30235 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. O
BUILDING DIVISION' - APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL ON
0 8 1. 5 W WATeS 'j --�-q,6
OWNER'SNAME: PHONE: CONTRACfOR'SNAME: LIC NO:
A)SOnI 26-3 - 2 5-2H CW1USuv ergic405/ NIC coNTRO a
ARCHITECI'IENGINEER: LIC NO'. ADDRESS: ❑
2040) A/1R
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLLECCTT PLUMB MECH
1:1y ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nal I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 7")off)"isionlofthe Business and Professions Cade,and my licence is
�DO y RESIDENTIAL'
full force lad effect. PERMIT ISSUANCE,
rp
aFUV License Class - Lica Sl GSFUWI. D KITCHEN REMODEL
y<i Do¢ Convector APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTSDECLARATION PANELS [DMULTI-UNIT ❑STRUCTURAL
Z O Z„ 1 understand my plans shall be used as public records
�i p /y/7k MODIFICATION
O ZL'a 2v UPTO 200 AMPS "l l,J
F�.F.W Lice ..P.Profcesianel ❑INTERIOR ❑CHIMNEY REPAIR
�X.X,'4j OWNER-BUILDER DECLAHA3'ION 21)1-IINNIAMPS IMPROVEMENT
y tY W Q I hereby affirm that I am exempt from the Contractors License law for the OVER San AMPS D BATH REMODEL/REPAIR D DEMOLITION
�(O a U 413 following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL - DOTHER
C y which requires a permisu
t to consumer,alter,improve,demolish,or repair any acture /e
�Q prior fits issuanec,al.so requires theapplicont for such Rami,,,file osigneJsaauan 1 SPECIAL CIRCUIT/MISC.
Wg ds that he it licensed pursuant m the pookiomnfthe Carlo mods License Law(Chapter
�CO (commencing wird Section 2000)of llisisiunJof Ne Rosiness and Pmfeusion,Cole)or TEME METER OR POLE INST. COMMERCIAL-
6 a c that he is exempt dNerefrom laid the basis for Ne alleged exemption.Any violation of
El NEW BLDG/ADDITION GDEMQLITIQN
Section 7031.5 by any applicant fora
Permit mbjecr the applicant oacivil penalty of POWER DEVICES
a� not more than five hundred dollars 8500, GTENgNT
[_1 FOOD SERVICE
�J-ZQ ❑I,
as Owner of the pr,pery,or my employees with wages as their sole compensotion, SWIM M ING FOOL ELECTRIC IMPROVEMENT
2C• m will do the work,ndthcstmatureis not intended or n0ered fnrsale(Sea 21W4.Ration's IMPROVEMENT
Land Professions Cale:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves themon,and who does such work himself or through
his own employees,provided my such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SO CE
sale.It,howevee the building orimpmvcment is sold within one year ofcompletion,the SQ.IT.FLOOR AREA SISQ.ET.
enholder will have the Imdennf proving that he did nal build or improve for par- fn P "x
Rove of sale.). t
D I.as owner of the property,am exclusively contracting with Increased contractors to ) -0'eL 2 3 1(1nC
construct the project(Sec.2014.Business amt Professions Cade:)The Commcmrs Li. J'
JL
m law does motopply tp a a owncrof propcny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who mnaraets for such projects with u contumtorts)licensed pursuant m the Gmonaors 19 JU
License Law.
D 1 am exempt under Sec. .B&PC tar Nis reaPEkMIT ISSUANCEson I) UP ✓liters1 us. ,
ALTER-DRAIN&VENT-WATER EA)Owner Dare VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby tdlinn under penalty of Iurjury one of the Gdlnwing declumduns
❑Ihm'e and will muim:nneCeniOnr of Cansem u.wll-insure ha Worker's Compcn- DRAINS-FLOOR.ROUP.AREA,COND.
