31359 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY f .i
CITY OF CUPERTINO 'BUILDING-ELECTRICAL PERMIT NO. II /� C (]
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 J J J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPWION SUB ITTAL DATF
1075 0o wel /0y 9(0
OWNERS NAME: n PHONE.� p CONTRACTOR'S NAME: / LIC NO p: p
L•- A -Ilei ^LDOS M S •�Vx,%J i" 1.181581
N/C CONTR LN
RCHITECT/ENGINEER: LIC NO: ADDRESSf/ El.0+ box 6Z $AMW V d
CONTACT: PHONE: • BUILDING PERMIT INFO
P)..,4
r 4 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
ONt1 S \IVW1.N1' YUU 61/0� ❑ ❑ .� ❑
LICENSED C RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that l um licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
�'� with Section Division 3 of the Business and Professions Cade,and my license is PERMIT ISSUANCB i.
O RESIDENTIAL'
in fu11 force and effect.
aUV License Class L—ISI. Lick yg156'/ t - ❑SFDWL [I KITCHEN REMODEL'
F �W Data Comrector APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RF PIPE
p`�,pr�nj . ARCHITECTS DECLAR PANELS ,0MULTI-UNIT ❑STRUCTURAL
z O on,zj I understand my plans shall be uwd us puMi cents MODIFICATION
Oz—O - UPT02MAMP5 ❑INTERIOR [I CHIMNEY REPAIR
g4w Licensed Professumul 201-1000AMPS IMPROVEMENT -
CCC777C •aj 1 OWNER-BUILDER DECLARATION Contr ON OVER RXEIAMPS BATH REMODEL/ EP IR (]DEMO ION
yy I hereby affirm that I am exempt from the C.no-ettor'.c License Lew for one !I VT
Dd 3 d FU following reason.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER tl 5 (( ql4 /iKIL �p_
u GN which requires a permit to constrict,alley,improve,demolish,or repair any structure
¢ rt it,Mutant,also requires the
rn.] trio q applicant for Contractors
ow L (Cha mem SPECIALCIRCUfT/MISC..' ,a
y boommthat he licensed pectionursuant t the previsions Division
3 of the
GmwnessaL Law(Chaprer9 COMMERCIAL
W�GO (comm nmg wran Section]p(MI) fD'v sion3 of the Business and Professions Code)or TEMP.METER OR POLE INST. -
Il q y that he is exempt thamficur and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION'
i� tint.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICES ..
4TENANT ❑FOODSERVICE
qqnot more Nan five hundred dollars($500).
C ❑ I,as owner of Ne prapeoy,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the strucmra is not intended craffered forsale(Sec.7044,Business ❑OTHER
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'3 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 ELECTR SQ UT.
sale.If.however the brildingerimprove.ent is sold wianin one yeorofcompletionpar-
the SQ.FT.FLOORAREA $6Q,ET.
owner bmifer will have the burden f proving that he did nod timid or improve fur
pmeofsale) - b"A' ® •...
i]I•as owner of the Employ, exclusively contracting with licensed commctera to TOTAL: '®
conswct the project(Sec]044,Business and Professions Coda:)Thn Contmcmr s Li-
cense Law dcei not.pply m an owner of property who builds or improves Ihercon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant mane Comrecmr's
License i Law. - PERMIT ISSUANCE
❑
lamLaw. o undSec. ,B&PC[.r his reason Il �7
ALTER-DRAIN&VENT-WATER(EA)
Owner WORKER'S COMPENSATION DECLARATION
VALUATION
WORKER
BACK FLOW PROTECT DEVICE •I
1 hereby afOrmunder penally of perjury one of ane following declarations:
❑Ihave and will maintains Certificateof Consent to self-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND..
$.tion,as provided for by Section 37M of the Labor Cade,for the performance of Ne STORIES _ TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,askindredby Section
37M of can,Labor Cade,for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP - APN
My Worker's tape sari. Imurmiecarrierand Policypulm4b�ore: 7 GAS-EA.SYSTEM-OVER 4(EA)
Cartier:�p�Italy No.:N ] S(Py�
"CERTIF ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF9NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need not he completed ifthe permit is porous,hundred dollars($100) GREASE TRAP
or less) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any..auto ones m beasme subject to the Workers'ComFlen- ENERGY PEE
OZ satin.Laws of California.Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after nuking his Cambrme of Exemption,you should WATER SYSTEM/TREATING
become subject w the Worker's Cbmpensation prode,visions of the Labor Cayou must - SOILS ME
RI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE ,
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V I hereby affirm that hem is a construction lending agency for the perfirmanceof Date Receipt If
{L f~'( Ne work for which anis permit is issued(Sec 301 Civ.C.) -
U Lender's Name TOTAL:
Lenders Address T
d 7 I cattily that I have read this application and state NFE
Fiat the above information is BUILDING E
h
correct.I agree to comply with all city and aunty ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
(.)a building construction,and hereby auanonm representatives ofthiscity toenterupon the SEISMIC FEE
above-mentioned Property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify end 4ecp harmless the City of Cupertino against ELECTRU ME.
liabilities,judgments,costs and expenses which may in any way.cane against said City ALTER OR ADD TO MECH.
in consequence of me granting of this pemrit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0041 CFM)�] MECHANICAL FEE _
Op p _ 'a/ZJ/, AIR HANDLING UNIT(OVER IO,OgI CPM)
1ZIti9r1 lX'Me`—� 'I 0 CONSTRUCTION TAX
t educe of pplicant/Contracmr s I net, EXHAUST HGOD(W+/DUCT) '
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future holding occupant store or handle hazardous material HEATING UNIT(TO 100.1)(10 BTU)
as dented by me Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'1 HEATING UNIT(OVER 100,000 BTU)
r7 Yes Onto'"; VENTILATION FAN(SINGLE BUSED) PAID „
Will the applicant m future building occupant use equipment or devices which - Date Receiptif
emit hazallous air contaminants as defined b the Ba Area Ar BOILER-COMP 3HPI OR 100.000 BTU) ,
Dlstnc@ y y Quality Management (
TOT L:
'ElYes No BOILER-COMP(OVER 100,000BT0)
I have read the hazardous materials requirementsP under Chapter 6.95 of me Coli. AIR CONDITIONER
fomi.Health&Safety Code.Sections 25505,25533 and 25534.I ondetsmnd ihat if the ISSUANCE TNEW RESIDENTIAL MECH. SQ.FT. // �-1V•n//)
building does not currently haveatenant,the it is my responsibility to notify the nee. t
of the requirements which must be met prior to issuance of a Certificate of Occupancy. +
Owner or authorized agent - Date TOTAL: ISSUED Y.
OFFICE