30724 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^ 0 /� //II
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL <
BUILDING PROJECI'IDENTIFICATION 3 L
ILDING ADDRESS: SANITARY NO. APPLIC NNIBMITTAL DA
0 04"Co1_0jkjHtL&1�.j H(�L5 LNl VVER'S NAMMEpE:YySy,�p/J,, E:��_(� C R CTDWSN/TJrJrQ�a+ ) rI t�� CONTROLI
RCHITECT/ENGINEER: ; DRESS: T ❑7012�S pcVCc S., r
CONTACT E: BUILDING PERMIT INFO
` ���Z ❑ Consultant Fem Paid by AppliCant(Initial) BLDG ELECT PLUMB MECH
❑ ❑LICENSED CONN QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat I am licensed under pmvisiom of Chapter 9(commencing IDB DESCRIPTION
w0Z wish Sectum 7")of Division 3 ofthe Business and Prefessiom Cale,and my license is
FILO in full force and IT PERMIT ISSUANCE RESIDENTIAL
NTIAL
.t U t Liccnu Class _Li,.p - ❑SFD WL ❑KITCHEN REMODEL
F W Data Contract., APPLIANCES ❑AUDITION UMBING RE-PIPE
[F-�gyp ARCHI � UI? ARATIffit PANELS ❑MULTI-UNIT RUCTURAL
ZO I nJ hon nypsn s o 'c
02 ❑ UP T02W AMPS MODIFICATION
h ❑INTERIOR 0CHIMNEY REPAIR
gam� tt� L' csst 1 201-100TIAMPS IMPROVEMENT
CY �i Oat I am exempt T o DECLARATION OVER 11100 AMPS
yK I hereby offiw that I am exempt from the Coavecmo License Law far the ❑BATH REMODEUREPAIR DEMOLITION
�C 4 U following rcaua(Section]onsum Business and vet.de deli Cale:Any city or county ❑OTHER
SIGNS ELECTRICAL
F�O which requires a pcnnit m consumer,cher,improve,demolish,or repair any structure -
qq m prior to its issuance,also requires the applicant for such pewito file a.signed statement SPECIAL CIRCUITIMISC.
that he is licensed pimmonuo she provisions of the Conuacmr's License Law(Chapter 9
6W�'❑0 (commencing with soodon7")of Division 3nf the Business and Professions Code)or Al•TEMP.MFTF.R OR POLE INST. COMMERCIAL:.
6 c n Nat he is exempt theufom and the huis for Ne alleged exemption.Any violation of El NEW ERCIADDITION ❑DEMOLITION^m Section]031.5 by any applicant for a pewit subjects the applicants)a civil penalty of POWER DEVICES
F Z} not more than five hundred dollars(1510). ❑TENANT ❑FOOD SERVICE
G ❑h as owner of the Prepeny,or my employees with wages its their sole compcnwtion, SWIMMING POLL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended oroffeml foraale(Sec.](W4,Business _ []OTHER
and Pofessions Cade:The Convector's License Law does not apply le an owner of OUTLETS-SWI I'CHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employers,p voided That such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'.
sale.IL however,the building or improvement is sold withinane ycarof completion,me SQ.PT.FLOOR AREA 1/SQ.PL
owner-builder will have the burden of proving that he did not build or improve for put.
pose of saleJ.
❑1.as owner of the property,am exclusively contracting with licensed convectors to TOTAL: A
cunstma the project(Sce.]044,Business and Professions CWeJ The Convector's Li- Ise '
c se Law does not apply a,an owner of property who builds or I up...a,thelcno,and QTY, PLUMBING PERMIT DF
who contracts for such Projects with a contmetm(s)licensed u
pursuano the Convenors O
AEE c
License Law.
