30830 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, OHO O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGAUDRESS. SANITARY NO. APPLICATION SUBMITTAL ON]
oZ1-7?5 Sli62.
OWNER' NAML ZOAANE:��^^�� 616-7
CO ACTOk'S AME: LIC NO:
T as eiT�/Z �1Vp,-6/r! / Q / NIC CONTROL#
�4RCHI'FECLIENGINEER: LIC NO: ADDRESS: C GYM
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRAC'POR'S DECLARATION QTY. ELECTRIC PERMIT FEE � ❑
I hereby aflon that I.am licensed under provisions of Chapter 9(commencing
WOO with SecJ.n Toa fDivi,io.3.Dhe Ba,in,,xmT Prefeahrns Coca.amd m I JOB DESCRIPTION
�p )o y)conte is PERMIT ISSUANCE RESIDENTIAL
F,U� Inftllc Class d,Rea.�-ZW License Class Com ❑SFUWL ❑KITCHEN
yGi Dam Comracmr APPLIANCES-Rf•SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
OZ�2 Z ]understand my plans shall treated as public records PANELS
mFWINTERIO
UP TD 2n0AMP5 MODIFICATION
❑ R EYR PAIR
❑CHIM
FQ...�j Licensed Professional201-1000AMPS IMP . ;NT
OWNER-BUILDERDECLARATION OVER IWUAM
lay.K W Q 1 hereby affirm that 1 am exempt front the Contractor's License Law for the PS H REMODFIJREPAIR (]DEMOLITION
{y 3%U following reason.(Section 7031.5.Business and Professions CW,:Any city or county - SIGNS ELECTRICAL ❑OTHEII
F=O ti which pictures a permit to construct,alter,improve,demoinh,or repair any umcmrc
y1' prior to its issuance,also requires the applicant for such Permit rile a signed statement SPECIAL CIRCUITIMISC. N
} that he is licensed pursuant to are provisions of the Contractor's License Law(Chapter 9
u1�0ka
0 (commereingwim Section 7W)).f Division 3.1 me BoJm,,send Pmfiw, .,CNe)m TEMP.METER OR POLE]NST COMMERCIAL
a q o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NBW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit.subjects the applicant to a civil penalty of POWER DEVICES
t mom than five hundred dollars(S500). a
❑TENANT El FOOD SFRVICE
SQp ❑ I,as owrerof the 1111-1.a1m1 employees with wages astheirmlecomper,ainn, SWIMMING I'----------- IMPROVEMENT
(.., %dido thework,and thestrucwre is notiatenJeJoroffered fmsale(Sec.7044,Business ❑OTHER
6 3 ro snit Professions Code:The Contractor's License Law does not ippty ro in owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dots such work himsalf or through
his own employee,provided that such improvements are oat imend,d or offered for NEW RESIDENTIAL ELECTR SQ ET.
ads.If.however the building or improvement is sold within oneymr of completionthe SQ.FTjFLQO;ARF,A g/SQ,FI'.
owner milder will have the burden of proving that he did not build or improve for par- /GI '
P er as owner
OR
V
1,as owner of the propery,704 am exclusively contracting Cas licensed contractors i- TOTAL:
'onstmm the project(Sec.7(004,nosiness and Pro .......s Cada)The Cnmmdurs Li- a
cense Law does not apply loan owner ofpmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE jyU 1 /1rj
who contracts for stch projects with a contractions)licensed pursuant n the Contractor'.. /.
License Law.
❑ PERMIT ISSUANCE �O h GVN
I exempt under Ser. - ,B&PCfor tris..on
Owner I are
ALTER-DRAIN&VENT-WATER(EA) s ell IY
DVALUATION
WORKER'SCOMPE SATION SCLARATTON BACK FLOW PROTECT.DEVICE k
IherebyalTm
runderpenaltyofperjoryone fthe following declarations:
❑I have and will maintain a Certificate ofConscnt to self-insure for Workers Cumber- Ile
DRAINS-FLOORROOFAkGA.COND.
