30827 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O 8 Z7
1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT(DENT IFICKI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
07j21 -1088 oL RoA1) 1 Lav IAln (pvilowe, D) P—Apek'I
OWNER'S NAME, PHONE: I CONTRACTOR, NA IE: LIC NO
CUN- Wa ilLLL44L Mo(t&7" 5-323 591635 NIC COONNROTROL#
ARC TGC /ENGINEER: LIC NO: A I RESS: ❑ �Z�1
EW DES( ,( Gr u cE3 2�oI Gn c - DQ
CO TACO ,^PHONE: BUILDING PERMIT INFO
TRIG C- Allot, -8� -5777 ❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PCE
O Z 1 bemhy:mirtn that I..Ranted.oder prnm,ntna of clramer 9(commencing JOB DESCRIPTION
WO, with Secrien]Oo(B of DivisinnJofthe Business and Pmfe,.simn.,.CWe,anJ mylicensc i, PERMITISSUANCE RESIDENTIAL:
F I= in full force and effect. 3 ❑SFDWL ❑KITCHEN REMODEL
�U� Liccnse Class Lit.p APPLIANCES-RESIDENTIAL ❑ADUI'TION ❑PLUMBING R&PIPE
�i 6 0. are
Comrmmr >(e�
F.Dw ARCHITECT'S DF.CLAR ON PANELS ❑MULTI-UNIT []STRUCTURAL
ZprnZ I understand my plans shall be used as public Tecoub MODIFICATION
UP TO 200 AMPS
O Z G ❑INTERIOR ❑CHIMNEY REPAIR
F+�i Ire] Gamed Pro[ssionol III(-IIHN)AMPS IMPROVEMENT
ad OWNER-BUILDER DECLARATION
a C C 6 1 hereby affirm that I am exempt from the Contmeor's License Law for the O- R 11X10 AMPS [IBATH REMODEIJREPAIR [IDEMOLITION
2 U following remmn.(Section 7031.5.Business and Professions Gsdc Any city or comity SIGNS ELECTRICAL []OTHER
3 LL whim requires a Permit to com uct,alter,improve,demolish,or repair any souaam
prior to its is.,.aance,ah,,,c r,e,,Pcapplicant forsach pe.it o fileasignedstmement SPECIAL-CIRCUi'DMISC.
fly that he is licensed Panama to the pnovikims,mtlh,Comrvnors License I,.(Chapter 9
11+116 C) (commencingwith Section'!0000of Divisi^n 3ofthe Business and Professions Coi TEMP,METER OR POLE INST. COMMERCIAL'
44 ay that he is exempt increferin and Ibe bods for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^LL Section 7031.5 by any applicant for a penal subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
not mom than five hundred dollars(15001.
^Zi+ 1 PROVEhfENT
f=0a �hasowner work,the pmpcmy,unnyot intienoplityres
ndedi ithwagc,as lhciSt70H,Breaion, SWIMMING POOL ELECTRIC A��,J�Ip rQ�lyj;
F., will dothe...a,and the he Cones.s om', riam or Law
de(s rsmk(SecAOan ovaraess TI11:H
and Professions Cade:The Convnemrs License Law Jne,.mol apply In an owner of OIITLEfS-SW ITCHBS-FlXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ
,�_N/ �E,
sale.if,howcvca thebuilding in linpmvemenli,,,,Id within enc year ofenmpleime.the S EA $/SQ.FT.
