30965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 309Illy5
BUILDING PROJECT IDENTIFICATION
BUILUING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I0710 ! ( wo
OWNER'S NAME: PHONE CONTg01'S NAME: LIC NO: _
n I Pio f /✓ _�G,.. NIC CONTROLp
tCH ECT/ENGINEER: LIC NO: ADDRESS: �'lF�/ O ❑
$-22 M E11vJ'12.IJ
CONTACT: PHONE: HUILIJING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
G Z 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
N Section]OOI)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
F�� nl full ince Doti effete_y j '3O S I o I PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�UZU License Crus l. Contractor
S N APPLIANCES-RPSIUIiNTIAL ❑ADDITION ❑PLUMBING RF,PIPIT
y G i Date Comm• a 1-f+�+�
ARCHITECTS DECLARATION []MULTI-UNIT' [I STRUCTURAL
E)on N PANELS
Z p m Z I understand my plans shall Be used us public records MODIFICATION
oz`3 0 UY 9Y)200 AMPS
F4tul Licensed Professional Ll INTERIOR [I CHIMNEY REPAIR
201-IfXXIAMPS BATHR MODEL
� Oat I am esculd R DECLARATION OVER["AMPS Ll BATH REMODEIJREPAIR [I DEMOLITION
Q I hereby affirm that 11. esanpt from the Gonl;slCo Liceme Low for the
k O a U following rcasen.(Section]031.5,Business mJ 1'mfeseions Cade:Any city or county SIGNS ELECTRICAL []OTHER
W 3lL which requires a Penn,to construct,due,improve,demolish,or repair any someone
F-LL0¢ prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Fly thin he is licensed pursuant the provisions of the Contrdcm's License Law(Chapter 9
�CCO� (commencing with Section 7000) Division 3 of the Businss eand Prons fessioCode)or TEMP.METER OR PULE INST. COMMERCIAL:
IMI
61 ay the he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
to Section 7031.5 by any applicant for a pemtit subjects the applicant a civil penalty of POWER DEVICES
a' t more than five hundred dollars(55018. ❑TENANT [I FOOD SERVICE
Z} IMPROVEMENT
Q Lon owner of the pmpeny,or my employees wllh wages us their sale compcns:ninn, SWIMMINGPOOLELF:C'1'
O will Ao l6c work,unJ lM1e smucwrc is nal inumAW nreBbred for sale(Sec.9144.11usinco, ❑OTHER
3 sad Profesninns Code:The Cournour'e License Law does nor apply to an owner of OUTLETS-SWI"T 1 F TURES l�
pm,Oy who builds m improves thereon,and wbo does otch work himself tar Ihnegh
his own employees,provided that such improvements are not intended or offered fur NEW RESIDENTIAL .LECTR SQ FT.
sale.If.however.the building or improvement is sold within one yearofcompletion.the SQ.FT.FLOOR ARE® &SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for par- P PNS
❑f'l
1
1,as owner of the propcny,em exclusively contracting with licensed contractors to
nmtme,the project(Sec.704y Business and Profnsians Cade,The Cemmeor',Li-
cense B 2 6 BEC'
use Law does not apply to an owner of properly who builds or improves thereon, QTy. PLUMBING PERK Faw TVFEE
who contracts for such pmjects with u corrosions)licensed pursuant the Contractor's
[Accuse Lnw. PERMIT ISSUANCE
❑ l mm exempt under See. .B&P C for this reason Ur Wr[HIIN
ALTER-DRAIN&VENT'-WATER(EA) VALUATION
Owner DIO
WORKER'S COMPENSATION peri TION DECLARATIBN BACK PLOW YkOI'I3C1'.DEVICE I /Y
I hand will
under penally of perjury one of the following declarations:m: / sOC1
Son,as and will fairy Senion 37W Ccroficale ofComsent
LabrCcdlinsur the performance
DRAINS-ILWR.RWF.AkFA.COND. STORIES TYPE CONS'I'Rl1Cl'ION
;tion,as provided far ro Ssition d. of the Labor Code,for the perfomtanm mf the
yk for which this permit is issued. FIXTURES-PER TRAP
)"j I have and will maintain Worker's Compensation work
which
az required by Section
J9(Xl of the taboo Code.for the Mrfomance of doe work for which this permit is issued. GAS-FA.SYSTEM-]INC.4OUTLETS OCC.GROUP APN
My Workei Compensmiopp In u carrier uad Policy numbe[ar{
Carrier lis /IC (eYllA(� Policy No.:uJdfe daal3-. GAS-EA.SYSTEM"OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE HUILDING DIVISION RIES
(Enksectlon neclmolhcmmplmcd if lbe pemnit isfornnchImalmddollarr SIM) GREASF.'FRAP
or less) PLANCHECK LEI?
