30537 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'if
1'' �y N�IIILDINO PROJN:<;'I'IDF.NTIpFI^Gk'DON
BUILDINGADDRESS: SW COILHE.0. OF' 4 51^`� AI.117 OI-ES aW SANITARY NO. APPLICATION SUBMTUEAL DATF
\4l\LU0 PA'K+ stb a cs COqM r-uA m o \JILL, e U
OWNER'S NAME: PHONE: 16-344 CONTRACTOR'S NAME: LIC NO:
CU 0 S$ i 1 C XhWC. SIC CONI R/O�Lp
ARCHITECT INGI EER: I.IC NO:RCE 0b,%C ADDRESS: ❑ 61 �
4 '210%1 COM W LI /Vl
C NTACII vnoNE: CJk-m15. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - _ B,,L--D,,G// ELECT ECH
C C- 10
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT M
I hereby affirm mat l am Erten.a ander Provisions of chu,sery(co m rung JOB DESCRIPTION
WOO with Section 700dof Division 3 ofthe Business and Pmfesiuns Cale,and my firm..,is RESIDENTIAL:
FWD nfull forecind effect. PERMIT ISSUANCE,
QU ❑A DWL ❑KITCHPLUMBING
REMODEL
�UV LocDate Class Lich APPLIANCES-RIiSIDEN'IAI. El ADDITION ❑PLUMBING R61'll'li
Gc. Date—Cnnimnnr
H y ARCHI'FF.CTS DECLARATION ,ANEIS ❑MULTI-UNIT ❑STRUCTURAL
Z O n ZI understand my plans.shall be used as public records MODIFICATION
CZ. 39 UPTO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
Fa 4tiW Licensed l'mm,moal Ir 201-11Np AMPS IMPROVEMENT
Cw�.4 . OWNER-BUILDER DECLARATION (OVER ItN)1AMl'S .►� LJ(OVER REMODI?URI?PAIR El DEMOLITION
'a 1 hcmby Aft That I am caempt front the Convuchas License Lvw for the
d a V
following Section 701.5.Business and Professions Code:An T t O'I'HIiR
xx g reason.( y city or recon y SIGNS ELECTRICAL
W 3 C v~i which requires n e.also re comswn,aper,improve.for such
demolish,of repair any saacnre
�� prior to its issuance.also requires the applicant for tach pcmtiuo file asigneJ statement SPECIAL CIRCUIT/MISC.
�y that he is licensed pursuant a+the provisions of The Commcmr's License Law(Chupter9
14C (commencing with Section 7lXID)d Division 3ol'the Business and Professions Gde)or 'TEMP.METER OR POLE INS'I
OL '. COMMRRGIAL_
a e LLw
Ill.,he is esonpt thercfmnt d the basis for the alleged exemption.Any vinlatimn of [INEW BLDG/ADDITION ❑DEMOLITION
_ Station 9031.5 by any applicant for a permit subjects me applicant m a civil Penalty of POWER DEVICES OTENANT ❑FOODSERVICE
F=OW not mart than five hundred dollars D0500). IMPROVEMENT W4
❑ I.as owners The progeny,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC W�� IELSTALL thl oFL
will domework,andrvm
theaem Nano intended or offered formlc(Sec.TB44,nosiness ask tysrTHER T
Lal m and Profession.Code:'The Comtmvtur',License Law does not apply to an nw^ar of (I6 UTLETS-SW I'ICI .S-FIXTURES y 44— V(N(IC RaQ0, AND SFOR6
property who builds or Improves thereon,and who does.cuch work himself or through
his own employees,provided that such imProvemems are not intended or offered for NEW RESIDF. L ELECTR SQ Fr.
aT
safe.If,however.the buildingnr improvement issold withinorm oarofcompictian.she FLOORARF.A VSQ.FT.
er-builder will have the human of proving mat he did not build or improve for par- AA 4 I 0
pose fr sale.). F� p
I,as owner of The property,am exclusively contracting with licensed mntmrtors to TOTAL: {�
construct Rte project(Sec 70,16,Business and Professions Coda)The Contractor'.,Li- V�'w/
Li-
cerise Law
msaes not apply m an owner of property who builds or improves themon.and QTY. PLUM ERM FEE •v � D ,
who comcls for such Projects with a contmnnds)licensed pursuant to the Contmemea ff VV
License Law. PERMIT ISSUANCE
❑I.m attempt under Sec. .U&P C for mix racoon
ALTER-DRAIN&VEND-WR AI
Owner Dam
WORKERS COMPEIJSA'r10N DECLARATION HACK FLOW PROTECT.DCVICCfp
Ihereby
and%it] under cemalDof pefCoreery neo the self-mare
� CI !'