mer-builder will have the burden of proving that he did mot build or improve for pur- �J
qac of n or net
1,as owner of the propcny.um exclusively contractinges with ,licensed heL n—t-a cs m TOTAL: JAN O 9 REM eve La the project(Sec.]DW.Business and oy wh i hri C-,the Contractors Li- „ �i/�/ RLl!l.{
«n.e Law Jnes^ns,apply m on owner us,pmpcny who builds or improves thereon,and Ql'Y. PLUMBING PERMIT FEE
whocontreets forsuch projects vith.,urnmenatO licensed partloNe Contactors 011Y Ur CUNEHTIN0
License Low. PERMIT ISSUANCE
C]1 am exempt ander Sec. .B&to C for 11n,mitwo
Owner Dna ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT'.DEVICE
00 1 hherebyvffirm under
er penalty of perjury are.(,he following dcdaations: 5/0 a�
I have and will maintain a Certificate of Consent to self-amore for Worker'.,.Couper- DRAINS-FLOOR ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
tion,as provided for by Section 3700 of me Labor Cade,for the performunc,of the
k rwhichthis permnisisaed, FIXTURES-PER TRAP O./r ��
and will maintain Worker's Com,niontion Insurance,as required by Section v /YC
Ipof the Loden Core,for the performance of the work for which this permit is issued. GAS-FA.SYSTEM-1 INCAOUTLETS OCC GROUP APN
My Worker'sCm,(ne/maionln.a:rance extric,;md Pnllcy nyyryry h�yylIa�
Carrier�a.tt>�FHSLt Policy N., N 3yTt GAS-FA.SYS'1'GM-OVERg1EA) Q
CERTIFICATE OF EXEMPTION FROM WORKEkS' GREgSPJINDIJSTRL WASTE INTERCEPTOR a
COMI'ENSA'1'ION INSURANCE 11IRLDJAGDIVISION FEES
(This section need units,completed ifthe permit is foronc hundred dollars(5110) GREASETRAP
it,lo,".) PLANCHEC
Iccnify that in the perfonnen<c of lls work for which lhiz penal is issual,lshull SEWER-SANITARY-S'IORM EA.200 F1'.
not employ any Person in any manner m as to become subject olhe Wnrkers'Compen- ENERGY E
Z sutimn haws of Coolifomiti.Date WATER I WATER WNISNT/ELECTR
O APPliciml GRAIJA4
r'- NOTICE TO APPLICANT:If.afar making this Certificate or Exemption,you should WATER SYSTEM TRGTING
I•' N become subject to the Workers Compmn,.ation pmvioimnvor the Labor Coale,you must gO1L5 F
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F, PA[
V 0 l hereby affirm that there is a commotion lending agency for the performance of D to, Receipt#
F^ the work for which this permit is i...ed(Sec.36)].Civ.CJ
0 U Lenders Name If TOTAL:
Lender's Address TOTAL: 11OUSING
UILDING(
G 1 comity that 1 have read this applicatiam and state that the above information is
rft h coram,1 agate m comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
fJZ building construction,and hereby naanrire,ne...mivesmf this city mcmer upon thc EISMIC FEF.
above-mentioned proprny for improtor pu ses. PERMIT ISSUANCE
(We)agrca to r, ,indcmnify vndk phandcss the City of Cupcnino against LF,CI'RIC FCLrIiabilifies,judgmen¢;cowls and experss w cit may nanny wayaccrucsgatinsaid City ALTER OR ADDTO MECH. LUMBING FEtiin nICAN ttofD gamingStispeAPPLICANTULATIONANUS AND\ LL COMPLY WITH DLI.NON-POINT AIR EIANDLIN6 UNIT(TO II1.UIpChM) ECHANICAL.FEE
SOURCIi REGULATIONS.
-Tp AIR HANDLING UNIT(0VER HLUX)CFM) ONSTRUC'HON TAX
Signature ofApplica^UCnn rate EXHAUST HOOD(WNUCT) MITIGATION Eh
HA Z DOUS M .RIALS DISCLOSURE
Willtheapplicwt or forum build g«apmistnr,nr hanJle hezaNnus material HEATINGUNI'I'(TO 100,(HHIBTU)
ax defined by the Cupertino Municiryl e,Chapter 9.12,and the Health and Safety
Cade,Section 25532(.)'1 ^� HEATING UNIT(OVER 10(t.000 BTU)
p Yes �V VENTILATION FAN(SINGLE RE.SID) PAID
Will thea applicant or future building occupant use equipment or devices which Date R.xipl#
pP b the
Area
BOILER-COMP(3HP OR 100.0011 BTU)
mit hmardous sir contaminants as defined by the Bay Arta A"v Quality Mmwgemem TOTAL:
Di,.niel'l / BOILER-COMP(OVER 100,000 B U)
E3 Yes V".
I have read theKaram! serials requirements under Chapter 6.95 or me Cali- AIR CONDITIONER ISSUANCE DATE
fornix Health&Safety Code,Sec ns 25505.25533 and 25530.1 valersaml that if the NEW RESIDENTIAL.MECH. SQ.FT.
huilda,dcesnotemmcntly have t sent,their isnry rospmnsihil'ay to notify thener,cunt
ofthe regWer.^ts, imast bnTn Wrcc ofv Cemireme of Occupancy.
Owner nr out i Date ITOTAL: I ISSUED BY:
OFFICE