,anal,as provided for by Section 32W of the Labor Code,for the perf nummoc of the STORIES TYPE CONSTRUCTS)
work for which this permit is issued. MIXTURES-PER TRAP
T1 have and will maintain Workers Compensation Insumnce,as required by Section
2W of the Labor Cod,A,ttffoor the permonsnce,of the work for which this permit is issued. GAS-CA.SYSTEM-I INC.4 OUTLF1S OCC GROUP MIN
My WarkcQ CnmgNUClff1 male lathy,and Policy�L the ���p 1, GAS-
Carrier:CC LL / �I✓L Policy No.: /w Jnf� UFI EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASESNDUSTRL WASTE INTERCEPTOR
ar IcssO
no section need not be completed Bthe permit is for one hundred dollars($1 00) GREASE.TRAP
) BUILDING DIVISION FRES
I cenif that in the peno.mill Orthe work fur whieh,his NCHECK FEE
y y person in any mons,so as m become subject the Workers Camper-
norempin n SEWER-SANITARY-STORM FA.2(q FT.
Z ration Laws of California.Date ENERGY FEE
WATER HEATER W/VENT/ELECTR
z Applicant GRADING ME
h NOTICE TO APPLICANT:IC after making this
oll,u ,of of Exemption,you should WgTiiH SYSTEM/1'RCgTING
becmnc suhjeu m the Worker,If loo Comlwnsm is provisions of the Lobar Cndu,you mus SOILS FEC
� Q forthwith rnmply with flit provisions nr this permit shall Mdcemed revoked. WATER SERVICE
a
U2 CONSTRUCTION ENDINGACENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V k far by which
that isaconstruction lending agency for the Performance of Dom Recciptk
{gs F the work for which This permit is issued(Sol,3092,Civ.CJ
0 U Lender's Nunn -
} � Lenders Address TOTAL: TOTAL:
1 lenity IMI I have read This application and ,are that the If information is BUILDING FEE
Uh correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
2 building construction.and hereby mahorizc representatives of this city to enter upon the SEISMIC PER allose-hoseproperty far inspeedan purpose,.
(we)agree to save,indemnify and keep harmless But City of Cu rims against PERMIT ISSUANCE
cots and expenses which ma d ELECTS IC FEE
liabilities,
judgments, pe yin any way acerae ageinxt said City
in ALTER OR ADDTO MECH.
consequence of she granting of this Renoir. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000 CPM)
SOURCE HT/iULATjY �SS/.�� MECHANICAL PER
//�/('yy(/ ff-i -7/1)46 AIR HANDLING UNIT(OVER 10,0W CFM) CONSTRUCTION TAX
Signore 4Apphcant/Cimmaelr Doc EXHAUST HOOD IW/UUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building arcupam store or handle hazardous material HEATINGUNIT(TO100.000 TU)
as defined by she Cupertino Municipal Cadc.Chapter 9,12,ani the Health and Safety
Code,Suction 25532(x)° HEATING UNIT(OVER 100,(100 BTU)
❑Yes 0 N
VENTILATION FAN(SINGLE RESID) PAID
WII the applicant infuture building occupant y A equipment or devices which Unte Receipt N
emit hazardous air contaminants as delinal by the Bay Arca Aa Quality Manogemnl BOILER-COMP(3HP OR "BTU)
District,
❑Yes FlNo BOILER-COMP(OVF.R 100,000 BTU) TOTAL:
1 have read the hvardns anterial,requiremenu under Chapmr h.95 of the Cali- AIR CONDITIONER
fomia Health&Safely Cole,Sections 25505.25533 and 25531 I understand that if the ISSUANCE DATE
building Ne,nmurcmly hove a roam,that it is my rcapnnsilahm Initially the occupant NEWRESIDENTIALMECH. SQ.ET.
of the requirements which must be met prior to issuance of Certificate of Occupancy.
Owner or aulhorizN agrnr Doc
TOTAL: ISSUED BY:
OFFICE