30973 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES_ -USE BALLPOINT PEN ONLY
CITY OF CUPERTINO I - ' _Y_, .BUILDING=ELECTRICAL: PERMIT NO�
BUILDING DIVISION , ^ APPLICATION/PERMIT 'PLUMBING-MECHANICAL." +w- '3003
i:., BUILDING PROJECT IDENTIFICATION 1
BUILDING ADDRESS: _i ;y ,�� , "SANITARY NO. APPLICATIONSUBMITTAL DATE
LD�O �C�1li air% �s� �° ., . ' �,•
OWNER' - -PHONE; COJyTJj�C SHAM& ' � II N/C - CONTROL# ,
.?... ARClilr C N ER •a LIC NO - •q pig$ '
i' CONTACT':, 'XTU d�+V PH Nom_ - - BUILDING PERMIT INFO
i�No�C- e
G_ c ❑ Consultant Fees Paid by Applicant(Initial) - BLDG E,L,EEC--�CT// PLUMB ' MCH,
s • LICENSED CONTRACTORS DECLARATION"' - QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 licensed d previsions of Chapter 9(commencing
LOB DESCRIPTION t
U0000 with Section 7001 D 3 of the Business and Profession.Codc'and my license is RESIDENTIAL: 'I `
0 PERMIT ISSUANCE -
in full foree and affect �,�
G U U License Class Lic.q 6`S p� ❑SFDWL. IiLCITCHEN REMODEL„
Pzw are Cup(. J e+ � APPLIANCES-RESIDENTIAL. - 'CIADDITION 1 ❑PUMBING RE-PIPE
arq •ARCHITECT'S DECLARATION iPANELS ❑MULTI-UNIT ❑STRUCTURAL
OIp. aerstand my plans all h use . ecards - ` MODIFICATION
Z-pop UP TO 200 AMPS. TERIOR EJ CHIMNEY REPAIR
i need Professional 201-1000AMPS - - I ROVEMENT:
OWNER-BUILDER DECLARATION OVER Until TH REMODEIJItEPA1R ❑DEMOI:ITION
1 hereby affirm that 1 am exempt from the Contractor's L,cen.e Law for the
3 H fM lowing reason (Secmmm 90315,Business and Professions Code,Anycty or otary SIGNS ELECTRICAL ' _ ElOTHER
y which respites a permit m construct alter,improve,demolish p y structure -
F,u'.,Oa prior 0 It,issuance,1110mcluess the applicant format Permit to fi&a signal statement SPECIAL CIRCUIT/MISC. '
j.,•l
that he licensed pursuant to theprovisions of the Contractor License L (Chapter 9
q 0
(commenting wub Section 7111 of Divisimn3 of the Business and Proesums,Code)or TEMP.METER OR POLE INSL ' COMMERCIAL: I'-
0.p.M eC that he mot theist d the b to for the allegul exempt n A y I t nL. 0 NEW BLDG/ADDITION ❑DEMOLITION'
Section 90315 by any applicant fpermit subjects the applicant to a civil penalty of ENEWRESIDENTIAL
VICES {n •.(]TENANT FOOD SERVICE
t thanfive hundred dollars($500)
G ❑1 fthep geny, my,employeeswith wagesas their sole compensation, POOL ELECTRIC IMPROVEMENT
weld th k nd thet ct cin 1intendedo ffeedf rsale(Sec 9044,Business, ''�' OTHER `
W " and Pr fe i n Cade The Contractors L lit d not apply to an owner of OUTLETS SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through -
his own employees provided that such impruvemenu are not intended or offered for ELECTR SQFTsale lf.howevem the bold g improvement is sold within one year efcompletion the Stan['T.[if.OQ EA $/SQ.FTneo budder will have the burden of proving that he d d nut build or improve for pur 1,as ow r of the ppony am exclu'ively contract ng w th I W t t t - FEBomalonathe project(Sec 9044 B ' end Professions C d.)TT C t a L �+ .1411[(Ir(�cense Law does not apply to an owner of property who builds improves thereon,and QTY. PLUMBING PERMIT FEE REC Is1whowntracts for such projects with.emarmmro)licensedpursuant to the Cmaractdrs
License Law - PERMIT ISSUANCE -' - V 1 (�h CU�J - b/}
I am exempt under Sec ,B&PCfor thio reason EH'��NV.
