMOLITION
tiaCl u. Section 1011,1 by any applicant for a parritsubjecsthe applicam to a civil penaI yal POWER DEVICES rITENANT ❑FOOD SERVICE
Z N rant more than Five hundred dollars($500).
OLnsowink.the pmpcny,nrI,not moyaswiNered fostheir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will Jo the work,and the slmmurc is not intended ornffered for sale(Sec.]034,Rusincss ❑OTHER
' and Professions Code:The Connector's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTUR
properly who builds or improves thereon,and who does such work but or through
his awn employees,provided that.such improvements are not intended or offered for NEW RESIDENTIAL ELEM FE
sale.If,however,the building ter improvement issold within one year ofcompletioo,the SQ.PI'.•FLOOR AREA $NQ.IT.
owneT-builderwill have the burden of proving that he did not build or improve for pun
pose of sale.). A
Q 1,es owner of the --ropeny,am exduzivelY cammctinB with littnsed conwcmrs m TO AU MUG 2 11996 a96
consthe pmjcG(Sea.NEED,Buaineas and Professions Code)The Contractor's Li.connote,
cense Law does nolapply to un owner of property who builds or improves thereon,and QTY PLUMBING PERMIT -EE I /
whocontracta forvuchprojectswith.cutmaorts)licemedpumctil Ne Cimaactw's •-r r,L -`
Licenic U. - PERMIT ISSUANCE !u•U
❑I nm exempt under Sea ,11&P C for this'reason
AIA Ell-DRAIN&VENT-WATER(EA)
Owner DoVALUATION
• m
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1herebyaffirm under penalty of perjury one(if the imnurr or docker'Co
❑Ihave and will moinminu Cenificme of Cnnsenuo self-insure far Workers Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE.CONSTRUCTION
smion.m provided far by Sation PW of the Isbor Cade.fw the pertomunce of the .
wEk for which this panda is issued. TEXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
)of the Labor Code,for the performance of the work for which this permit ixissu d. GAS-EA.SYSTEM-I INC.4 OUTLETS
C�coher'aSomrcrpayo ug✓g,gartierand Polsy No.Y Y f GAS-EA.SYMM OVER 4(EA) OCC.CROUP APN
''�YC�EERR.TIIFTFIICATE OFF/EXXEM ITON MOM WORKERS'
COMPENSATION INSURANCE GRE.ASEANDUSTRL WASTE INTERCEPTOR -
(Tbissationneednot N,emn letW if the permit is(wane hundred dollars($100) BUILDING DIVISION FEES
or IeasJ GREASETRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,I shall SIiWER-SAN ITARY-STORM EA.200 PI'.
not craft,any person' wn
m any tner so to rc n e ss t to the Workers'Compete ENERGY HE section Lawsof Cal' mim Date WATER HEATER WNENT/ELECTR
O Applicant • GRADING FEE
NOTICETOAPI CANT:U, I makingthis Cenificamof Esempticatyou shaul0 WR'I'ER SYSTIIM/IREATING
beconne subject m the Workers mpensation provisions of the Labor Cole,yov must SOILS FEE
forthwith comply with such provisions or this prmrdishall he deemed revoked. WATER SERVICE
Q
GDtthem A a const LENDING AGENCY NEW RESIUI?N'BAI.PLM 13, SQ,Pf. PAID
U p I hereby hichtnuhatthere issued(Sec.construction lending agency lin the performance of Date Receipt
0 F the work for which this permit is issued(See.Jf19].Civ.C.)
0 V Lendera Name TOTAL:
W LenderAddress - 'IOTA L:
I
certify that I have rend this appllcminn and sat¢that the nMve information is - BUILDING FEE
:-t Vl correct.lagree to comply with all city and county ordinances sal atom laws relating to QTY, MECHANICAL PERMIT FEE
V z building comavation,and hembyauNarizerepmuntativesarthis city menterulwn me SEISMIC FEE
abovennmajim d property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Imbilitica,judgments,costs and expenses which may in any way accrue against said City ALTERORAODTOMECIL
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IL"CFM)
SOURCE.REGULATI NS. /'� r MECHANICAL FEE
!1 1/^s s 'rel f 1 b AIR HANDLING UNIT(OVER 10,00)CFM)',�^ 1I -�,� - CONSTRUCTION TAX
Signa co(ApplieConvector - Dote EXHAUSTHOOD(W/DUCT)
VIAHOUSING MITIGATION FEE
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aacupant store or handle brtardous ant HEATING UNIT(TO 100,000)BTU)
as defoal by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)] HEATING UNIT(OVER 100.000 BTI)
❑Yes 0 N VENTILATION FAN(SINGLE RCS IDI PAID
Will rile applicant or future building sucupant use equipment or devices which Date Receipt If
emit hmsadems it contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP LHIP OR 100,000 RTU)
District? 'TOTAL:
El ❑ 0 BTUJ No BOILER-COMP(OVER 100,00
I have read the haarebms materials mryiremen¢under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
tori.Health&Salety Qde,Sections 255(15,25533 and 25534.1 understand trial if the NEW RESIDENTIAL MECII, SQ.I7.
building does not currently have a tenant,that it is my respamsibility to notify Ne receptor
of he acquirements which must he met Prism bourse of a Cenifncme of Gespmmy.
OwnertermalmouJ.gem Date TOTAL: ISSUED B
F Is
OFFICE