❑Ihave andwill maintainaCertificate nfCe Labor Cash,for the WofkeQce of the
O TRAINS-FLUOR.ROOEAREA.COND. STORIES YPI1CONSTRUCYION
work...provided for by Section 3700 of The Labor Cale,for the cedecrmunee of the
work have
and will parnil is",sued. Iy XTURF,S-1'CH TRAP
Cl 1 have and will maintain Workers ante Compensation Inmos which
ac his cr by SectionrB
JTW of the lnlmr Coda for The performance of the work for which this permit is issued Q +AS-EA.SYSTCM-1 INC.6OUTLETS OCC.GROUP APN
Aly WmU4e,Com�E+eenmtiecn In.antis and Policy numbe art:',q
Carrier:CsO 1Db! F�4Lfi PolicYNo.: NWL�$L$- OAS-EA.SYSTEM-OVER 6(RA)
CERTIFICATEOF EXCMPTION FROM GREASEcTsPUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILD i];VISION FEES
(Psis section nendnd he conatnal lfthe .it is boom,hundred doll...(5100) GRCASETRAP
or lea) PLANCHECK FEE '
Loy any that in the any
nce rof as tohe
for whichthis the it Workersuedlshallch- SEWER-SANITARY-STORM EA.200 FT. b
not employ any person In anY manner so avec hecnme subject m the Worker"Cnmgcn- ENERGY FEC
C) z sation Laws of California.Data WATER HEATER WNEN'I TLECTR GRADING FEE
z Applicant
NOTICE 10 APPLICANT:If,after making this Campeau,of Exemption,you should WATER SYS'1'IzmnHEATING SOILS Bili
F� ? become sabject to the Workers Compertmtlon provisions of the labor CMe,you most
foldwim comply with such provisions or this Permit shall be deemed revoked eATER SERVICE
Q
Uz CONS1'RUCGONLENDING AGENCY NIiWRF:SIUENTIALPLMB. SQ. T. PAID Date Itoceip N
I hereby affirm that there is o construction lending agency for the perfor;n;mec of
U O the wok for which this cefail is ls.ad(Site 3047.Civ.C.)
C) Iendbes Name OTAI.'
Lenders Address TOTAL:
a 1 eci ify that P have read this application and state that the above information is BUILDING FEE i-
;F.t fn correct.1 agree n+comply with a city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z builAlug con.ammien.unJ hcrcb amhai,a nPrescntative,nllhi.,city to ether upon the SEISMIC PF.E
abecv>mentinned progeny fnr i; Pecom puym.as. 1 PERMIT ISSUANCE ELECTRIC FEE
(We) mem e.in nify and keep har tlea the Cityof Cupertino against
cov
liabilities,judgments,costs and apensc%which may in any way accrue against mid City ALTER OR ADD TO MECH.
in asequence of me gaming (this permit. PLUMB ING FE
APPLICANT UNITE STAN S ANI)WILT.COMPLY WI'IfI ALL NON-POINT .AIR HANDLING ON IT Iii)N CFM)
SOURCE REGULATE) A MECHANICAL FEE
APR HANDLING UNIT(OVER 10,(Np CFM) , CONSTRUCTION TA
Sigramm o(Appli at 1 )ate YJ EXHAUST HOOD(W/DUC) HOUSING MITIGATIONFE:E
HILA US MATERIALS DISCLOSURE /�
Will the applicant info re baihlingnccupantstomorhandleharrd+usm.terivl 6 EATING 11Nl'C TTO IW,IXX)li'I'U)
ss defined by The Chardon'
M nicipvl Cale,Chapter 9.12.and the Headband Safety
Code.Section 25532(a)'! „W('N/ HEATING UNIT(OVER Pfli BTU)
C3 Yes Q }'f±NT'ILATION FAN(SINGLE RCSID) PAID Date RttdpT
WIII the apPlia of of future building by doe Bay
Area
Air Qu or Marta which
emit hururdnu.c air nmtnmiwnla as del fined by the day Arta Air Quality Management BOILER-EOMI'(JHP OR IINI,(NXI BTU) T 'AI.
District? BOILER-COMP(OVER 00.0A)BTU)
Yes
1 have Trail the bazar taus...Hot,reymmannit,made,Chapter 695 of the Cali- oliffR CONDITIONER ISSUANCE DATE
famia Health&Safety C, .Sections 25505,25533 and 25534.d understand that if the NCW RESIDENTIAL MECH. SQ.PT
buddingdoma not currently encore .....ra"ntididny et notify The occupant
more require, net prinnn iswance nfa Ce 7�y'alrlo 9p�tcy
Oxncr or authuriz ag Pan, ISSUEDTOTAL: ISSUED BY':
OFFICE