30104 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. �O �O�
BUILDING DIVISION APPLICATIONPERMIT nU11,DIPLNGUh1vRQBING-MECHANICAL
aIel11LU1NGAWJECT IDENTIFICATIONRE55: SANITARY NO. APPLICAT ION SUBMI ITAI.DATE.
loo X.- "LOW RQ sw3- ?S0 6 --?tv4tG
NER'S NAME: PHONE: O CTOR'SNAMHLIC NO:
SO 0 N/C 4COIMR2LM
-�ARCHITECUENGINEER: LIC NO ji
CONTACT: PHONE: 0 BUILDING PERMIT INFO
r � �� Consultant Fees Paid by Applicant(Initial) BLDG EL- F:C'I' FLUME MP H
LICENSED CON-RAC'MR;S DECIAR ION QTY ELECTRIC PERMIT FEE If
t}—�C 'Y�j-'yam
1 hereby affirm Lha 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QaZ with Section]UW)of Division 3 ofthe Business andvrofessionvCWc.wd mylicensc i. RESIDENTIAL:
O p PERMIT ISSUANCE
Fes,C F infill fol... effect. L O Q ❑SFDWL ❑KITCHEN REMODEL
QUU Lmenu Clans N Licn 7 AYI`LIABCIS-RESIDFMIAL []ADDITION ❑PLUMBING REPIPEN Dal[ nlE
F.,Dta ARCHITECTT DECLARATION DECLARATION PANEfS [I MULTI-UNIT ❑ I'URAI.
Z O w Z 1 understand my plans shall he used us puM1lic records MODIFMODIFICATION
OZ�� UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
F�F'W Licensed Professional 201-1000AMPS IMPROVEMENT
C � OWNER-BUILDER DECLARATION OVER IINNsnMI'S El BATH REMODEIIRIiPAIR ❑DhMOLITION
qO C Q 1 hereby minim thin 1 oro exempt from the Counselor's Licert•e I,aw for Ne
x d U following moron.(Seclinn]031.5,Badness and Professions Coda.Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL I- which requires a permit to common,alter,improve demolish,or repair any structure
Cprior to its issuance,aknrequires the apdmmd for such permiun Bleasigned.....mcut SPLCIALCIRCUIT/MISC.
MMy that be is I ecrool pursuant to the pmvisime
rs of the Commmr's License Law(Chapter 9
f+1�G�0 (commencing with Section H(IOn)of Division 3 of the Business and Professions Code)or TEMP.m EEfR OR POLE INST. COMMERCIAL:
d y o K that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
IaXI 4y
Section 7031.5 by anyapplicant for o permit subject•the applicant to a civil penalty of POWFR DEVICES �ENANT ❑FOOD SERVICE
not mom than five hundred dollars($50M IMPROVEMENT
Q
Las owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL(eLE IC
L will dothe work,and loaremiure isnot immadeduroffeml foraleSee](Wi.Business [I OTHER
3 m and Profnssins Code:The Commerce's Liee se law does oat apply m an msver of OUTLITS-SWITC - ES
progeny who builds or improves d¢rcaa and who does such.,,,it himself or through
his own employees,prosnded that such empmrvamats arc not!,limited err offered for NEW RESIDENTIAL ELECTR SQ lT
sale.If,however,the building.'impnwemcm is wed within one year ofcoaideao.,the SO.FE.FLOOR AREA $/SQ.IT.
owner-0uildcr,will have We buwito of p,rvimg that he did not build m improve fm par- -2
pose of sale.). -
1.as owner of the pmpeny,am exclusively umuuc,ing with licensed armmdon m OTAI
otic,the project(See.Heal,Baseness and professions Codc;)the Contmaor'n Li
cense Law docs not apply man owner of properly who builds or improves thereon,and QTY. PLUMBING PE FEE JUS 241996
who contracts for such primitives with a commetons)licensed pursuant to the Contractor's
license Law. PERMIT ISSUANCE
Q Imeexempt under See .B&PC for his reason :'IIY Uh GUtYcrvI
ALTER-DRAIN&VENT'-WATT (GAL VALUATION
Owner Dam a�
WORKERS COMPENSATION
on DECLARATION BACK FLOW PROTECT.DEVICE �/`MW00f
1 band waffirm undo Ccoalty of ofCoY one of the ansure log declar's Camped-
a
❑Ihsve and will for maintain 37M of the Labor
Code.forth. Worker's Comp the DRAINS-Ff.00R.ROOF AREA. STORIES TYPE.CONSTRUCTION
.µlion,as prodded for by Section 3]W of the IaNn CnJe,for the perfnnunce of the
ark for which this permit is imucd, FIXq'URFS-ITER TRAP
I have and will maintain Worker's Compensation Insurance, requited by Sed
3700.f th<WMa Gale,for the performencc of the work far whichli this permit is issusmed.. GAS-EA.SYSTEM-]INC.40UTLETS OCC.GHOUP APN
/ Ca rtrkin's CovmQemsatic^I�umnce�ranJYolicynum�rere.
