30455 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 5
WILDING PRO.IKCT IDItNTIF'ICAI'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI'I'I'AL DATI
0/N�2/��70
OWN /�//�1' 255kypH0 E: ORTpA 1'OR'S NAMIi: � � Ll �jl�36 NIC CONTROL#
RCHITECIENGINF.ER: LIC NO: ADD S Nr
CONTACT. -PHONE: BUILDING PI7RMIT INTO
❑ Consultant Fecs Paid by Applicant(initial) BLD[lITT ECT PLUMB i MO i
11
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE rL7Y—N` lf�el/
00
I h nebyPost at I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
mz with Serono9(X10)of Division 3oOhe Businessand Profession,Cod,and my license is - RESI_ DEN I IAL;
PERMIT ISSUANCE
C1� in full force and ef&a 9 73a O SPOWL 0 KITCHEN REMODEL
QUZtF,) License Class Lit
.N ' APPLIANCES-RESIDENTIAL
[]ADDITIONtiQ Date Contmcmr ADDITION MB
1ING RE-PIPE
o!)
ARCHITECTS DECLARATION PANELS GMULT4UNIT []STRUCTURAL.
y sh
l understand my plans all be usenl as public records MODIFICATION
O'z:70 UPT0200AMPS I ElINTERIOR 0CHIMNEY REPAIR
P:4I,W Licensed Profemn...I 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IWOAMPS O BATH REMODEIJREPAIR [I DEMOLITION
yy M 6 1 hereby affirm that I am exempt from the Counselors License Lew Letts,
following reason.Section 7031.5,Business end Pmlcto n,Cale:Any city or cnuuty SIGNS ELECTRICAL 0OTHER
which requires a permit to construct,mus,improve,demolish,or repair ony structure
(^�O priorro its issuance,also requires the applicantmsuchpermiuofile asigned statement SPECIAL CIRCUITIMISC,
ythat he is l'menseciptomm mthepmvisiom.fum Contractor's license Law(Cm mr9
(cnmmencingwith Section?00(paf Di mon3of Ne Businemmul Pmfeaions Culc)o, TEMP.METER OR POLE INST. COMMERCIAL•
0.y m Y that he iemp,domenom and the basis for the alleged uurniumn.Any violation of 0NEW BLDG/ADDITION 0 DEMOLITION
u%I Y• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penaltyof POWER DEVICES ❑T17NANf ❑FOOD SERVICE
�N nm mom than Rve hundred doll ars($5W), IMPROVEMENT
C ❑Las owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do Ne work,and the scruc um is not imendedoroRered for sale(Sec.]814,Business OOTHER
4 m and Professions Code:The C....cmr's License Law does not apply m on owner of OUTLETS-SWITCHES
- ES
6566 IF pery who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELF SQ Pf.
sal,IL however the haildingorimprovemem ismId within.ne yemoformpItion.the SQ.FT.FLUOR AREA S/SQ.ff.
ownerhuilder will have the burden of proving that he did torn boil;m improve for pur-
pm a of sale.).
0 1.a1 owner,of the propeny,am exclusively enhancing wit licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Ca1e:)The ConOamors Li
cense Law does not apply to an ownero'propeny who builds or improves thereon,and QTY. PLUMBING PERMT FEE
who contracts for such projects with a contmctogs)licensed pursuanuo the Contractors
License Law. PERMIT ISSUANCE 's b
❑I am exempt order Sec. ,Id&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(PA) VALUATION
`
WORKER'Srdep COMPENSATION DECLARATION BACK PLOW PROTECT.❑EVICC / ^00
� Ihcrehy atlirm under penalty of perjury one of the following declnrmiom: lJ�
have and will maintain a Certificate ofConsemuo self-insure,for Workers Compeer- DRAINS-FLOOR,ROOK AREA,GOND. STORIES TYPE CONSTRUCTION
ation,as provided for by Section 37W of the Labor Cade,for the performance of the
or for which this permit is issued, FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for to Performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Cionnor ition Insumoce carrier and Policy number am:
Carrier: Policy No GAS-FA.SYSUW-OVER 4(BA)
CERTIFICATE Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINWSTRL WASTE INTERCEPTOR
EI111.DING DIVISION FEES(This section need not he completed if the permit is for hundred dollars(81(X)
nr less.) GREASE TRAP PLANCHECK FEE
(certify them rfomtaf1lIttofthe v{irk forwl/y�,r,eehtisperWmkumsCmps.- SEWER-SANITARY-STORM EA. FT.
torn employ ony erxt soya �I{crs o,c d1,Al,LI the Workers Camper- ENERGY FP.P.
z ,Z smion La is.D r/'T�'1ICC WATER HFAT'BN WNFN'TIELECTR
0 Appli<an �/ GRADING FEE
V) NOTICE )APPLICANT:If,elie,making This Certificate of Exemption,you should I WATER SYS3EMLTREATING
a become subject to the Worker's Campensuli..provisions of the Labor Cade,you must SOILS FEE
forthwith comply with such provisions.,this permit shall be deemed revoked. WAT17R SERVICE
Uj
0
C6 G CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.Ff. O PAID
VO 1hmbyufGrm the them isuconsudimi lcadingugcncy fimlhelermorromen of Dam Receipt
ILL. the work for which this permit is issued(Sec.3097,Civ,C.)
F" ladders NameTOTAL:
V Lenders Address TOTAL: ra-w��1
a1 certify tat 1 hove read his application and state that the above inf..6.n is / •Dv BUILDING FEE
In cored.l agree to comply with all city and countymmumares and state laws relating to QTY. MECHANICAL PERMIT FEE
U bmoidgconsuoctio,and hereby nutherizemprevmums nfthis citywametupon the SEISMIC FEE
Anse-mentioned property for inspection purpmea PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamtless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway sector against said City ALTER OR ADD TO MECH. -
incounipmenceofthe linna itofthis prrrrd. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON�POINT AIR HANDLING UNIT(TO IBC00 CFM)
SOURCE REGULAflONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX '
Signature of ApplicanVCnnvust Dam EXHAUST HOOT)OVIDUCT) HOUSING MITIGATION FEE
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harsnlous material HEATING UNIT(TO I(x),000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,oust the Health and Safety
Cade,Section 255321x)? HEATING UNIT(OVER IW,000 BLV) Q� -C
❑YesI�yo VENTILATION VAN(SINGLC RESIO) PAID —�
Data Receipt
Will the applicant or future building uecepanl use equipment or devices which
le mil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100.003 BTU) TOTAL:
1 District? TIO • W
❑Yes pQNn BOILER-COMP(OVER I( UMO H'fU)
I have at the haretious materials"comments under Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DATE
forms Heals&Safety GWe,Sections 25505.25533 and 25534.1 undetxmnd Out if the NEW RESIDEM'[AL MF.CH. SQ.Ff.
building does not currently have a tenant that it is my responsibility to nodfy the recepvnt
.f the requirements which must be met prior to isso mor of a Cenificate of Occupancy.
Owner or authorized agent Due TOTAL: ISSUED BY:�`0e
OFFICE