30532 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. rk O r a�532/N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3
BUILDING P110JECT IDENTIFICATION
BUILDINGAl3DRESS: 'Oma �� ,a 0.r �� pv& GA.e,,I-+44o SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS 'S NAME: S P/oHONE: G
_ CONT CfOR'S NAME: LIC NO:
N/C CONTROLg
41 ARCHITEC9'/ENGI 'EN: LICNO: ADDNOT
RESS: paw ❑
FCOMACT. PHONEqsIvz BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLLDDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION ^—' ❑ ❑ ❑QTY' ELECTRIC PERMIT FEE
Zi-n7(00)o(Dlvision3-ltheBusinessandProfessiorwCode.andmylicenseis JOB DESCRIPTION
rce nrM eft_ PERMIT ISSUANCE
RESIDENTIAL
ear
{I: Licenm Clear Lic.p ❑SFDWL '
;Za Date Contractor a!< J APPLIANCES—RESIDENTIAL ❑ADDITION . ❑KI'fCHIiN REMODEL
F.7m> ARCHITECTS DECLARATION ❑PLUh10ING RE-PIPE
C 2�❑ I understand my plans shall be used as public records PANELS ❑MULTI-UNIT ❑STRUCTURAL
o UP T020g1AMP5 MODIFICATION
Licensed Professional 13 INTERIOR 5aCHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IoOOAMPS IMPROVEMENT
y�y < I hereby amrm that I am esempt from the Commctors License Low for the OVER]"AMPS ❑BATH REMOD• EPAIR DEMOLITIO
5la6U following ocomr.(Section 7(IT.5.Businesa and Professions Code:Any city,,,county SIGNS ELECTRIC ❑OTHER J C
a a.LL which requires a Pony t In construct,alter,improve,demolish.-r repair any suucmre
vy prior to its issuance,also requires the applicant for such permino file.signedatmemem SPECIAL CIRCLE S .
vWW11y that he is licensed Farman, ,the provisions of the Contractor's License Law(Chapter 9
C�0 (commencing with Section 7000)-I'Division 3 atom Business sad Professions Catheter TEMP.METE OR LE INST, OMM R IA •
d y Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
' y
Section 101 IS by any applicantfor a Permit subjects the applicant In a civil penalty of PO DEVICES
[I NEW BLDG/ADDITION ❑DEMOLITION
nor more than five hundred dollars(55oo). ❑TENANT ❑FOOD SERVICE
SpEl 1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Ne work,and the swaure is not intended or-Rercd for sale(Sec.7044.Business []OTHER
3 and Professions Cale:The Conauctors License Use does not apply an an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided drat such improvemena are nolintended or offered for NEW RESIDENTIAL ELECfR SQ
sale.If.however.the building or improvement is sold within one yearofcompletiogthe SQ.FT.FLOOR AREA $/SQ.ff.
-
owner-builder will have the holden of proving that he did not build it,improve for Pur-
pose of sale.).
❑1.as owner of the property,am exclusively contracting with liccmed comnclon m T� P p
construct the project(Sec.7(NQ Business and Professions Care q The Commmur's Li-
censeLawdoesnotapplymanownerofproper,who builds or improves thumem mal QTY, PLUMBING PERMIT
who contracts for such Projects with a convector(a)licensed pursuant to the Commences
License Law. JAN 6 RECD
❑1 nm exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
Owner Dam ALTER—DRAIN&VENT—WATER EEA) r VsYR43pfQQBJU
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIC I s,�0 0
+w. T hereby affirm under penalty ofperjury one of Ne following declarations: I
❑I have and will maintain a Certificate ofC-nunuo self-insure for WmInces Comper. DRAINS—MOOR ROOF. RE b.
sation,as provided for by Section 37M of the Labor Gale,for the perfomtance of the STORIES TYPE CONSTRUCTION
Work for which this permit is issued. Fl%TERES—PER P '
have and will maintain Winkel C-mprmarmis Insurems.as restricted by Serous
3W of the Labor Cale,for the performance ofthe work for which this permit is issued GAS—EA.SYSTE I 40 '!LETS
My Work 4Compnsularm sra a rand Policynu rare: OCC.GROUP APN
Cachet. .L�Policy No.: Y�g _ GAS-EA.SYST• V 4(EA)
CERTIFICATED XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS' US'fRL WASTE INTERCEPTOR
(This section need not Wcompirao doe permit is for one hundred dollen El la)j BUILDING DIVISION FEES
m le".) GREASE TRAP
I ecnify that in the peduranance of the walk for which Nis PLANCHECK FEE
penWorkrs*Corrigan.
SANITARY-STORM U.200 FT.
Z nocemploy any Canon in any manner so asmhmome subject 1. Wnrkere'Compcn- SEWER-,s ENERGY FEE
Applicant
Laws ws nl Caifornia:Date WATER HEATER WNENT/F,LECTR
'ZOnt GRADING FEE
NOT7C
wr NOTICE TO APPLICANT:If.Char making this a Cerins,of of Exemption,you should WATER SYS'TEII'
MREATING
me becosubject In Ne Worker's Compensation provisions of the Loh,,Code,you must - SOILS FEE
{kl Q (-MwiN comply wird such provision,or this permit xhall be deemed rtvokM. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUSH. SQ.ET. PAID
U O I hereby inn Nat there is a c-newction lending agency forte performance of Data Receiptp
1-t the work for which this permit is issued(See,31197,CIv,C.)
U Umders Name TOTAL
{✓a Lime.Address TOTAL:
Qw I rectify that I have read this application and state that the above information is BUILDING FEE
y correct.I agree to comply with all city and county ordinances and state laws tdating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
almve-mentioned property for inspection purposes, -
(We)agree to save,indemnify and keep harmless Ne City ofCLpenim against PERMIT ISSUANCE
ELECTRIC FEE
incoitiexuance ofthe standing
expenses which may in any way accrue against said City ALTER OR ADD TO MECH,
Aconsequence Nthegruntingof this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO dON M)
SOURCE REGULATIONS. MECHANICAL FEE
Signature [AFPhC i¢tm Item
AIR HANDLING U (OV told CFM) CONSTRUCTION TAX
HoaaAR
HAZARDOUS MATERIALS DISCLOSURE EXHAUSTHOOD( CT HOUSING MITIGATION FEE
W0 by tepCulant orrram Municipal
Codec hantr9.12.tore handle hazardous material BUYING UNIT(TO ,(X TU)
as defined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Code,Section 2553200? HEATINGU IT(OVE IOg000B'Gn
❑Yes KNo
VENTILATION PAN(SINGLE RESIDE PAID
Will the applicant or future Wilding accupanf use equipment or devices which Data Receipt M
emit hazardous air r-nmmin.ntx as calmed by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Distrin7 TOTAL:
❑Yes RN. BOILER—COME(OVER 100,000 BTU)
I have most Ne hazardous materials resprom tenta under Chapter 695 of the Cali AIR CONDITIONER
Form.Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the ISSUANCE DATE
building does not currently have a tenant,than it is my responsibility to notify fie occupant NEW RESIDENTIAL MECH. SQ.FT.
ofthe rcqu've is which m she tpri mixsuantt ofa Certificate of cy.
Owner or au boozed gent Dae TOTAL \/ 1
ISSUED 13Y.-
OFFICE
YOFFICE