Calver:_-ff_T If/I Pnld Nn.: GAS-EA.SYS'I EM-OVER 4(EA)
CHRI F -A'P OF 13X'MPHON FROM E S' GRF.ASFJ]NDUSTRi.WASTIi1MIiRCEPTOR
COMPENSATION INSURANCE BUILDING DIVIIIION IRS
(T his section need not be completed blue prrmit is forone hundred dollars($IW) GREASE 9'RAP
or les") PLANCHECK FEE
Loy any person
in the Ferrianymnnerofthew n for auric subjectch to
perthe it Wrixs Compact SEWER-SANITARY-STORM EA.2M
not employ unY parson!n any manner w a�tar bcs,me suhjm,to the Wnrkcn'Googol. ENERGY PER
O ,Z anon Laws of C.ffomim Date NATER BEATER W/VEN17ELECIR GRADING PERZ Applies.,
y NOTICE TO APPLICANT.If,after making this Ccnifi,me of Exnniumq you should WATER SYSTF,MTEAI'ING
a ; become subject to the Workers Compensmeon Issomos of the IoM,Code,you must SOILS PER
W fnnhwitheomply with such provisions or this permit shall be Jecntedrevoked. WATER SERVICE
y0
D z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhM15. SQ.fT. PAID Date Receipt p
UQ I herebywhich tor that themhis psoiti isacn (Sec.397.Con lending agency forth.performance of
4. the work for which This permit is issued(Sec.3W1.Civ.Cd
0 [-t Lender's Name TOTAL:
U Lender'"Address TOTAL:
tiW I cenify that 1 have read this application and state that the above infurmaticn is BUILDING PI '
to correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby imhonee representatives ofihis city m enter upon the SEISMIC PE
r. above-mentioned property for inspection puryims. PERMIT ISSUANCE.
(we)agree m save,indemnify and keep homeless the City of Cupertino against ELECTRI FEE t
liabilihes,judl encs and expenses which may in any way acerae against mid City ALTER OR ADD TO MECH.
in nxquiwe of the grading of this pmoril. PLIIMBI GFEE
APPLICAT IND
BRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNG(TO 10,M)CFM)
SOUR .R[G 'NATIONS. SUCH [CAI,Ftili
AIR HANDLING IINIT(OVER Io."CFM) CONS UCTION TAX
Signawry ppliumuccuntmem, Date EXHAUST HOOD(WOUC) HOUS GMITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the app]icumor future buildmgoccupwtstorc or handle hw.akmS maerml HEAT]NO ON]F(TO I(140n0 BTU)
ss defined by the Cupertino Municipal Coc e.Chapter 9.12,and dse Health and Safety
Gide,Section 255321X? HEATING UNIT(OVER IM."BTU)
l
C]Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt p
Will the ow,omunrfumrc defined necument Quordeviceswhine BOILER-COMP@IP OR IW.UUe BTU)
'it bweNuus an nm,aminanw as defined by d¢nay Arca Air Quality Management OT
BOILER-COMP(OVER IIM,eeU BTU)
E]Yes C]No
I have read the hazardous materials requirement•under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cale,Sections 25W,,533 and 25534.1 undentund,hm if the NEW RESIDENTIAL MECH. SQ.FT.
buildingJce urn curmn,ly havcamnane that i]ir my msrymsibility to notify the ac,pam
of nue requirements which must be met prior m ivmance of o Cenificam of Occupancy.
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE _� _—