30858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY r^g}�[
CITY OF CUPERTINO BUILDING-ELECTRICAL - - PERMIT N030858
. O 8 V N/
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENPIFICAI'ION
� BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
Z �1P3 Corte, madeAw Lan L 2- 7
OWNE AME: PHONE: CONTRALTO 'S ME: LIC NO:
NIC77 CONTROLM
leiARCHDECDENGINEER: LUNO: AD BSS: - ❑
CONTACT: PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDMat I a CONTRACTOR'S undeDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat 1 em licensed undo provisions of Chapter 9(commencing JOB DESCRIPTION
�0O0'Z with Sttlion 7")of Division 3 of the Business and Pmfessiors Code,and my tire.is RESIDENTIAL
0 PERMIT ISSUANCE
� n full force and effect. ❑SFDWI. El KITCHEN REMODEL
U E License Class Lic.M
Dam Convenor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F.
Z O z I understand my plum shell M1c need ms public records PANE S MODIFICATION
OZ—^ - UY 102110 AMPS -
G
El INTERIOR El CHIMNEY REPAIR
W Licensed Pr ucasionM 201-Ifk1tIAMPS IMPROVEMENT
raj Oat I ma eURDER DECLARATION OVER I"AMPS ❑BATH REMODEIIREPAIR [I DEMOLITION
1 herehy affirm that 1 am exempt from the Comoro Co License Law rot the
ip5,O LU following rima..(Semina 703LS,Busirrss all Professions Code:Any city or coumy SIGNS ELECTRICAL []OTHER
su 40
F" 'which requires a pannm m m,.thr aper.improve,demolish,or file.signed
any swcmre
Pool to its issuonce,Mso requires the epplicem for such permino filrasigned stetcment SPECIAL CIRCUIT/MISC.
(commit licensed Purtion70hcpmvisiom ofthe Business
License Law(Chapter9
p�QO (commencing with Section 7000)ol Division Sof the Business enJ Professions Cwle)or TEMP.METER OR POLE INST. COMMERCIAL:
6 O that he is exempt therefrom and the basis Tai the alleged exemption,Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
qG Section 1031.5 by my applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
I++^m y ❑TENANT ❑FOOD SERVICE
F Z i' not more than Eve hundred dollars(SSg)' OTHER IMPROVEMENT
Qa0 (]Las ownerof the pmperty,or my employtts with wagesm Neir rule rnmpensmion, SWIMMING POOL ELECTRIC
ct and do the work,andeh he Cone is not s Licenst,Law
dos Sala ply to an owner
❑OTHER
41 and Prty%hom Cndc The C es then rs L nd w Inw does not apply to if owner of OUTLETS-SWITCHES-FLYTURFS
property wM employees,
or improves thereon,and who nts such irate himself or through'
his own employeese provided that such improvements aro not intended or offend for NEW RESIDENTIAL ELT:Cfit SQ FT.
sale,IL ho dsr will have tthe bur en of improvement is at he did n t build or improve
the SQ.FT.FLOOR AREA S/SQ.PI'.
ownerb ane will have the burden of proving that he did not buil)or improve fur put- PAID
qq
fsel1). TOTAL: P A 9 D
r of Ne property,um exclusively contmning with lircnsed emincion to
mtmm Iheephoom Due.7091,Business and Profess....GMC:)The—no—'..s Li-
enaeLawdoennotopplytoanownerofpropertywhohuildsorimprovestherson,and QTY, PLUMBING PERMIT FEE APR
whoconnims forsuch projects with a contracuds)]treated par min to the Cmumcmrs APR 2 []rasa
License Law. PERM IT ISSUANCE R[4
❑Iamexcmptunder Sec. _ ,B&PCfim Nism.
0wner pate ALTER-DRAIN&VENT-WATER(EA) f•CKlJI%UATION
WORKT: COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 herehy uRir i under Penalty of perjury.of the following dkelmutions:
❑ Ihuve unJ will mnimein aCMiBcae of Cons cnttosdLinxuefm Wmron's Compen- DRAINS-FLOOR,ROOF,AREA,COND. Q
sation.m provided for by Section 37M of the Labor Cale,for the performance of the STORIES TYPE CONS'fRUCT10N
work for which this pemdt is issued. FIXTURES-PI?R TRAP
C T have and will maintain Worker's Compensation Insurance,m required by Section
3701G.Ohe Labor Code,for the peffomunceof Ito work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLL'TS OCC.GROUP APN
My Workers Compensation Insurance Cartier and Policy number are: GAS EA
Carrier: Policy No.: ( )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION hEES
(This section need oat be completed if the permit is for one booMreJ Dollar 18100)
or less) GRE PLANCHECK FEE ,
I county that in the performanceofthe work for which this perom is ismed,I doll (EWER-S TARY-STORM BA. PI'.
Too rmpmy any person in any manner so as to benne eobjeo m the Worker',mp ai- ENERGY FEE
Z satin,Laws of Califomia.Date WATER HEATER WNENT/ELECTR
C) Applicant GRADING FEE
fA NOTICE TO APPLICANT.If,after making this Cerificate of Exemption,you should WATER SYSTEM,TREATING
a ? become subject to the Workers Compensation provisions of the Labor Code,you must SOILS HE
{la r.t forthwith comply wilt such provisions or this Permit shot]he deemed revoked. WATER SERVICE
U Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID Date Racei tg
U0 week
by which his
Thai them isacd(Sce.nom let Ming agency fnr Ne Pedormance of P
W. f•t the work for which this permit is issued(Sec.3097,Civ.CJ _
O U Leade a Name TOTAL:
Lenders Address
I ect ify that I have read this application and some that the above information is BUILDING FEE
U V) correct.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
U building convection.mid hereby authorize representatives dithis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the Cuy of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER ORADDTO MECH. PLUMBING FEE '
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. c
&144j%j_6, 711&A i 14h 7 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature ApplicanuCuromtor � v EXHAUST HOOD(W/DUCO
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupmt store or handle hnzmdous material HEATING UNIT(TO 100,0100 BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
E]Yes CNo VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt is
emit hazardous air emateramantx as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,110(i BTU)
TOTAL:
District?
CYm No BOILER-COMP(OVER 100.000 BTU)
AIR CONDITIONER
li ]have Safer hoedle,Se mn,1555.2553enuunderLTapteni.95ofrhe Cali. - ISSUANCE DATE
folie gHealthdoes&Safety Code,Sections 25505,25533 rund 25534.1 umdermad Nm if the NEW RESIDENTIAL MECH. SQ.PT.
building dos oat curemly have a tenon]out itis my responsibil'ny to notify the eacupam
ofthemems w 'c must be me 'ono ix once of a Certificme f Q pane . - DEC'
Owner or au mud agent m TOTAL- ISSY..
OFFICE