leenilythat m ductieformancofthework li+rwhichthispennit in iswed.I.hall SEWER-SANITARY-STORM EA.200 FT.
not employ any pante in any manner m av Ie bettor c su(yc the Workers'Compete ENERGY IEE
OZ smion Lax.of Califon.Dalt WATER HEATER WNFNT/ELECTR
Applicant I L GRADING FEE
'znJ y NOTICETO APPLI NT lf.a ar teak,g this CemficIe of Exemption,you dtnuld WATER SYSlE2,1/IREATING
F ; became subject to the Workers Compeninion previsions of the labor Code.Toa mast SOILS FEE
forlhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
D z Ihereby affirm that them is a construction lending agency for the performance of Dec Receiptp
W f~- the work for which This pennil is icuuJ(Sec.31rJ].Civ.CJ
leader',Nome TOTAL:
WI-andcr's AJNcsa TOTAU
0.1 1 vemly That I have read his upplicunon and state but the above iaft unnnldm is BUILDING FEE
cooat.l agree m comply wAh all city and county Ordinances andstme laws mining ou QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby mahorivemprentatives ofthis city In enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agru m save,indemnify and keep harmless Ne Cily of C.,rumn.gains
liabilities,judgmem,costs and expenses which may in any way same againsuaid CityALTER OR AUDTO MECIL
in nstnence of the granting of this Permit. PLUMBING FEE
UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(100 CFM) MECHANICAL FEE
SOURCE RE ULAT1/�\VS.
U ]�A� AIR HANDLING UNIT(UVEB 10.003 CFM) CONSTRUCTION TAX
Signature nlA plicunJCnnmvcnu Data-I EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS NINUAGAIS DISCLOSURE
Will the applicant or future building occupant atom or handle hainam.snmtcrial HEATING UNIT(D)I M.SX)BTU)
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Hcallh and Safely
Code.Section 25532mo? HEATING UNIT(OVER 11XI,(XX)BTU)
❑Yes 0116 VENTILATION PAN(SINGLE RESID) PAID Dam Receipt#
Will Ne applicant or furore building occupant use equipment or devices which
.mit loomdws air crummorun¢as defined by the Bay Area Air Quality Management BOILER-C(IMY(JHPUR t00.000BTU) TOTAL:
Oi'met? / BOILER-COME(OVER 100,000 BTU)
❑Yes HN
I have read the hamNom notional,requirements ander,Chapter 6.95 of the Cali.. AIR CONDITION ER ISSUANCE,DATE
fomia Health&Safety Code,Sections 255115,25533 and 25534.1 undersand that it the NEW RESIUEN'HAI,MECH. SQ.FlT�
huili ing Nes not currently have a meant.that 11 is my tenpomibibly Ia notily the occupant
Oldie mlNrememts ice he titp�pr mlaaamhhaera Cem;fumy Offxaipancy.
h \[,Ann-C.11. Z-13,�I-)
Owner or authorised agent Umc TOTAL: ISSUED BY:
OFFICE