C] m PERMIT ISSUANCE /x/�
laexempt underSec. ,B@PCfor this rtaun 1. O
Owner Dole _ ALTER-DRAIN&VENT-WATER(IA)
WORKER'S COMPENSATION DECLARATION AL
of BACK FLOW PROTECT.DEVICE a,
Thereby offw under penaltyta in urone ofThe following declarations:
❑Ihave andwillfil eden37M of he Cluator ster
orae,surchn Workersa,ofCompon.
he DRAINS-FLOOR,ROOF,AREA,GOND.
worn,as hick this
for by Section 3]00 of the Lahor Code,for she performance of the STORIES TYPE CONSTRUCTION
work barhave
which Nis lawn is issued. FUtTURFS-PER TRAP
1 have and will maintain Workers Compensation Insurance,which
h resuiredax Perm by Section
37W ofshelabm CWafm the perfomance of thework for which Nis pewit is issued. GAS-FA.SYSTEM.1 INC.40I1TLLT5
My Wm erS gpggytion,)ara�nnciVvrier and Polic
Carrier: /TYC f�l/NJ Policy No.: GAS-EA.SYSTEM-OVER OCQ GROUP ppN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRI,WASTE INTERCEPTOR
or xsJ
(This section ncrJut the completed if the pcmtit is for onGREASE TRAP
e hundred dolhrs IS BUILDING DIVISION FEES
Ie
I certify dela the peAowance of ths work fim.mch this permit is issued,I shall PLANCHECK FEE
nm i
employ any penin in my manner o as o subject become subjeco the Workers' SEWER-SANITARY-STEA
ORM .2WFL-
Q z Anon laws of California.Date ENERGY FEE
WATER HEATER WNENTMLECTR
Z Applicant GRADING FEE
ay NOTICE bj APPLICANT:If,after making this Ci,i..s of of 8 ima, od you should WATER SYSTEMaREATING
roomwihecamnwompyct to the WnrhrsCamps or its provisions of themedrCode,you mu.et SOILS I+EF
W foMwish comply with such provisions or Nis permit shell be deemed revoked. WATER SERVICE
0. C
p z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL POdlL SQ.FT. PAID
UQ lhmbyeffiw Natthem isaconswctimnlendingagencyforthcperfotmanccmf Date Receipts
[4 she work for which this pewit is issued(Sec.uNG,Co.C.)
0 Lenders Name
U
Lemll Address _ 'IUTALi
W 1 avidly the,1 have mad this application and shote that Ne above information is L. BUILDING FEE.
Z) correct l agree to comply wish all city and county ordinaneas'and state laws Mind. 1. QTy, MECHANICAL PERMIT FEE
U z Msilding conswction.and hcmby nushodze rtprtunhotives of this citymcnmr upon the SEISMICFEE
above-mantimrcd property for inspection Puryoset PERMIT ISSUANCE
(We)some to save,indcmrdfy and kap bowlers the City of Cupertino against ELECTRIC FEE
liabilitics,judgmenu.costs and expenses which may in any way wcmc against saidCity ALTER OR ADD TO MECH.
consequence of the gaming of 's permit. PLUMBING FEE
PPLICANT.UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT qIR HANDLING UNIT(TO I(I,IXXt CPM)
)1. CE EGULATIONS. MECHANICAL FEE
1Z 0s) AIR HANDLING UNIT(OVER 10,000 CME CONSTRUCTIONTAX
Sig tum odAppli nVConwctor ate EXHAUSTHOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will she applicant of future building occupant store or handle hazardous material HEATING UNIT(TO IW,WO BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
CWT,Section 25532oo? HEATING UNIT(OVER 100,(101)BHI
rYes ❑No '
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dom Receipt x
eamil included,sir conumion ms as defined by Ne Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District?
TOTAL:
❑Yes ❑No BOILER-COMP(OVER IW,"BTU)
I have read the hmnrdous materials requirements under Chapter 6.95 of she Cali- AIR CONDITIONER
fomia Health&Safety Cede,Sections 25505,25533 and 25534.1 understand that if the ISSUANCE DATE
huildin docs no¢uwntl heveemnan0 Third is NEW RESIDENTIAL MECH. SQ.CL
g Y .efasceniytnnmifytlowly,ant
ofshe requiremrnu which musth met prim to issuarRe ofa Ccnificute ofOsupancy.
Owner or authorized agent Date TOTAL:
ISSUED BY:
i
— nFFICE '