Owner e Date ALTER-DRAIN&VENT-WATER(EA) b y VALUATION
'WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Q Ao
I hereby off under penalty of perjury one ofthe following declarations., r V G./
❑I have and will maintain aCertificate of Consent to self-insure for Worker's Compen DRAINS-FLOOR,ROOF,AREA,COND.
action,as provided for by Section 37M fine Labor Code,for the performance of the STORIES 'TYPE CONSTRUCf10N
war or which this pe t' issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insumnce'as regmred by Section
300 ofthe labor Cale for the performance ofthe work for which this Permit is issued GAS-EA.SYSTE14-1 INC.4OUTLETS m DEC.GROUP - -APNt
My Worked Cy�gn l Win ce ca rend Policy npgi}F - I - J.
MyWCardekite, Pnlcyolicy '��9'7 GAg-EA.SYSTEM-OVER4(EA) i
CERTIFICATE OF EXEMPTION FROM WORKERS'# _, GREASPIINDUSTRL WASTE INTERCEPTOR
,f.-COMPENSATION INSURANCE I BUILDING DIVISION FEES
(This saadmueednot becomp rated ifthe permit e hundred dollars O ilii
rut tis for on GREASE TRAP
or less) d r r. PLANCHECK FEE
Loy any that in person in any manner
the okf+wubjech this
to per mu.issued,I shall
'Citioed- SEWER-SANITARY STORM EA:200 FT.
not employ any person in any manner so a t be 'me subject t theW k rs'_Compen- ENERGY FEE '.
cation Laws of Califemia D!ute WATER HEATER WHEN VELECTR
OC Applicant - - GRADING FEE," -
G NOTICE TO APPLICANT If after make g th C n ficate f E mption,you should !WATER SYSTEMaREATING
abecome subject to the Worker's Compensation provisions of the Labor Code you must _ SOILS FEE `
{>a forthwith comply with such provision,ortnepemil shall be deemed revoked WATER SERVICE.
I 'Oil
CONSTRUCTION LENDING AGENCY '" NEW RESIDENTIAL PLMB 1 ,.�• SQ.Pf. PAID '
I huebyaffirm ere that res construction Iaradar,.,cncyfor the performance of Date •9
the work for which this permit is issued(Sec.3097,Civ.C)
(~
Ixnders his , TAL:
V Londe Add a ' - •` L: .
-y o 1 defy that I have read this application aide t that thebo format is BUILDING F E
Wc ore t 1 agme to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
7
V G building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEE
above-mentioned progeny for inspection purposes. IPERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against - ELECTRIC FEE
.. liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the granting of this permit. . PLUMBING FEE
APPLICANT UNDERSTANDS AND'WILC'COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM),
SOURCE REGULATIONS. MECHANICAL FEE
' AIR HANDLING UNIT(OVER'10,M)CFM)-. p
CONSTRUCTION TAX
gnatore of AppicarmContracmr • - Date lt� - EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
HAZARDOUS MAT ALS DISCLOSURE ,t
Will theapplicammfumre buildingcoc ,arrastman,handleh...Nous material HEATING UNIT(TO 100,000 BTU) ! -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety d -
Code,Section 25532(a)? HEATING UNIT(OVER 100,00)BTU) t6pt#
DYex ❑No .
. PAID -
VENTILATION FAN(SINGLE RESID)' W II the app)e nt r future building occupant use equipment or devices whichDateemit hazardous air conmmmntsas defined by the Buy Area Air Quality Management BOILER-COMP(3 HP OR 100,000 BTUyDistnct? - - TOTAL
❑Yes ON. I' BOILER-COME(OVER 100AX)BTU' ,
` 1 have read the haou
zards matenals rrem
equients under Chapter 6.95 of the Cali- AIR CONDITIONER gSSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.FT.
buil ' does not,currently have a tenant,Nat it is my mspnnsibility to notify Ne occupant
of e s me which must tact priors cegfe Certificate Oc Doty., g - -
�e / {
erorauthonzed agent Dote ^a 1�- ISSUE LEY.
'OF,FICE ' .