,alio.,as provided for by Section 3791 of the Latour Code.for the perforanc .
e of the - - TOk 'TYPE CONSTRUCTIOD
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,its required by Sec9ion' _
3700 of the labor Cvdk rime Ne performance of the work for which this permit 1,).,sued. GAS-HA.SYSTEM-I INC.4 OUTLETS
My Worker',Compensation Insurance carrier and Policy number are: OCC.GROUP APN
Currier: Policy No.: GAS-F.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
or less)
(This union need not becomplep d Bthe lateral is fmonc hundred!dollars
dollars(3100) BUILDING DIVISION FEES
I cenify that in the Wfl'ormance of the work fmwhich this PLANCHECK FEL!
permitises Co shall
not employ any pcnoni ny mmmerm ml+ecnm 'cit to the Workers Compeer- SEWER-SANITARY-STORM EA.2W 1'r. ENERGY EEE
O z ration Lawn of C .Dam '- f WATER HEATER WIVENT/ELLLTR
7 T APPlicanl a��D—=� x GRADING IEE
C. NOTICE TO A PLICANV T:If,after making this Certificate n emption,You should WATER SYSTENV REATING
F2' ; beco oat subject to the Worker's Compensation Provisions of the Labor CW c,you most SOILS ME
forthwith ennrply with such provisions or this permit shall he deemed revoked.
A WAIDR SERVICE
ow
=) z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI NIB SQ.Fr. PAID
V O l hereby affirm that there is a roan
n.bewior lending agency for the performance of Date Regi t#
LG F' the work for which this pemm is issued(Sec.3197,Civ.C.)
U Leader',Name
nders Address T TAL:
O Ley 1 certify that I have read this application and pato that the alcove information is TOTAL. is
BUILDING FEF (fQ
Uh correct l agree memmply.wnh all city and county ordinances and sum lows relating to QT,y. MECHANICAL PERMIT FEE "r
Z bui]dingconswetiunand herebyaathofiee reprchemetives ofthis city to cnmrapon the SEISMIC PEE
.bole-mentioned property for inspection purposes. K.
(We)agree in save.indemnify and keep harmless Jae City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmark.costs and expenses which may in any way aceme against said City
in consequence of the greming of this permit ALTER OR ADD TO MECH. PLUMBING IEE
SOURCE REGULATIONS.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10. NO
CONSTRUCTION TAX
Stgnawrc
HAZARDOUS
C1')Date EXHAUST HOOD(WMUS MATERIALS DISCLOSURE HOUSING MITIGATIO FEE
Will me Cic.rtor furore building occupant,Chpatorcnr handle Health
and Safety HEATING UNIT(TO IW BTU)
as defined by the Cupertino Municipal Craft,Chapter 9.12,and the Hcahh and Safety
Code,Section 25532pd? HEATINGUNIT(O . joo.ofa BTU)
❑Yes
KIN.
VENTILATIO AN(SINGLERESID) PAID
Will the applicant or future building occupant use equipment or deviccx which Date Re ip p
emit monomers air contaminants as definW by the Bay Area Air QnAity Managemmit BOILS OMP LHP OR 100,00(i BTU)
Id"11,1/ >>�-''
❑Yes l�tvo BO -R-COMP(OVER 100,000 BTU)
I have read the h.cvNo/us`materials notarcmcros under Chapter 6,95 of the Cali. IR CONDH IONER
moan Health&Safety Code,Section.25505,25533 and 25 53 4.1 understand that if The ISSUANCE DATX
mr
building does not eerly haveatanan,tha it in my re,ponsibiligmnotify the necupant NLW'RFSIUEYTIAI.MF,CH. SQ.IT.
offs,require Uwhich must be fila iso ceofo Cenificam of Occupancy.
Owner rauthsov.agent FVale
TO'T'AL: ISSUED BY:
OFFICE